Gastroenterology Today - Spring 2021
Volume 31 No. 1
Spring 2021
Gastroenterology Today
What approach has 18 Week Support
taken with regards to building an
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Dr Matthew Banks is the Clinical Director for 18 Week Support Gastroenterology. He believes it starts with recruiting the
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quest to develop excellent teams who deliver a world-class service, we must focus on NTS’.
Tammy and Lisa’s Perspective:
Tammy Kingstree is Lead Nurse for Endoscopy.
‘It is extremely important that there are good working relationships within the team. This starts with strong leadership from
our senior nurse coordinators who are trained to manage the patient pathway, manage a team of staff they may not know
and to deal effectively with any issues which may arise on the day’.
Lisa Phillips is Lead Nurse for Endoscopy.
‘The team objectives are clear. Excellent patient experience and good patient outcomes. Because the objectives are clear,
team cohesion and focus are exceptionally good. It therefore shouldn’t matter that we are in an unfamiliar endoscopy unit,
the service should be seamless. If it isn’t, we do not stop until we get it right.
If you have an excellent NHS record and want to help clear NHS waiting list backlogs, reduce RTT waiting times and provide
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CONTENTS
CONTENTS
Gastroenterology Today
5 EDITORS COMMENT
6 FEATURE Delayed bowel obstruction after seat belt injury:
a case report
12 FEATURE Capsule captures culprit: Dieulafoy’s Lesion in
the small bowel
14 FEATURE Restoring Intestinal Barrier Function: A Promising
New Approach for the Treatment of Inflammatory
Gastrointestinal Diseases
16 NEWS
22 COMPANY NEWS
This issue edited by:
What approach has 18 Week Support
Dr Andrew Poullis
c/o Media Publishing Company
taken with regards to
Greenoaks
building an
Lockhill
Upper Sapey, Worcester, WR6 6XR
expert insourcing team?
Matthew’s Perspective:
ADVERTISING & CIRCULATION:
Media Publishing Company
Greenoaks, Lockhill
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Tel: 01886 853715
E: info@mediapublishingcompany.com
www.MediaPublishingCompany.com
Dr Matthew Banks is the Clinical Director for 18 Week Support Gastroenterology. He believes it starts with recruiting the
best clinicians. ‘At 18 Week Support we set the bar very high. We only recruit clinicians whose JAG performance data is well
above the national standards. In addition, we monitor each clinician’s KPIs while they work with 18 WS. While the JAG data
is an excellent quality indicator, we now want to go a step beyond that and monitor the Non-Technical skills (NTS) of each
clinician as well. We now know that NTS plays an important role in safe and effective team performance. Therefore, in our
quest to develop excellent teams who deliver a world-class service, we must focus on NTS’.
Tammy and Lisa’s Perspective:
Tammy Kingstree is Lead Nurse for Endoscopy.
PUBLISHING DATES:
March, June, September and December.
‘It is extremely important that there are good working relationships within the team. This starts with strong leadership from
our senior nurse coordinators who are trained to manage the patient pathway, COPYRIGHT:
manage a team of staff they may not know
and to deal effectively with any issues which may arise on the day’.
Media Publishing Company
Lisa Phillips is Lead Nurse for Endoscopy.
Greenoaks
‘The team objectives are clear. Excellent patient experience and good patient Lockhill outcomes. Because the objectives are clear,
team cohesion and focus are exceptionally good. It therefore shouldn’t matter that we are in an unfamiliar endoscopy unit,
Upper Sapey, Worcester, WR6 6XR
the service should be seamless. If it isn’t, we do not stop until we get it right.
COVER STORY
If you have an excellent NHS record and want to help clear NHS waiting list PUBLISHERS backlogs, reduce RTT waiting STATEMENT:
times and provide
high-quality patient care, get in touch by calling on 020 3892 6162 or email The Gastro.Recruitment@18weeksupport.com
views and opinions expressed in
this issue are not necessarily those of
the Publisher, the Editors or Media
Publishing Company.
Next Issue Summer 2021
ENDOSCOPY ALTERNATIVES AT A TIME OF COVID
Last year, in the Autumn edition of the magazine, we looked at how innovative
thinking and different ways of working with new technologies could help NHS
Trusts clear waiting lists. Since then, waiting lists have continued to grow
rapidly, and in some treatment areas the time to diagnosis and treatment is at
record levels due to the impact of Covid on NHS resources.
New technologies can have a key role to play in delivering safe, accurate but
faster diagnoses, and this is as true in endoscopy as in many other areas.
In last Autumn’s edition we looked specifically at developments in transnasal
endoscopy, but there have also been important and meaningful changes in
other areas of endoscopy too, either from improvements in the technologies
themselves or from new research on how those technologies can be better
used.
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EDITORS COMMENT
EDITORS COMMENT
“The amazing
success of the
vaccine and
its distribution
and
administration
will be one
of the few
positives
about the
pandemic. As
we all start
planning to
return to work
the size of
the challenge
ahead is
somewhat
daunting”
Lockdown Irritable Bowel Syndrome
As we are now on a route out of lockdown there is a lot to be optimistic about. The amazing
success of the vaccine and its distribution and administration will be one of the few positives
about the pandemic. As we all start planning to return to work the size of the challenge
ahead is somewhat daunting.
In addition to learning about a completely new viral disease, the acute manifestations of
infection, non-acute manifestations and treatments rapidly evolving from supportive to
evidence based therapeutics we have also had to learn how to continue our day jobs.
The impact on endoscopy waiting lists, delayed diagnosis and risks to our patients with
long term conditions are well recognised.
Our regular clinical work has also been impacted in addition to the abovementioned
problems. Those with busy clinical practices will have noticed a new group of patients
coming through as new referrals. A group who do not fit the well known demographics of
the pre-lockdown IBS patients yet have similar symptoms. The combination of a sustained
and dramatic change to lifestyle, diet, social interaction, leisure, working practice and
mental health is a potent cocktail for an epidemic of functional gastro-intestinal disorders
– Lockdown IBS. For many of us IBS is a diagnosis of exclusion, with so many organic
mimics to common “IBS symptoms” the need for further investigation is the norm.
In parallel with the mountain we need to climb to deal with the waiting lists created by the
pandemic, our referral volume is likely to increase as an indirect result of the pandemic,
putting additional pressure on diagnostics and waiting lists. Hopefully as we exit lockdown,
Lockdown IBS will, like lockdown itself, just become a distant memory.
Andy Poullis
St George’s Hospital
London
GASTROENTEROLOGY TODAY - SPRING 2021
5
FEATURE
DELAYED BOWEL OBSTRUCTION
AFTER SEAT BELT INJURY:
A CASE REPORT
Xing-Bin Ma 1† , Bao-Guang Hu 2† , Wei Wang 1 , Xian-Yong Cheng 1 , Chun-Di Guan 1 and Cheng-Xia Liu 1*
GASTROENTEROLOGY TODAY - SPRING 2021
Abstract
Background
Delayed bowel obstruction due to seat belt injury is extremely rare.
The delayed onset of nonspecifi c symptoms makes a timely diagnosis
diffi cult. A deep understanding of the characteristics of this condition is
helpful for early diagnosis and treatment.
Case presentation
A 39-year-old male was transferred to our hospital from another hospital
complaints of progressive abdominal distension and severe weakness. In
the previous hospital, he was diagnosed with “adult megacolon” and was
recommended for surgical treatment. In our hospital, he was diagnosed with
delayed bowel obstruction due to seat belt injury and underwent surgical
intervention. Following laparoscopic adhesiolysis and resection of the narrow
small intestine, his symptoms improved rapidly, and he was discharged.
Conclusion
Delayed bowel obstruction due to seat belt injury may present clinical
symptoms any time after the injury. Imaging examination, ileus tube and
small colonoscopy may provide us with valuable cues for the diagnosis
and treatment of delayed bowel obstruction, and laparoscopy may be
an alternative approach in surgical intervention.
Keywords
Delayed bowel obstruction, Seat belt injury, Endoscopy, Laparoscopy,
Case report
Core tip
We reported a rare case of delayed small bowel obstruction due to
seat belt injury. Based on the experience in this case, we suggest that
delayed bowel obstruction due to seat belt injury may present clinical
symptoms any time after the injury. Imaging examination, ileus tube and
small colonoscopy may provide valuable cues for the diagnosis and
treatment of delayed bowel obstruction, and laparoscopy may be an
alternative approach in surgical intervention.
