Gastroenterology Today - Spring 2021


Gastroenterology Today - Spring 2021

Volume 31 No. 1

Spring 2021

Gastroenterology Today

What approach has 18 Week Support

taken with regards to building an

expert insourcing team?

Matthew’s Perspective:

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.

‘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

18 Week Support Gastroenterology:

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high-quality patient care, get in touch by calling on 020 3892 6162 or email

Dr Matthew Banks

Clinical Lead for Gastroenterology

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Gastroenterology Today


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



This issue edited by:

What approach has 18 Week Support

Dr Andrew Poullis

c/o Media Publishing Company

taken with regards to


building an


Upper Sapey, Worcester, WR6 6XR

expert insourcing team?

Matthew’s Perspective:


Media Publishing Company

Greenoaks, Lockhill

Upper Sapey, Worcester, WR6 6XR

Tel: 01886 853715


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.


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.


‘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.


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

views and opinions expressed in

this issue are not necessarily those of

the Publisher, the Editors or Media

Publishing Company.

Next Issue Summer 2021


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


Subscription Information – Spring 2021

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“The amazing

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will be one

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the size of

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ahead is



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








Xing-Bin Ma 1† , Bao-Guang Hu 2† , Wei Wang 1 , Xian-Yong Cheng 1 , Chun-Di Guan 1 and Cheng-Xia Liu 1*




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.


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.


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.


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).




Xing-Bin Ma and Bao-Guang Hu contributed equally to this work.


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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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.




Fig. 2 CT scan demonstrating yellow circle indicates the abrupt narrowing zone of the jejunum (a; cross-sectional image, b; coronal image)



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



Fig. 4 a-b. Gross image depicting the Stenosis and extremely dilated small bowel (arrow, star)







Fig. 5 a-b. Histopathological findings. Ulcers were observed and inflammatory cells and fibroblasts infiltrated to the whole layers (a × 20, b × 100)



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


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.


SBO: small bowel obstruction; CT: Computed tomography; Kg: kilogram


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.



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


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


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intestinal injuries due to seat belt without seat belt sign. J Surg Case Rep.


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.


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

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Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in

published maps and institutional affiliations.


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Date of preparation: July 2020. PU-00377.


03437_Ent v Pred Ad_GASTRO TODAY_297x210_AW.indd 1 18/08/2020 12:35





Dr Nisha Patel, Core Medical Trainee, Princess Royal University Hospital,

Dr Sukhdev Chatu, Consultant Gastroenterologist & Physician, Honorary Senior Clinical Lecturer,

King’s College London, King’s College Hospital NHS Trust.


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.


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


Figure a- Video Capsule Endoscopy showing jejunal bleeding


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


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


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.


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








Dr Daniel Vitt, CEO and President,

Jessica Breu, Head of Investor Relations and Communications,

Immunic Therapeutics, New York and Gräfelfing, Germany


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



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.


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.


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.


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


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

If you have any queries please contact the publisher Terry Gardner via:





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


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.


18 Week Support

Clinical team



NHS Facility NHS Staff NHS



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.


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.


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


Alternatively if you are procurer of 18 Week Support services,

please contact

18 Week Support

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




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


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

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.



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

If you have any queries please contact the publisher Terry Gardner via:







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


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


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.”


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



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://



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

If you have any queries please contact the publisher Terry Gardner via:






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