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Mistakes in refractory coeliac disease and how to avoid them
Assessing adherence to a GFD and the initial coeliac disease diagnosis are important
Refractory coeliac disease (RCD) is characterized by the persistence or recurrence of symptoms and signs of malabsorption associated with villous atrophy in patients with coeliac disease who have adhered to a strict gluten-free diet (GFD) for more than 12 months.1–3 Serology is usually negative or, in a small percentage of cases, positive at a low titre.4 Splenic hypofunction, a risk factor for RCD, can be indicated by Howell–Jolly bodies and pitted red cells in a peripheral blood smear. A reduced spleen size visible on ultrasound examination also provides direct evidence of hyposplenism.5
From clinical fellow to clinical lecturer – how to secure a post
Neel Sharma of the University of Birmingham shares his tips.
Post undertaking a research fellowship, the decision to remain as a clinician academic is the first one to take. If motivated and passionate enough it is a no brainer. However entering the next stage of training from fellow to lecturer is no easy feat; limited funding and posts. That in itself is a true test of your commitment.
Dr Neel Sharma, GI Registrar and Clinical Lecturer at the Institute of Immunology and Immunotherapy and Institute of Translational Medicine, University of Birmingham shares his tips that may prove useful for those hoping to secure a post.
- Reach out to potential supervisors before submitting your application. It is advisable to show interest early on. Sending out an email and arranging an informal meeting helps to demonstrate your background thus far, your research progression during your fellowship and more importantly your understanding of the field. Supervisors are keen to know how well you recognise the current gaps in the evidence and how you may choose to solve them. Of course there is no one solution but the exchange of thinking is a fundamental element in academia. By meeting potential supervisors they can gauge how well you would fit their lab or research interests and if not which other supervisors may be better suited to you.
- The application form. The application process is fairly straight forward, highlighting your degrees thus far, prizes, publications and presentations. Where you will be able to set yourself apart is highlighting your long-term plan and what you can bring to the department in terms of your skillset. And here there is no right or wrong. Collaboration is key for any successful researcher. You must demonstrate an awareness of such and potential collaborations thus far is crucial. It is now overtly outdated to think that one centre can achieve academic success without reliance on other institutions. There is now no single expert. Have you taken steps to develop a network early on? Are you culturally aware? Ensuring diversity in your research network with a willingness to embrace expertise both East and West will set you apart from the rest.
- The interview. And last but by no means least the interview. Interviews are never plain sailing. You may have to face several. But your approach should be consistent each time. It is highly likely that you will be asked to analyse a research study. This will help to highlight to panel members your ability to condense a paper in to its main findings and of more importance its potential flaws. Gain an understanding of trial methodology and data analysis, most of which you will be familiar with post fellowship but there may be some methods or stats you may not be aware of. You will be asked about your research vision and so be concrete in your beliefs. Even if some panel members disagree stick to what you believe. And what you want to add to the field, even if widely different to the panel. Remember you are not here to solve all the research gaps but to add to the understanding of the discipline over your career. Demonstrate to the interviewers your motivation and even if criticised remember the criticisms are designed simply to ensure what you aim to contribute will be more rigorous and more translatable in the future.
Achalasia: Physician versus Surgeon
Two European experts give their opposing views on the best treatment option for achalasia
Oesophageal achalasia is a rare motility disorder, in which peristalsis is impaired or absent and the lower oesophageal sphincter fails to relax. Symptoms of achalasia include dysphagia, regurgitation of undigested food, coughing and choking, chest pain and chest infections.
We invited two European experts to give their opposing viewpoints—physician versus surgeon—on the best treatment option for achalasia.
A Physician's Viewpoint—Paul FockensAlthough the title of this blog quickly attracted your attention, it is actually not a choice between physician and surgeon but a choice between peroral endoscopic myotomy (POEM) and laparoscopic Heller myotomy (LHM). From a patient's point of view, the natural orifice approach will be preferred as it diminishes complications and reduces recovery time. But are both treatments equal in their efficacy and safety profile? There are many studies that suggest the efficacy of both POEM and LHM is excellent, but POEM has not been around very long so less evidence is available. Two large randomized controlled trials presented in abstract form and awaiting full publication both demonstrate the high efficacy of POEM, which seems equal to LHM and superior to a set of two pneumatic dilations. But how about safety? POEM is significantly less invasive, and thereby safer, than LHM; complications are very rare and usually mild. Therefore, with comparable efficacy and improved safety when compared with LHM, POEM seems to have a bright future. Is there any disadvantage to POEM? Yes, there is one issue and that is reflux. POEM can currently not be combined with an endoscopic antireflux procedure, so a significant percentage of patients will have to use proton pump inhibitors after POEM. It is up to the patient, after care has been taken to inform them about all available treatment options, to come to a shared decision with their doctor. Without a doubt in my mind, I believe POEM will frequently be the patient's favourite choice! References
- Ponds FA, et al. Peroral endoscopic myotomy (POEM) versus pneumatic dilatation in therapy-naive patients with achalasia: results of a randomized controlled trial [abstract 637]. Gastroenterology 2017; 152 (suppl 1): S139.