Background
Bowel obstruction due to blunt abdominal trauma is common, whereas
the delayed presentation of bowel obstruction following seat belt
injuries is extremely rare. The delayed onset of nonspecifi c symptoms
following seat belt injuries usually makes a timely diagnosis diffi cult.
The underlying pathophysiological mechanism of delayed presentation
following trauma remains unclear, and the characteristics of this
condition have not been well described.
This report presents a rare case of delayed bowel obstruction in a male
patient following seat belt injury during a car accident. Additionally, we
discuss the possible mechanism for the delayed symptoms and the
diagnosis and treatment of patients who experience a delayed bowel
obstruction following seat belt injury.
Case presentation
A 39-year-old male was transferred to our hospital from another hospital.
He had mild tenderness, an obvious bowel pattern and hyperactive
bowel sounds; he was able to pass gas occasionally. Before admission,
he suffered progressive abdominal distention and gradual deterioration,
and he developed malnutrition for two months. A total alimentary tract
angiography showed partial enlargement of the ascending colon and
transverse colon and partial dilation of the distal small intestine (Fig. 1).
He was diagnosed with “adult megacolon” and recommended for surgical
treatment. However, the operation was not performed because of a
signifi cant decrease in platelets (with a minimum of 19 × 10 9 /L) and severe
malnutrition. He had been in a car accident 2 years previously. He was the
driver and was wearing a seat belt at the time of the accident. During that
admission, he was always conscious and was found to have left clavicle
fractures and multiple rib fractures. Abdominal examination showed seat
belt marks and mild localized tenderness at the site of the abrasions. An
abdominal CT scan showed a small amount of fl uid (approximately 150
ml) in the abdominal cavity with no solid organ abnormalities. He was
hemodynamically stable and was able to pass gas and defecate. He
improved rapidly with conservative treatment, was discharged after several
days and was asymptomatic. Two months after discharge, he started to
have episodes of abdominal distension and intermittent mild tenderness,
and he passed gas less frequently than before. However, he improved
rapidly again after receiving treatment with traditional Chinese medicine.
After admission, we fi rst tried to improve the general condition of the
patient by strengthening parenteral nutrition and correcting electrolyte
imbalances. Then, a series of additional examinations were performed
to explore the possible reasons for these problems. An abdominal
CT scan showed an abrupt narrowing zone at the jejunum (Fig. 2).
6
*
Correspondence: phdlcx@163.com
†
Xing-Bin Ma and Bao-Guang Hu contributed equally to this work.
1
Department of Gastroenterology and Hepatology, Binzhou Medical University Hospital, No. 661, Huanghe 2nd Road, Binzhou 256603, Shandong, China
Full list of author information is available at the end of the article
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7
FEATURE
Fig. 1 a-b. Single anteroposterior abdominal radiograph showing markedly dilated colon in the initial stage
Small balloon colonoscopy found a narrow zone approximately
40–50 cm from the ileocecal valve; the surface mucosa was swollen
and erosive, and the upper segment of the intestine was obviously
expanded (Fig. 3).
Laparoscopy was performed on the patient after multidisciplinary
discussion and detailed preoperative evaluation. We found severe
adhesion between the abdominal wall and intestine as well as a narrow
small bowel with a length of 12 cm at approximately 40–50 cm from the
ileocecal valve. The mesentery corresponding to the narrow part of the
small intestine was also absent, and the proximal intestine was markedly
dilatated. Additionally, a thick adhesive band was also found between
the dilated proximal intestine and the sigmoid colon, and we thought
it might be the main cause of colonic dilation (Fig. 4). Therefore, we
performed laparoscopic adhesiolysis and partial small bowel resection,
and the thick adhesive bands were destroyed. The narrow small bowel
with length of 20 cm was removed. Histologically, the area was fibrotic
(Fig. 5). The patient recovered rapidly and gained 5 kg in the 3 months
after surgery. He was very satisfied with the treatment.
Discussion and conclusions
The use of seat belts has significantly reduced the overall mortality associated
with motor vehicle accidents. However, physicians should know that the
use of seat belts is also associated with certain patterns of injury, including
abdominal injuries, neck and spine injuries, chest trauma and vascular
injuries [1]. Hollow viscus injury due to a seat belt is uncommon; it occurs in
approximately 1% of all blunt abdominal trauma patients, and delayed small
bowel obstruction (SBO) following hollow viscus injury is rarer [2, 3]. The
case we reported is a typical seat belt injury, and the patient presented with a
delayed SBO at 2 years after injury. The case indicates that seat belt injuries
might not produce severe symptoms immediately, and the related symptoms
such as bowel obstruction might present any time after injury.
Since the initial description in 1962, few articles have been published on
delayed SBO due to seat belt injury [4]. Therefore, the exact cause of the
obstruction remains unclear. However, the possible mechanism may be
associated with a small perforation of the small intestine and perforationinduced
adhesive, localized bowel ischemia, and injury to the mesentery.
a
b
GASTROENTEROLOGY TODAY - SPRING 2021
Fig. 2 CT scan demonstrating yellow circle indicates the abrupt narrowing zone of the jejunum (a; cross-sectional image, b; coronal image)
8
FEATURE
Fig. 3 a. Small balloon colonoscopy can be seen mucosal congestion, edema, erosion, intestinal stenosis. b. The proximal dilated bowel cavity
and the end of the ileus tube
Most authors suggest that the most likely cause of delayed SBO due to seat
belt injury is injury to the mesentery. Mesenteric injuries are commonly defined
as small hematomas, contusions, or lacerations that do not compromise
bowel circulation [5, 6]. Our case supports the mesenteric injury theory since
there was a large mesenteric defect corresponding to the narrow part of
the small intestine. In addition, we believe that delayed bowel obstruction
was also due to a combination of posttraumatic ischemia and the adhesive
between the small intestine and sigmoid colon.
Preoperative diagnosis for patients with delayed bowel obstruction due to
seat belt injuries remains a challenge to surgeons. A patient may be relatively
asymptomatic, have stable vital signs, have no clinical evidence for peritonitis,
and may even have negative initial image [7]. In most cases, CT findings
are often subtle and nonspecific. The presence of free intraperitoneal fluid
in the abdomen without any evidence of solid organ injury may be the sole
piece of evidence of a significant bowel injury at the first CT evaluation on
first admission [8]. Moreover, multislice computed tomography enterography
may help to identify the location of the obstruction when delayed bowel
obstruction occurs. Additionally, small colonoscopy may be helpful in the
differential diagnosis of delayed bowel obstruction; this procedure not only
helps to identify the location of the obstruction but also helps to investigate
the cause or nature of the lesion. In the current case, the presence of free
intraperitoneal fluid at the first CT evaluation, the narrow small intestine
observed in the secondary imaging examination, and the findings from
the small colonoscopy provided us with valuable cues for the preoperative
diagnosis of delayed bowel obstruction due to seat belt injury. Meanwhile,
the application of ileus tubes also greatly aided in bowel preparation,
diagnosis and treatment in the current case.
However, there is still debate regarding the optimum duration of conservative
management and the timing of surgery for SBO, especially when the SBO
is due to seat belt injuries, because no high-quality studies have been
performed to examine these issues [9, 10]. To date, most data with beneficial
effects are from case reports or observational studies that enrolled a limited
number of patients. The presence of free intraperitoneal fluid in the abdomen
is not observed in stable patients [11]. Open surgery has been the preferred
method for surgical treatment of strangulating adhesive SBO and SBO that is
refractory to conservative management. Currently, laparoscopic approaches
have become increasingly popular because of their multiple advantages
such as being minimally invasive and having potentially better outcomes
than traditional approaches. Laparoscopic approaches can also be applied
for SBO and trauma to assess and treat intra-abdominal adhesions and
abdominal injuries [12, 13]. In this case, we first performed a laparoscopy
and laparoscopic adhesiolysis. Then, we removed the narrow small intestine
a
b
Fig. 4 a-b. Gross image depicting the Stenosis and extremely dilated small bowel (arrow, star)
GASTROENTEROLOGY TODAY - SPRING 2021
9
03437
FEATURE
a
b
Fig. 5 a-b. Histopathological findings. Ulcers were observed and inflammatory cells and fibroblasts infiltrated to the whole layers (a × 20, b × 100)
GASTROENTEROLOGY TODAY - SPRING 2021
10
and reconstructed the digestive tract via a small abdominal incision. The
patient recovered rapidly after surgical intervention. Our case revealed that
laparoscopy might be useful in delayed bowel obstruction due to seat belt
injury. However, we must note that laparoscopic adhesiolysis is not feasible
for all patients or all surgeons, and a detailed preoperative evaluation is
essential.
Based on our experience and knowledge of the reported cases in the
literature, we propose that delayed bowel obstruction due to seat belt
injury may present clinical symptoms any time after the injury, and these
patients should be closely monitored. Imaging examination, ileus tube
and small colonoscopy may provide valuable cues for the diagnosis
and treatment of delayed bowel obstruction, and laparoscopy may be
an alternative approach for surgical intervention.
Abbreviations
SBO: small bowel obstruction; CT: Computed tomography; Kg: kilogram
Acknowledgements
Not applicable.
Authors’ contributions
XBM, BGH: Manuscript writing, literature research. WW, XYC and CDG:
Management of the case, editing the manuscript. CXL: Manuscript
writing, management of case and final approval of manuscript. All
authors have read and approved the manuscript.
Funding
None.
Availability of data and materials
Data sharing is not applicable to this article as no datasets were
generated or analyzed during the current study.
Ethics approval and consent to participate
Ethics approval by committee was not required for this case report.
Consent for publication
Written informed consent was obtained from the patient for publication
of this case report and any accompanying images.
Competing interests
The authors declare that they have no competing interests.
Author details
1
Department of Gastroenterology and Hepatology, Binzhou Medical
University Hospital, No. 661, Huanghe 2nd Road, Binzhou 256603,
Shandong, China. 2 Department of Gastrointestinal Surgery, Binzhou
Medical University Hospital, Shandong, China.
Received: 8 April 2020 Accepted: 14 July 2020
Published online: 08 August 2020
References
1. Özçay N, Brosova I, Ferkodic M, Özant A, Arslan K, Besim H. Two cases of
intestinal injuries due to seat belt without seat belt sign. J Surg Case Rep.
2018;2018(11):rjy298.
2. Vailas MG, Moris D, Orfanos S, Vergadis C, Papalampros A. Seatbelt sign in a case
of blunt abdominal trauma; what lies beneath it? BMC Surg. 2015;15:121.
3. Borgialli DA, Ellison AM, Ehrlich P, Bonsu B, Menaker J, Wisner DH, Atabaki S,
Olsen CS, Sokolove PE, Lillis K, et al. Association between the seat belt sign
and intra-abdominal injuries in children with blunt torso trauma in motor vehicle
collisions. Acad Emerg Med. 2014;21(11):1240–8.
4. Garrett JW, Braunstein PW. The seat belt syndrome. J Trauma. 1962;2:220–38.
5. Szadkowski MA, Bolte RG. Seatbelt syndrome in children. Pediatr Emerg Care.
2017;33(2):120–5.
6. Mahmood A, Mahmood N, Busch D. Asynchronous small bowel obstruction: a
complication of blunt abdominal trauma. Radiol Case Rep. 2007;2(2):37–40.
7. Chatzis I, Katsourakis A, Noussios G, Chouridis P, Chatzitheoklitos E. Delayed
small bowel obstruction after blunt abdominal trauma. A case report. Acta Chir
Belg. 2008;108(5):597–9.
8. Johnson MC, Eastridge BJ. Redefining the abdominal seatbelt sign: enhanced CT
imaging metrics improve injury prediction. Am J Surg. 2017;214(6):1175–9.
9. Hajibandeh S, Hajibandeh S, Panda N, Khan RMA, Bandyopadhyay SK, Dalmia
S, Malik S, Huq Z, Mansour M. Operative versus non-operative management of
adhesive small bowel obstruction: a systematic review and meta-analysis. Int J
Surg. 2017;45:58–66.
10. Behman R, Nathens AB, Mason S, Byrne JP, Hong NL, Pechlivanoglou P,
Karanicolas P. Association of Surgical Intervention for adhesive small-bowel
obstruction with the risk of recurrence. JAMA Surg. 2019;154(5):413–20.
11. Bouliaris K, Karangelis D, Spanos K, Germanos S, Alexiou E, Giaglaras A.
Ileosigmoid fistula and delayed ileal obstruction secondary to blunt abdominal
trauma: a case report. J Med Case Rep. 2011;5:507.
12. Sajid MS, Khawaja AH, Sains P, Singh KK, Baig MK. A systematic review
comparing laparoscopic vs open adhesiolysis in patients with adhesional small
bowel obstruction. Am J Surg. 2016;212(1):138–50.
13. Byrne J, Saleh F, Ambrosini L, Quereshy F, Jackson TD, Okrainec A. Laparoscopic
versus open surgical management of adhesive small bowel obstruction: a
comparison of outcomes. Surg Endosc. 2015;29(9):2525–32.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
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inhibitors, such as ketoconazole and cobicistat-containing
products, is expected to increase the risk of systemic side
effects and should be avoided unless the benefits outweigh
the risks. Excessive grapefruit juice may increase systemic
exposure and should be avoided. Patients with fructose
intolerance, glucose-galactose malabsorption or sucroseisomaltase
insufficiency should not take Entocort CR. Monitor
height of children who use prolonged glucocorticoid therapy
for risk of growth suppression. Interactions: Concomitant
colestyramine may reduce Entocort CR uptake. Concomitant
oestrogen and contraceptive steroids may increase effects.
CYP3A4 inhibitors may increase systemic exposure. CYP3A4
inducers may reduce systemic exposure. May cause low
values in ACTH stimulation test. Fertility, pregnancy and
lactation: Only to be used during pregnancy when the
potential benefits to the mother outweigh the risks for the
foetus. May be used during breast feeding. Adverse
reactions: Common: Cushingoid features, hypokalaemia,
behavioural changes such as nervousness, insomnia, mood
swings and depression, palpitations, dyspepsia, skin reactions
(urticaria, exanthema), muscle cramps, menstrual disorders.
Uncommon: anxiety, tremor, psychomotor hyperactivity.
Rare: aggression, glaucoma, cataract, blurred vision,
ecchymosis. Very rare: Anaphylactic reaction, growth
retardation. Prescribers should consult the summary of
product characteristics in relation to other adverse reactions.
Marketing Authorisation Numbers, Package
Quantities and basic NHS price: PL 36633/0006. Packs of
50 capsules: £37.53. Packs of 100 capsules: £75.05. Legal
category: POM. Marketing Authorisation Holder: Tillotts
Pharma UK Ltd, The Stables, Wellingore Hall, Wellingore,
Lincoln, LN5 0HX. Date of preparation of PI: February 2020
Adverse events should be reported.
Reporting forms and information can be found at
https://yellowcard.mhra.gov.uk. Adverse events
should also be reported to Tillotts Pharma UK Ltd.
Tel: 01522 813500.
GASTROENTEROLOGY TODAY - SPRING 2021
References: 1. Kennedy NA et al. Gut 2020; 0: 1–7. 2. Campieri M
et al. Gut 1997; 41(2): 209–214. 3. Lamb CA et al. Gut 2019; 0: 1–106.
4. Entocort ® CR 3 mg capsules – Summary of Product Characteristics.
Date of preparation: July 2020. PU-00377.
11
03437_Ent v Pred Ad_GASTRO TODAY_297x210_AW.indd 1 18/08/2020 12:35
FEATURE
CAPSULE CAPTURES CULPRIT:
DIEULAFOY’S LESION IN THE
SMALL BOWEL
Dr Nisha Patel, Core Medical Trainee, Princess Royal University Hospital, nisha.patel20@nhs.net
Dr Sukhdev Chatu, Consultant Gastroenterologist & Physician, Honorary Senior Clinical Lecturer,
King’s College London, King’s College Hospital NHS Trust. Sukhdev.chatu@nhs.net
Presentation
Case progression and outcome
A 77 year old female presented to our Emergency Department with
a three day history of melaena. She did not report haematemsesis
or abdominal pain. The patient was anticoagulated with
rivaroxaban for atrial fibrillation and was also on aspirin for
secondary prophylaxis of Ischaemic Heart Disease. Her other
past medical history included a Coronary Artery Bypass Graft with
tissue Aortic Valve replacement for Aortic Stenosis, left Carotid
Endarterectomy and Chronic Obstructive Pulmonary Disease. She
was an ex-smoker and abstinent from alcohol.