- Werner YB, et al. Endoscopic versus surgical myotomy in patients with primary idiopathic achalasia [abstract LB08]. United European Gastroenterology Journal 2018; 6: 1590.
A Surgeon's Viewpoint—Giovanni ZaninottoSurgical treatment of oesophageal achalasia divides the muscle fibresof the distal oesophagus and cardia, leaving the underlying mucosa intact. Consequently, resistance of the lower oesophageal sphincter to the flow of the bolus is diminished. Heller myotomy, named for the German surgeon who performed it first (in 1913), has been completed laparoscopically (LHM) since 1990, with a partial wrap of the fundus added to prevent iatrogenic gastro-oesophageal reflux disease (GORD). LHM has gained vast popularity because of its efficacy in reducing dysphagia (89% and 85% of patients are asymptomatic at 5 and 10 years, respectively) while maintaining a very good safety profile (mortality <0.1%, morbidity <7%). Postoperative reflux is observed in 10–20% of patients when a partial fundoplication is added to LHM. Three randomized controltrials and three meta-analyses have compared the efficacy of LHM with that of pneumatic dilation, revealing that pneumatic dilation can achieve the same efficacy as LHM only after multiple, sequential dilations. Moreover, LHM is more effective than pneumatic dilation for treatment of type III spastic achalasia. There are no randomized control trials published in full that compare LHM with POEM, though two meta-analyses show that POEM achieves slightly (but significantly) better symptomatic control than LHM, especially for type III achalasia. However, the duration of the patient follow-up was shorter for POEM, and POEM presented a higher risk of postoperative reflux (20–40%). I believe five small abdominal scars are preferable to an increased risk of GORD, and that LHM remains the 'single-shot' better option for achalasia patients. References
- Boeckxstaens G, Zaninotto G and Richter JE. Achalasia. Lancet 2013; 383: 83–93.
- Zaninotto G, et al. The 2018 ISDE achalasia guidelines. Dis Esoph 2018; 9: 1–31.
Dealing with nutrition, diet, microbiota and IBS
Nutrition expert Heidi Staudacher speaks about advances in IBS research.
Heidi Staudacher is a research dietician at the University of Queensland in Australia.With Rune Stensvold from the UEG E-learning Team, she speaks about advances in IBS research and how it can be used to help IBS patients. Have also a look at Heidi Staudacher's presentation "The low FODMAP diet: Selecting the right candidate" at UEG Week Vienna 2018
UEG Image Hub
A new source of GI images online, freely available to download.
As an editor I’m clearly a big fan of words, but I’m also a big fan of images and the way they can add value and visual interest. As part of our work, the UEG E-learning Team is always thinking about how best to illustrate our content, be it on online courses (and their summary infographics), “Mistakes in…” articles or our latest news blogs. Although we necessarily do use third-party figures or photos, as often as possible we work with our art editor and authors to develop original images, such as the few shared here in this blog.
Mistakes in the management of carbohydrate intolerance and how to avoid them
Carbohydrates not absorbed in the small intestine are fermented by colonic bacteria to organic acids and gases1 (e.g. carbon dioxide, hydrogen and methane), part of which is absorbed in the colon, the other part remaining in the lumen.2,3 Large interindividual differences have been demonstrated for the production of such acids and gas.4,5 Carbohydrate malabsorption can be diagnosed by using the hydrogen breath test, because the gases produced after administration of a provocative dose of carbohydrate are unique products of bacterial carbohydrate fermentation.6,7
A rare biopsy finding with many possible causes
What's causing epigastric abdominal pain and nausea in this 55-year-old man?