The patient had been extensively investigated for iron defi ciency
anaemia over a four year period. Oesophago-gastro-duodenospcopy
(OGD) and colonoscopy had previously revealed no abnormalities.
In 2017 a video capsule endoscopy (VCE) demonstrated blood in
the jejunum however a push enteroscopy revealed no cause for the
bleeding. Mesenteric angiogram was unremarkable at the time. A repeat
video capsule endoscopy in May 2018 was normal. Over this time
period; the patient had recurrent admissions for blood transfusions and
was on oral iron supplementation.
The VCE performed within 72 hours showed active bleeding in the
proximal small bowel (fig a). A push enteroscopy was conducted
using a paediatric colonoscope which revealed active bleeding
from a Dieulafoy lesion (fig b). This was cauterised using Argon
Plasma Coagulation (fig c). After 24 hours; rivaroxaban was
initiated again due to a high CHASVAS2 score and the patient
was monitored for any clinical evidence of bleeding or a fall in
haemoglobin. Aspirin was re-started as an out-patient in view of
IHD. She remains well with no further episodes of meleana and
a stable haemoglobin 11 months following discharge on both
rivaroxaban and aspirin.
GASTROENTEROLOGY TODAY - SPRING 2021
On assessment, the patient was haemodynamically stable with mild
epigastric tenderness. A digital rectal examination demonstrated
melaena. Investigations revealed a haemoglobin level of 70g/dL with a
urea of 14 with a normal internal normalised ratio. She was transfused 2
units of packed red cells and we discontinued rivaroxaban and aspirin.
The haemoglobin incremented to 82g/dL.
Management and prognosis
On day two, an OGD revealed multiple tiny 3mm fundic gland polyps in
the stomach. There was no evidence of active or recent upper gastrointestinal
(GI) bleeding. The patient had ongoing melaena on day 3
with a haemoglobin drop from 83g/dL to 74g/dL; a decision was made
to repeat video capsule endoscopy, and if normal, to proceed with an
inpatient colonoscopy. If the patient were to become haemodynamically
unstable, consider CT angiography with view for embolisation.
Figure a- Video Capsule Endoscopy showing jejunal bleeding
Figure a - Video Capsule Endoscopy showing jejunal bleeding
12
Figure a- Video Capsule Endoscopy showing jejunal bleeding
FEATURE
Figure b- Active arterial bleeding in 10’oclock position
Figure b - Active arterial bleeding in 10’oclock position
Figure c- Post APC
Figure c - Post APC
Discussion
We describe a case where an active bleeding lesion was
demonstrated on VCE and subsequently successfully treated with
argon plasma coagulation. Without the VCE, it is almost certain that
this lesion would have been missed. In this case, the bleeding lesion
fi t the criteria for a Dieulafoy lesion as there appeared to be active
arterial spurting from a mucosal defect. [1] An alternative cause for the
obscure- overt GI bleeding we might have considered was Heyde’s
syndrome leading to angiodysplasia and GI blood loss; however
a recent echocardiogram revealed no stenosis of the aortic valve
replacement.
Dieulafoy lesions are believed to account for 1-2% of acute GI
bleeding and are largely under-recognised or missed via endoscopy.
Aspirin and alcohol consumption are known risk factors associated
with Dieulafoy lesions in the upper gastrointestinal tract [2].
This case highlighted the often-challenging dilemma of utilising
anticoagulation and anti-platelets with an unidentifi ed bleeding source.
We believe that this strongly supports the use of video capsule
endoscopy within 72 hours when there is on-going melaena if initial
OGD is negative.
References
1. Baxter M and Aly EH. Dieulafoy’s lesion: current trends in diagnosis
and management. The annals of the Royal College of Surgeons of
England 2010, 92(7): 548-554
2. Shin HJ et al. Risk Factors for Dieulafoy Lesions in the Upper
Gastrointestinal Tract. Clinical Endoscopy 2015, 48(3): 228-233
The European Society of Gastrointestinal Endoscopy (ESGE)
guidelines recommend performance of small-bowel capsule
endoscopy as fi rst-line, before consideration of device-assisted
enteroscopy, when small-bowel evaluation is indicated for obscure
gastrointestinal bleeding. This should ideally be done within a 14 day
period to maximize the diagnostic yield. [3] They also advocate for
VCE prior to second look endoscopy [4]. This has been supported
by a recent Randomised Controlled Trial which demonstrated that a
bleeding source was identifi ed in the early capsule arm compared to
the standard of care [5].
Deploying VCE within 3 days of admission is associated with higher
diagnostic yield and therapeutic intervention rate and a reduced length
of stay. [6]
The patient required both anti-platelets and anticoagulation. These
had been used intermittently over four years as no source for GI
bleeding had been identifi ed.
3. ASGE Standards of Practice Committee, Fisher L, Lee Krinsky M,
et al. The role of endoscopy in the management of obscure GI
bleeding. Gastrointest Endosc 2010;72:471–479
4. Pennazio M et al. Small-bowel capsule endoscopy and deviceassisted
enteroscopy for diagnosis and treatment of small bowel
disorders. European Society of Gastrointestinal Endoscopy (ESGE)
Clinical Guideline. Endoscopy 2015: 47(04): 352-386
5. NB Marya et al. A randomised controlled trial comparing effi cacy
of early video capsule endoscopy with standard of care in
the approach to non- hematemesis GI bleeding (with videos).
Gastrointestinal Endoscopy 2019: 89(1): 33 - 43.e4
6. Singh et al. Timing of video capsule endoscopy relative to overt
obscure GI bleeding: implications from a retrospective study.
Gastrointestinal Endoscopy 2013, 77(5): 761-766
The authors are not aware of any confl icts of interests
GASTROENTEROLOGY TODAY - SPRING 2021
13
FEATURE
RESTORING INTESTINAL BARRIER FUNCTION:
A PROMISING NEW APPROACH FOR
THE TREATMENT OF INFLAMMATORY
GASTROINTESTINAL DISEASES
Dr Daniel Vitt, CEO and President, Daniel.Vitt@imux.com
Jessica Breu, Head of Investor Relations and Communications, Jessica.Breu@imux.com
Immunic Therapeutics, New York and Gräfelfing, Germany
GASTROENTEROLOGY TODAY - SPRING 2021
Inflammatory diseases of the digestive tract include conditions
such as inflammatory bowel disease (IBD), with its two most
common representatives, ulcerative colitis and Crohn’s
disease; irritable bowel syndrome; and celiac disease. The
pathophysiology of these diseases is multifactorial, including
various genetic, environmental, dietary and host-related
factors. 1,2,3 Due to an excessive inflammatory reaction, this
causes tissular injury of the affected organ and triggers a loss of
tolerance to autoantigens and environment antigens.
Over the last decades, researchers have made tremendous progress
in finding new treatment options for inflammatory gastrointestinal (GI)
diseases and a number of treatments are available. 4,5 The challenge 5 ,
however, is that some of these drugs elicit substantial side effects,
have problematic drug-drug-interaction profiles, or either non-response
or loss of response occurs over time. One of the main problems is
that most available therapies with the goal of reducing or eliminating
disease symptoms have comprehensive immunosuppressive effects,
inhibiting or preventing an adequate immune system response. This
not only causes severe adverse reactions but also increases the risk of
infections. In addition, a long-term risk of malignancies is believed to be
associated with anti-TNF drugs, which have become the treatment-ofchoice
for inflammatory GI diseases.
The Role of the Intestinal Barrier
In multicellular organisms, the GI tract is the largest mucosal surface with
a balanced microflora. The mucosal barrier, consisting of a monolayer
of epithelial cells covered at the luminal side by a mucus layer, protects
the body’s internal environment. 6,7 The columnar epithelial cells in this
monolayer are connected through intercellular junctions, serving as a
dynamic, selectively permeable barrier to the luminal contents. On one
hand, it is an effective barrier to prevent harmful pathogens, luminal
antigens, or other pro-inflammatory factors from passing through
this membrane. On the other hand, the mucosal barrier needs to be
permeable for fluids, nutrients, and macromolecules to ensure survival,
growth and development. The barrier is dependent on constant regulation
by many different immunological, cellular, and biochemical factors to
ensure smooth transport and to keep unwanted solutes, microorganisms,
and luminal antigens out of the body. Disruption to this highly regulated
environment can cause several medical conditions or diseases. Injury
to the epithelial lining, caused by such factors as decreased mucosal
defense or exposure to pathogens and chemical therapeutic agents,
plays a role in the development of GI pathology.
Although the GI tract has a remarkable capability to rapidly reseal mucosal
erosions or ulceration, its metabolic profile alters under conditions of
active inflammation. One of the key characteristics is that these diseases
are typically accompanied by mucosal adherent bacteria and the
induction of continuous and overshooting immune responses against
normal commensal gut microbiota. In the literature, 8,9 there are numerous
examples of bowel barrier dysfunction and, as a result, disease-triggering
consequences caused by the interaction of the microbiome and the
immune system. There is growing evidence that defects in intestinal barrier
function and an increase in epithelial barrier permeability, also called “leaky
gut,” plays a pathogenic role in the development of GI diseases such as
celiac disease, IBD or diarrhea-predominant irritable bowel syndrome.
A Promising New Approach: Restoring
Intestinal Barrier Function
Regardless of the trigger for the multifactorial GI diseases, mounting
evidence indicates that the inflammation is influenced by an increased
epithelial permeability. The literature 10 has shown that changes in location or
expression of tight junction proteins that are part of the intercellular junctions
and, importantly, involved in the barrier function, can directly regulate intestinal
permeability. In addition, alteration in the cytoskeleton can indirectly influence
intestinal permeability. Thus, one of the presumed triggers for inflammatory
GI diseases is bacterial penetration through weakened cellular adhesion/tight
junctions, which cause immune overstimulation.
Increased bowel permeability means an impaired bowel barrier
compromised by genetic, environmental and/or other factors, allowing
pathogens to invade and cross the gut wall. The inflammatory
response triggered can cause symptoms including pain, diarrhea,
or the production and exposure of self-antigens that cause chronic
inflammatory and autoimmune reactions. This seems to occur in
diseases such as ulcerative colitis and Crohn’s disease, leading to
structural impairment and more progressive diseases in the GI tract.
Thus, an impaired intestinal barrier function appears to be a central
characteristic of many GI diseases. 9,11,12
14
FEATURE
There are different options to reduce the overall immunosuppressive
nature of current treatments. One option is therapies that are more
selective towards the pathogenic fraction of immune cells only, as
it is the case for targeting overshooting intracellular metabolism in
lymphocytes. A second option is to address one of the putative root
causes of GI diseases, intestinal barrier permeability. Strengthening or
restoring the bowel barrier would compartmentalize the microbiome
and the immune system, thereby reducing disease triggers without
suppressing the immune system. Targeting genes and or proteins
involved in the intestinal epithelial barrier function, such as tight junction
proteins, would also be an interesting and promising new approach.
Conclusion
In the past few years, the scientifi c and research communities have
gained signifi cant knowledge about intestinal permeability and
mechanisms regulating the intestinal barrier function. However,
additional understanding of the interaction between the microbiome
and the immune system is needed. There is currently no treatment
available that targets the small intestine and the interaction between the
bacterial fl ora of the microbiome and the intestinal barrier. So far, most
available treatments for GI diseases aim at reducing disease severity
and prolonging periods of disease-free remission by pharmaceutical
suppression of infl ammation.
The assumptions made in this article suggest a clear need to fi nd
new, more targeted therapeutic options that offer safe treatment of
GI diseases with long-term benefi ts for patients while decreasing
immunosuppression. Promising new approaches are already in clinical
development. Novel therapies could follow the path of targeting bowel
permeability, which addresses a primary disease trigger without the
side effects of traditional long-term immunosuppressive therapy, and
the risk of conversion of non-responders to biologics. Thus, future
research should focus on mechanisms and targets that can prevent
intestinal barrier dysfunction, reduce intestinal permeability, and make
the epithelial barrier less leaky.
References
1. Shouval DS, Rufo PA. The role of environmental factors in the pathogenesis of
infl ammatory bowel diseases: A review. JAMA Pediatr. 2017;171(10):999-1005
2. Ye Y, Pang Z, Chen W, Ju S, Zhou C. The epidemiology and risk factors of
infl ammatory bowel disease. Int J Clin Exp Med 2015;8(12):22529-22542
3. Shepherd SJ, Parker FC, Muir JG, Gibson PR. Dietary Triggers of Abdominal
Symptoms in Patients With Irritable Bowel Syndrome: Randomized Placebo-
Controlled Evidence. Clin Gastroenterol Hepatol. 2008;6(7):765-771
4. Li P, Zheng Y, Chen X. Drugs for Autoimmune Infl ammatory Diseases: From Small
Molecule Compounds to Anti-TNF Biologics. Front Pharmacol. 2017 Jul 12;8:460
5. Park SC, Jeen YT. Anti-integrin therapy for infl ammatory bowel disease. World J
Gastroenterol. 2018;24(17):1868-1880
6. Laukoetter MG, Nava P, Nusrat A. Role of the intestinal barrier in infl ammatory bowel
disease. World J Gastroenterol. 2008; 14:401–7
7. Turner JR. Intestinal mucosal barrier function in health and disease. Nat Rev
Immunol. 2009; 9:799–809
8. Porras M, Martín MT, Yang PC, Jury J, Perdue MH, Vergara P. Correlation between
cyclical epithelial barrier dysfunction and bacterial translocation in the relapses of
intestinal infl ammation. Infl amm Bowel Dis. 2006;12(9):843-852
9. Camilleri M, Madsen K, Spiller R, Greenwood-Van Meerveld B, Verne GN. Intestinal
barrier function in health and gastrointestinal disease. Neurogastroenterol Motil.
2012 Jun; 24(6): 503–512
10. Chelakkot, C, Ghim, J, Ryu, SH. Mechanisms regulating intestinal barrier integrity
and its pathological implications. Exp Mol Med 50, 103 (2018)
11. Chang J, Leong RW, Wasinger VC, Ip M, Yang M, Phan TG. Impaired
Intestinal Permeability Contributes to Ongoing Bowel Symptoms in Patients
With Infl ammatory Bowel Disease and Mucosal Healing. Gastroenterology.
2017;153(3):723-731.e1
12. Piche T et al. Impaired Intestinal barrier integrity in the colon of patients with irritable
bowel syndrome: Involvement of soluble mediators. Gut. 2009;58(2):196-201
WHY NOT WRITE FOR US?
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GASTROENTEROLOGY TODAY - SPRING 2021
15
NEWS
GASTROENTEROLOGY TODAY - SPRING 2021
Routine blood tests could
be key to stopping the silent
killer of liver disease
New research has shown that results of
blood tests routinely performed by GPs
everywhere contain a hidden fingerprint
that can identify people silently developing
potentially fatal liver cirrhosis. The
researchers have developed an algorithm
to detect this fingerprint that could be freely
installed on any clinical computer, making
this a low-cost way for GPs to carry out
large scale screening using patient data
they already hold.
Liver cirrhosis is the second leading disease
causing premature death in working-age
people (after heart disease). It develops
silently and most patients will have no signs
or symptoms until they experience a serious
medical emergency and the fi rst admission is
fatal in one in three patients. Unlike most major
diseases, the mortality rate for liver cirrhosis
continues to increase and is now four times
higher than forty years ago.
In this new study, published in the journal BMJ
Open, a team of researchers developed the
CIRRUS algorithm (CIRRhosis Using Standard
tests) which they then used to analyse
anonymised NHS data on blood test results
taken in primary and secondary care for nearly
600,000 patients.
The algorithm was able to pick up over 70% of
people with cirrhosis, months or years before
they had their fi rst emergency admission with
liver disease. The accuracy rate of the test was
around 90%.
The research was led by Professor Nick
Sheron of the Foundation for Liver Research,
who started the study whilst working at the
University of Southampton. Prof Sheron said:
“More than 80% of liver cirrhosis deaths
are linked to alcohol or obesity, and are
potentially preventable. However, the process
of developing liver cirrhosis is silent and often
completely unsuspected by GPs. In 90%
of these patients, the liver blood test that is
performed is normal, and so liver disease is
often excluded. This new CIRRUS algorithm
can fi nd a fi ngerprint for cirrhosis in the
common blood tests done routinely by GPs.