A 55-year-old man was referred to our general gastroenterology clinic by colleagues from the renal transplant unit for evaluation of persistent epigastric abdominal pain and nausea that had been present for the past 6 months and had started to interfere with his quality of life.The patient’s past medical history included allogeneic renal transplantation 3 years prior, secondary to progressive hypertensive kidney disease. His current immunosuppression regimen was mycophenolate mofetil, cyclosporine, everolimus and steroids, while his hypertension was being controlled with nebivolol. The only other drug taken on a regular basis was oral iron supplementation to manage mild hypochromic anaemia. His symptoms had failed to resolve with a proton pump inhibitor (PPI) trial administered by a gastroenterologist in private practice. He had also undergone noninvasive testing (urea breath test) for the presence of Helicobacter pyloriinfection, with the result being negative. He denied weight loss, vomiting, changes in bowel habit, fever or any other accompanying symptoms in the same time period as his main complaints. No significant information was elicited from his family or regarding his social history (including travels and sexual behaviour). Physical examination findings were unremarkable. The patient had recently undergone blood tests that revealed no significant changes from his previous baseline values. In view of the above symptoms and history an upper gastrointestinal endoscopy was scheduled and performed. The endoscopic findings included erythema with small erosions of the gastric mucosa. Multiple biopsy samples were obtained from areas with findings and also from macroscopically normal mucosa. Histological findings are shown in figure 1. Figure 1 | Histological findings in the stomach of the case patient. Haematoxylin and eosin (H&E) staining. Magnification x400.
Case Question 1WHAT IS THE HISTOLOGICAL DIAGNOSIS? A. MALT lymphoma B. H. pylori-associated chronic gastritis C. Granulomatous gastritis D. Gastric adenocarcinoma E. Collagenous gastritis
Case Question 2IN VIEW OF THE PAST HISTORY OF THIS PATIENT, WHAT WAS THE UNDERLYING CAUSE OF THE SYMPTOMS OBSERVED? A. Sarcoidosis B. Granulomatosis with polyangiitis C. Crohn’s disease D. Tuberculosis E. Histoplasmosis F. A drug-induced reaction G. Helicobacter pyloriinfection H. Whipple’s disease
Case Question 3HOW SHOULD WE PROCEED REGARDING THE MANAGEMENT OF THIS PATIENT? A. Acid suppression with PPIs B. Investigate other possible causes C. Stop iron supplementation and take repeat biopsy samples D. Stop iron supplementation and investigate other possible causes
Apply for a UEG Activity Grant to produce an online course
Developing an online course is not as complicated as you may think.
Mistakes in enteral stenting and how to avoid them
Indications include stenosis (oesophageal and colonic) and gastric outlet obstruction
Gastrointestinal stent placement was introduced at the end of the nineteenth century when it was performed in patients who had a malignant oesophageal obstruction.1 Nowadays, gastrointestinal stents are placed for multiple indications, such as oesophageal stenosis (Figure 1), gastric outlet obstruction (Figure 2) and colonic stenosis (Figure 3).
Tough but doable
8 Tips for passing the European Specialty Examination in Gastroenterology and Hepatology
Anthea Pisani is a gastroenterology trainee in Mater Dei Hospital in Malta. She passed the European Specialty Examination in Gastroenterology and Hepatology in April 2018 and gave a talk about “Tough but doable: A personal view on the exam” in the Young GI Lounge at the subsequent UEG Week in Vienna. Her presentation was very much appreciated, so we asked Anthea to share her top tips for passing the exam in the GI Hive.
So, you have decided to sit for the European Specialty Examination in Gastroenterology and Hepatology. Perhaps this was a voluntary decision on your behalf in order to broaden your horizons, or it may be a mandatory aspect of your training. It may be your first attempt or maybe a re-attempt and you might be at the beginning of your training or at the end of it. Either way, good luck with your preparations. Here are some points to help guide you towards becoming a European board certified Gastroenterologist.
Learn about Autoimmune Pancreatitis
From bench to the UEG floor
A personal experience from an young gastroenterologist from Egypt and how UEG helped him to achieve his goals.
Mohammed Khorshid, a young gastroenterologist, tells us his personal success story of being invited to give an oral presentation at UEG Week.
The London Neurogastroenterology Course
Learn about pathophysiology and evidence-based treatment of functional GI disorders
13th EDS Postgraduate Course
EDS aims to support young surgeons and gastroenterologists during their residency training.
UEG Classroom Courses
These educational events are perfect opportunities to increase your GI knowledge.