In most cases the data needed to fi nd these
patients already exists and we could give patients
the information they need to change their lifestyle.
Even at this late stage, if people address the
cause by stopping drinking alcohol or reducing
their weight, the liver can still recover.”
Pamela Healy OBE, Chief Executive of the
British Liver Trust said, “The UK is facing a
liver disease crisis. Three quarters of people
are diagnosed at a late stage when it is often
too late for treatment of intervention yet liver
disease does not get the same attention as
the other major killers such as heart disease
and diabetes. We are delighted to support
this important study that could dramatically
improve early detection rates. The challenge
now is to ensure that early detection is
embedded in NHS practice.”
Co-author Michael Moore, Professor of
Primary Health Care Research at the University
of Southampton added, “Whilst we are all
preoccupied with the coronavirus pandemic
we must not lose sight of other potentially
preventable causes of death and serious
illness. This test using routine blood test data,
gives us the opportunity to pick up serious
liver disease earlier which might prevent future
emergency admission to hospital and serious
ill health.”
If implemented, the research team believe
that the algorithm could be used in two
ways. Firstly, incorporating it within existing
GP systems could fl ag up warnings on an
individual basis as tests are carried out.
Secondly, a scan could be run across all
patient data and those identifi ed as being at
risk would be invited back to the surgery for a
confi rmatory test.
Teresa Hydes from the University of
Southampton who was also part of the
research team added, “This test is free in
many cases as a large proportion of UK adults
will have already had a blood test at some
point which would provide enough data to run
the CIRRUS algorithm.
“The algorithm is freely available to GP
practices or networks to install and therefore
offers a low cost way to identify at risk
individuals without using up limited NHS time
and resources.”
Professor Sheron concluded, “Liver cirrhosis
is a silent killer, the tests used most by GPs
are not picking up the right people, and too
many people are dying preventable deaths.
We looked at half a million anonymous records
and the data we needed to run CIRRUS was
already there in 96% of the people who went
on to have a fi rst liver admission. With just a
small change in the way we handle this data
it should be possible to intervene in time to
prevent many of these unnecessary deaths.”
Coeliac UK and Innovate UK
announce the award from
their 2019 research call
Coeliac UK, the UK charity for people who
need to live gluten free, along with Innovate
UK, the UK’s innovation agency, announces
joint funding of £180K from their 2019
research call, has been awarded to Lyzeum
Ltd.
Despite Covid-19, which has meant many
research projects being put on hold, this
joint funding from 2019 enabled the research
grant winners to commence the project earlier
this year. The funding will assist Cambridge
based Lyzeum Ltd, who is working with a
multi-disciplinary team of mathematicians
and pathologists from both the University of
Cambridge and the University of Edinburgh to
develop an AI (artifi cial intelligence) solution
to help and speed up the diagnosis of coeliac
disease, an autoimmune condition.
Currently in the majority of cases, in order
to diagnose coeliac disease, biopsies are
inspected by a trained pathologist to identify
the damage to intestinal cells which is
characteristic of coeliac disease. A process
which is time consuming and subjective, with
different opinions in up to 25% of cases.
With access to a large database of scanned,
high resolution, microscopic images of small
intestinal biopsies, this funding will allow the
researchers to develop a cloud based, digital
pathology tool to help with the diagnosis of
coeliac disease using an algorithm that can
diagnose biopsies as diseased or normal.
The aim is to substantially improve the speed
and accuracy of biopsy based coeliac disease
diagnosis and potentially automate part of
the process. The research may also provide
important new insights into the microscopic
appearances of coeliac disease and potentially
identify different subtypes of coeliac disease.
16
18 Week Support
Clinical team
Weekend
ENDOSCOPY ALTERNATIVES AT
NHS Facility NHS Staff NHS
processes
A TIME OF COVID
In last Autumn’s edition of Gastroenterology we commenced a short
series of articles looking at how new technologies could replace
endoscopy to achieve quicker and cheaper diagnoses. This is a key
requirement at the present time given the impact of Covid on diagnostic
Criteria & Quality
as well as treatment waiting times. Indeed, the latest NHS England
statistics for December 2020 show that, compared to December 2019,
the diagnostic test type with the largest increase in the proportion of
patients waiting six weeks or more was Endoscopy, with an increase of
38.7 percentage points. New technologies have a clear role to play in
delivering faster and more effi cient diagnoses.
In the Autumn issue our focus was on transnasal endoscopy, a
technology that can be deployed safely and easily in hospital settings,
delivering the early diagnoses needed to drive the best positive
outcomes for gastrointestinal tract diseases while keeping patients
and surgical teams separate from hospital red zones. In this edition we
consider the use of cytosponge for the detection and risk stratifi cation of
Barrett’s oesophagus.
Cytosponge
Clinical guidelines recommend routine referral for endoscopy for
patients with symptoms of gastro-oesophageal refl ux that persist
despite recommended lifestyle and pharmacological treatment, and
those with multiple additional risk factors for the disease. Urgent referral
is recommended for an endoscopy in patients with warning upper
gastrointestinal symptoms, such as dysphagia and weight loss. In those
who are diagnosed with Barrett’s oesophagus, guidelines recommend
Our commitment to improving the
NHS experience
endoscopic surveillance intervals between 6 months and 4 years and
early treatment to avoid the progression to cancer. Current evidence
has shown that treatment of dysplastic Barrett’s oesophagus prevents
progression to adenocarcinoma; however, the optimal diagnostic
strategy for Barrett’s oesophagus is unclear. These indications place a
signifi cant burden on endoscopic services. A new device, Cytosponge ® ,
has been shown to reliably diagnose Barrett’s oesophagus, and also
provide some information on the risk of progression to oesophageal
adenocarcinoma. Studies has shown the device to be safe, acceptable,
accurate, and cost-effective.
Gelatin capsule
Cytosponge ® (Medtronic) is a Class I, CE marked device consisting
of a tethered sponge enclosed in a gelatine capsule. This capsule is
swallowed by the patient while the operator holds the string outside
the patient. Once in the stomach, the gelatine dissolves and the
An ethical company
unfolded sponge is retrieved pulling the string. During passage in the
oesophagus, the sponge collects oesophageal cells. The sample is
then analysed for molecular (i.e. TFF3, P53 abnormality) and cellular
(i.e. glandular atypia) alterations. This procedure is well tolerated, does
not require any sedation and patients can be discharged immediately.
The test can be administered in a clinic room away from endoscopy.
A twenty minutes slot is suffi cient for each patient and up to ten cases
can be performed in a single session by one operator.
A recent randomised controlled study demonstrated that in a General
Practice setting, Cytosponge offered to patients taking acid-suppressant
therapy for symptoms of gastro-oesophageal refl ux, improves the
detection of Barrett’s oesophagus and early cancer when compared
with usual clinical practice (Fitzgerald et al. 2020). Of 1654 participants
who swallowed the Cytosponge successfully, 221 (13%) underwent
Who we’re looking for
endoscopy after testing positive for TFF3 and 131 were diagnosed
with Barrett’s oesophagus or cancer. 4 patients had dysplasia and 5
had early (potentially curable) stage cancer. Although this technique
improves the detection of Barrett’s and cancer, widespread use is
likely to increase the number of endoscopies if used in a Primary Care
setting. Its use in a secondary care setting for symptomatic patients
has not been investigated in a randomised study and thus the impact
on endoscopy referrals is not known. This device may also be useful
to stratify the risk of progression of Barrett’s oesophagus to cancer.
This stratifi cation could individualise surveillance strategies and in turn
reduce direct and indirect procedural risks allowing for prioritisation
of high-risk patients. Low risk patients could have their endoscopic
assessment postponed by 12 months when there will be a relaxation of
the current diagnostic restrictions.
Bibliography
About you
Happy patient
Fitzgerald, R.C., di Pietro, M., O’Donovan, M., et al. 2020. Cytospongetrefoil
factor 3 versus usual care to identify Barrett’s oesophagus in a
primary care setting: a multicentre, pragmatic, randomised controlled
trial. The Lancet 396(10247), pp. 333–344.
If you have an excellent NHS record and want to help clear waiting
list backlogs, reduce RTT waiting times and provide high-quality
patient care, get in touch by calling on 0203 869 8790 or email us
at Recruitment.team@18weeksupport.com
Alternatively if you are procurer of 18 Week Support services,
please contact busdev@18weeksupport.com
18 Week Support
www.18weeksupport.com
Dr Matthew Banks Banks
Clinical Lead for Gastroenterology
18 Week Support
London 3rd Floor, 19-21 Great Tower Street, London EC3R 5AR
Birmingham Unit 25, Lichfield Business Village, The Friary WS13 6QG
SPRING 2019
17
NEWS
Hilary Croft, CEO of Coeliac UK said: “This
new research is a tremendous step forward
to potentially help speed up one element of
the diagnosis journey, reduce subjectivity
and improve accuracy. Pioneering research
is essential to aid in developing new
testing methods and we are thrilled to have
combined forces with Innovate UK once
again to advance our knowledge and support
innovation that can improve the lives of people
with coeliac disease.”
Richard Hebdon, Head of Health and Medicine
at Innovate UK, said: “Innovate UK has long
supported businesses innovating in the areas
of healthcare diagnostics and nutrition, helping
to translate the UK’s world class research
into commercially available solutions. This
new research will not only help improve, but
also speed up diagnoses of one of the most
undiagnosed chronic conditions in the UK.”
In early 2019, three projects based in
Birmingham, Newcastle and Edinburgh, were
awarded Coeliac UK / Innovate UK grants
from the fi rst joint research call held in 2018.
Including the contribution from industry, a total
£750k was committed to research:
• A new test to provide a less invasive way of
diagnosing coeliac disease that may not rely
on someone having to eat ongoing amounts
of gluten if they have already adopted a
gluten free diet.
• Development of three new plant proteins
derived from crops, which are underused
in the UK: rapeseed cake, faba beans and
naked oats, to help improve the ingredients
used in gluten free bread. At the beginning
of the year, Nandi Proteins Ltd and the
team welcomed Finsbury Food Group –
Ultrapharm to the project, as one of the
industrial end users.
• Software innovation to help in the ongoing
management of coeliac disease, so that
those who need additional care receive
access to crucial support when they need
it and those living well can receive the
assurance of being clinically followed up
without the inconvenience, time and cost of
hospital appointments.
About Coeliac UK
Coeliac UK campaigns for better access to
diagnosis of coeliac disease and funds critical
research into potential cures. It provides
expert and independent information to 65,000
members and the wider gluten free community
to manage their health and gluten free diet.
The charity also fi ghts for wider availability
of gluten free food by working with food
manufacturers, service providers and venues.
Currently 3,000 products and 200 companies
use the charity’s Crossed Grain certifi cation
scheme and over 3,200 food outlets, cafés
and restaurants have achieved its Gluten Free
accreditation.
About Innovate UK
Innovate UK is part of UK Research and
Innovation, a non-departmental public
body funded by a grant-in-aid from the UK
government. For more information visit
www.ukri.org.
Innovate UK drives productivity and economic
growth by supporting businesses to develop
and realise the potential of new ideas,
including those from the UK’s world-class
research base.
We connect businesses to the partners,
customers and investors that can help them
turn ideas into commercially successful
products and services and business growth.
POSTER SUBMISSIONS
GASTROENTEROLOGY TODAY - SPRING 2021
If you have submitted a poster to previous BSG or
ENDOLIVE events and would like it published in
Gastroenterology Today please forward a PDF of your
poster to the email address listed below.
Material submitted will be seen by those working within all
UK gastroenterology departments and endoscopy units.
All submissions should be forwarded to info@mediapublishingcompany.com
If you have any queries please contact the publisher Terry Gardner via:
info@mediapublishingcompany.com
18
NEWS
GASTROENTEROLOGY TODAY - SPRING 2021
19
NEWS
GASTROENTEROLOGY TODAY - SPRING 2021
Study reveals over 50%
more people in Wales have
Crohn’s or Colitis
• New research has revealed that 23,000
people in Wales (around 1 in 117 people)
have Crohn’s or Colitis, the two main forms
of Inflammatory Bowel Disease (IBD).
• This data shows there is a large, hidden
cohort with Crohn’s or Colitis for whom
Health Boards in Wales are currently not
planning as they are unaware they exist.
• Crohn’s & Colitis UK are calling for Health
Boards to review their current IBD services
to ensure these meet the needs of everyone
with Crohn’s and Colitis.
Crohn’s & Colitis UK announce findings
from a study showing the scale of Crohn’s
and Colitis in Wales. Undertaken by the
Secure Anonymised Information Linkage
(SAIL) Database in Swansea and funded
by Crohn’s & Colitis UK, the research
looked at the numbers of people diagnosed
with Crohn’s and Colitis recorded in GP
Practices across Wales from 2008-2017. 1
Until now, there was limited reliable data to
help understand how many people in Wales
are affected by the conditions. Previous
estimates suggested around 15,000 in the
nation and 300,000 across the UK.
This study highlights the number of people
living in Wales with these debilitating and
misunderstood conditions if far greater than
thought, approaching 1% of the population.
It contributes to growing evidence that over
500,000 people across the UK now have
Crohn’s or Colitis. 2
Crohn’s and Colitis cause ulcers and
inflammation in the gut and there is no cure.
Symptoms include the urgent and frequent
need to poo (often with blood), extreme fatigue
and severe pain. The conditions can impact
nearly every part of the body, leading to a
lifetime of medication and, in many cases, lifealtering
surgery. They also impact many areas
of life, including mental health and personal
relationships.
Crohn’s & Colitis UK is highlighting this hidden
group of people, calling for Health Boards to
re-examine their current IBD service structures.
They must be reconfigured to meet the needs
of far more people than previously understood,
through support in the community, more
IBD nurse specialists and the smarter use of
remote monitoring and access technology.
Wayne Lewis, Policy Lead (Wales) at Crohn’s
& Colitis UK, says; “In a 2019 survey of IBD
services in Wales, most Welsh Health Boards
reported using the previous estimate of 1
person in every 250 when planning services for
people who have Crohn’s or Colitis. But these
new primary care figures show the number of
people diagnosed with the conditions is nearly
double that. We know that even more people
are suffering in silence, undiagnosed, due
to lack of awareness, difficulties in getting a
diagnosis, and the taboo symptoms.”
The research noted that the number of
people diagnosed with Crohn’s and Colitis
is increasing in almost every age group
but particularly in the 18-29 age group.
This is a difficult age to be diagnosed as
people explore personal relationships and
independence, and identity.
Nick Yates, 63-years old, lives with Crohn’s;
“Crohn’s on its own can be life limiting and
challenging. I struggle daily with feelings of
fatigue and waves of tiredness. I’m nervous
to be far from a toilet in case of an accident.
My IBD Nurses, my Gastroenterologist and
my Haematologist have all been great,
as have Medical Day Unit staff and my
local GP. I am aware that this excellent
support network, spanning both primary
and secondary care, is not a common
experience.”
Dr Barney Hawthorne, Consultant
Gastroenterologist and Clinical Lead on
IBD for Wales says; “We know very little
about people with Crohn’s and Colitis who
don’t attend clinics regularly and we don’t
know how symptomatic they are. It makes
it difficult to assess their impact on NHS
services. This ‘hidden’ group are there,
and many will be having prescriptions and
using other health resources. Now we have
a better understanding of the numbers, it
would be worthwhile for further studies to
assess whether there are unmet needs in
these patients, and the impact of their IBD
on quality of life.”
www.crohnsandcolitis.org.uk
References
1. One of the core datasets held in SAIL is
the Welsh Longitudinal General Practice
(WLGP) dataset which includes records
held 79% of GP practices in Wales.
This includes records for diagnoses,
observations, symptoms, referrals and
prescriptions. SAIL also includes records
of all individuals who at some point have
been registered with a GP in Wales.
Researchers used this data, looking
at over 3 million records, identifying
cases with a confirmed code for Crohn’s
Disease, Ulcerative Colitis, or other forms
of IBD which include Indeterminate Colitis
and Microscopic Colitis.
2. Research in parts of the UK strongly
suggest that 500,000 people in the UK
have Crohn’s or Colitis. A UK-wide study
we co-funded is due to report on the full
picture in May 2021.
How to make a business
case for better bowel care
Dr Benjamin Disney, Consultant
Gastroenterologist, University Hospitals
Coventry and Warwickshire NHS Trust
Recent issues of Gastroenterology Today
covered the prevalence of chronic constipation
in the UK, and the financial impact of this on
the NHS. The Bowel Interest Group’s Cost of
Constipation report found that in 2018–2019,
constipation cost NHS England £168 million.
Easing some of this burden on healthcare
services requires action in both primary
and secondary care, to reduce the delay in
treatment and to strengthen understanding
of constipation management. However, at
the BIG, we’re aware that wider improvement
of services has financial implications for
healthcare establishments.
Readers of this publication may recognise
the need for improved bowel care, but
may not know where to start with making
a business case for investment in better
services. Healthcare professionals working
in bowel, colorectal, gastroenterology, and
neurology services, or in A&E, are best placed
to recognise areas where improvement can
be made. Equipped with greater guidance
on how to petition payers, they can help to
provide better care for patients with chronic
constipation, and ultimately improve their
20
NEWS
quality of life. In this article, to support
healthcare professionals with this endeavour,
we’ll walk through key factors which they must
consider to be able to put together a sound
business case.
Who else is involved?
It’s likely that you will need additional support
during pitches and planning, so begin by
reaching out to other stakeholders. Securing
support from other departments and teams will
not only help to progress your business case,
but will also assist successful implementation
in the long-term. It may be benefi cial to lead
with Clinical Leads (Consultant), Clinical
Implementors (Nursing/Physio), Business
Managers, Directorate Managers, Finance
Managers, and where extra space is required,
the Estates department. Consider who may
be impacted by the proposed changes
and ensure clear communication from the
beginning. Most importantly, consider who will
be paying for the changes; don’t assume that
your employer will fi nance them.
How will you measure financial impact?
You cannot leave it to the payer to determine
the fi nancial impact of your proposal. Your
costing must be as thorough and accurate as
possible. Rather than attempting to achieve
this independently, work with business
and fi nance teams to ensure all bases are
covered. Firstly, how much investment is
needed to achieve your objectives? Once this
investment is made, which metrics can you
provide to demonstrate the positive impact
of this investment? Secondly, consider that
the proposal is more likely to gain traction
if you can demonstrate how it can be made
self-paying, by reducing the overall, long-term
treatment costs of patients with chronic bowel
dysfunction. Lastly, provide multiple options;
if the full investment cannot be secured, what
could be achieved with part of the investment?
Compare the benefi ts and costs of each
option, including the outcomes of making no
changes at all.
How will the solution be implemented?
Demonstrate that you have assessed the
wider impact of the proposed solution on
relevant departments, as well as the overall
organisation; implementation should not
increase the burden on staff or patients.
Moreover, the solution may be poorly
received if there is a negative impact on
any department or organisation’s KPIs.
Provide realistic estimates of timescales, the
resources required, and training needs. You
cannot assume that the solution will have an
immediate impact, so clarify how long it may
take before it will be running at full capacity,
to avoid over-expectations from investors.
Identify all potential implementation risks and
how these will be mitigated. For instance, how
would you address recruitment delays? Explain
the risks of not implementing the solution too;
what would be the cost to the organisation if
the problem is not dealt with proactively?
What are your recommendations?
Once you have carried out the necessary
research and compiled a business case,
conclude by recommending the best course
of action. Explain in concise terms which
option you would select and why. Avoid
ambiguity or making subjective claims;
instead, provide a clear, fact-based overview
of the measurable outcomes this option
would deliver, and the resources required. If
you are able to demonstrate in your business
case that you have assessed your proposal
comprehensively and in partnership with
other important stakeholders, this fi nal
recommendation will be a weighty conclusion
that is likely to be taken seriously by your
potential investors.
Find the Bowel Interest Group’s how-to guide
on making a business case here: https://
bowelinterestgroup.co.uk/resources/
business-cases-for-better-bowel-care-ahow-to-guide/
WHY NOT WRITE FOR US?
Gastroenterology Today welcomes the submission of
clinical papers and case reports or news that
you feel will be of interest to your colleagues.
Material submitted will be seen by those working within all
UK gastroenterology departments and endoscopy units.
All submissions should be forwarded to info@mediapublishingcompany.com
If you have any queries please contact the publisher Terry Gardner via:
info@mediapublishingcompany.com
GASTROENTEROLOGY TODAY - SPRING 2021
21
COMPANY NEWS
CRYOCHECK LUPUS ANTI-COAGULANT TESTING
SOLUTIONS FOR EVERY STAGE OF THE TESTING PATHWAY
For laboratories wishing to perform accurate testing for Lupus
Anti-Coagulant (LA), the cryocheck frozen controls and
reagents provide solutions to fit every stage of the pathway -
screen, mix, confirm and quality control.
Available in the UK exclusively from Alpha Laboratories, these products,
developed by Precision BioLogic, offer validated protocols. The range
of fresh frozen plasmas are designed for ease of use and to minimise
reagent waste. Elimination of reconstitution errors improves your
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offering faster more accurate results for your patients.
Recent additions to the range include cryocheck Lupus Negative
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Please visit www.alphalabs.co.uk/lupus-anticoagulant to find out
more about the extensive range of products that can be used to detect
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0800 38 77 32 or email marketing@alphalabs.co.uk
MANAGE WASTE MEDICINES & ENSURE COMPLIANCE
CONTROLLED DRUG DENATURE KITS
Now available from Alpha Laboratories is the Safer Options
range of Controlled Drug Denature Kits which can help you
safely manage waste medicines and comply with legislation
more easily and effectively.
Manufactured in the UK, these denature kits are simple and easy to
use. Waste medicines – tablets, liquids, patches etc. are placed in the
jar with the water-soluble sachet of denaturing formula. Water is then
added to the designated level and the jar closed and shaken to mix the
denaturing formula with the water and controlled drugs.
The denaturing formula congeals and denatures the drugs in a couple
of minutes and the kit can then be placed in a secure pharmaceutical
waste container prior to incineration. The denaturing formula has a bitter
taste as an additional deterrent and is contained in a sachet to protect
against spillage. Full instructions appear on every container so there is
no pack insert to get lost, especially when splitting up multipacks for use
in separate locations.
Under the Misuse of Drugs Regulations (2001) obsolete controlled
drugs (CDs) must be destroyed by being denatured and rendered
irretrievable before being placed into pharmaceutical waste containers.
These new controlled drugs denature kits are an innovative and unique
solution helping hospitals, pharmacies, hospices, care homes and other
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The kits are available in six container volumes and a range of pack sizes
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Please visit www.alphalabs.co.uk/denaturekits for further information
or contact Alpha Laboratories on 0800 38 77 32 or email
marketing@alphalabs.co.uk
SIMPLE IMAGING WITH RESULTS YOU CAN TRUST
GASTROENTEROLOGY TODAY - SPRING 2021
Now available from Alpha Laboratories, the new gelLITE gel
documentation system is a compact and convenient system for
documentation of agarose gels and stained protein gels.
A 302nm UV transilluminator enables imaging of large format agarose
gels or stained protein gels up to 20 x 20 cm, and can slide out from the
main body of the system allowing gel extraction of DNA fragments.
The gelLITE gel documentation system provides complete control with its
manually controlled camera zoom and focus. The 5 Megapixel camera also
gives excellent low light sensitivity for clear resolution of closely spaced
DNA bands and ensures even low levels of fluorescence are detected.
Included free of charge is the intuitive genePIX acquisition software
which enables a fast and efficient workflow. Additionally, the
geneQUANT analysis software features automated lane and
band detection, and pre-loaded DNA ladder standards for simple
quantification and automated report creation.
Optional converters are also available - blue light converters for safe
DNA extraction and reduced DNA damage, and white light converters
for enhanced contrast of visible protein stains.
The gelLITE gel documentation system offers an economic and effective
solution for agarose gel imaging, perfect in a GLP environment.
Please visit www.alphalabs.co.uk/gel-documentation for further
information or contact Alpha Laboratories on 0800 38 77 32 or email
marketing@alphalabs.co.uk
22
A Huge Thank You to The NHS COMPANY from NEWS the
Gastroenterology Today Junior Team
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GASTROENTEROLOGY TODAY - SPRING 2021
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23
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