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Alcohol Awareness Month
April is the perfect time to discuss UEG’s actions on alcoholic liver disease.
Last October, on the occasion of UEG Week 2017, we had a chance to sit and talk with Professor Helena Cortez-Pinto, a member of UEG’s Public Affairs Committee and author of the UEG Education article “Mistakes in alcoholic liver disease and how to avoid them.” Now, in the middle of Alcohol Awareness Month, we highlight the main points of our discussion and make the video of the interview available.During our interview, Helena conveyed the importance of several aspects related to state-of-the-art treatment for patients with alcoholic liver disease (ALD), such as the necessary involvement of multidisciplinary teams to deal with both the physical and psychological sides of the disease. She also touched on the specificities of performing a liver biopsy in ALD patients, as well as some of the alcohol-related issues the UEG Public Affairs Committee is trying to get onto the EU health agenda.
The current, evident disparity between ALD research and its burden, when compared with other liver diseases, was a key point mentioned by Helena during the interview. Supporting this point is evidence from Ramon Bataller and co-authors, who developed an Attention-to-Burden Index (ABI), comparing research activities during 2010–2014 with an estimate of disease burden for the four major liver diseases, namely hepatitis B and C, ALD and nonalcoholic fatty liver disease.1 Surprisingly (or not), they found that the mean research attention for ALD was only 5%, when its overall burden was 50%, highlighting the critical need to increase awareness of ALD in the liver research community. This need was also pointed out by Helena during her interview and is something she is working to convey to Members of the European Parliament, Representatives of the European Commission and Council, as well as other EU stakeholders, as part of her work on UEG’s Public Affairs Committee, which is chaired by Markus Peck-Radosavljevic.
In a related matter, earlier this year the “Alcohol and Digestive Cancers: Time for Change” report was published by UEG EU Affairs, highlighting the alarming scale of alcohol consumption across Europe and its direct and indirect impact on digestive cancers.
More information on the work of the UEG Public Affairs Committee can be found online, along with a copy of the “Mistakes in alcoholic liver disease and how to avoid them” article from Helena and co-author Pedro Marques da Costa and other articles in the “Mistakes in…” series.
We hope you enjoy the interview! Please be sure to let us know what you think, if there are any other issues we should be considering and if there’s anyone else you would like to see us interview in future. References
- Ndugga N, et al. Disparities between research attention and burden in liver diseases: implications on uneven advances in pharmacological therapies in Europe and the USA. BMJ Open 2017; 7: e013620.
- Singal AK, et al. ACG Clinical Guideline: Alcoholic Liver Disease. Am J Gastroenterol 2018; 113: 175–194.
- Marcellin P and Kutala BK. Liver diseases: A major, neglected global public health problem requiring urgent actions and large-scale screening. Liver Int 2018; 38 (Suppl 1): 2–6.
- Spence AD, et al. Communication of alcohol and smoking lifestyle advice to the gastroenterological patient. Best Pract Res Clin Gastroenterol 2017; 31: 597–604.
- Campbell EJ, Lawrence AJ and Perry CJ. New steps for treating alcohol use disorder. Psychopharmacology Epub ahead of print 25 March 2018. DOI: 10.1007/s00213-018-4887-7.
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Find new educational online content from UEG Week 2017 subtitled into Spanish.
Mistakes in the endoscopic diagnosis and management of Barrett’s oesophagus and how to avoid them
Barrett’s oesophagus is the precursor to oesophageal adenocarcinoma, which carries a poor prognosis,1 and it is likely that all endoscopists and gastroenterologists will encounter Barrett’s oesophagus in their clinical practice.Careful assessment and management of patients who have Barrett’s oesophagus with endoscopic surveillance and endoscopic endotherapy aim to reduce the risk of progression to invasive adenocarcinoma. Advances in endoscopic diagnosis and therapy should, therefore, help to reduce the risk of progression. As with all premalignant conditions and surveillance programmes,2 careful multidisciplinary management of the patient is important to reduce the risk of causing them to become unduly concerned. Here, we present some mistakes that in our experience are commonly made in the endoscopic diagnosis and management of Barrett’s oesophagus and give advice on how to avoid them.
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Mistakes in short bowel and how to avoid them
Short bowel manifests as high stomal output or diarrhoea, dehydration and malnutrition.
Short bowel is a condition that occurs after single or multiple intestinal resections. The incidence of short bowel in Europe is 2 per million of the population1–3 and it carries with it lifelong morbidity and mortality. The initial recognition and management of short bowel in the adult population tends to occur in the postoperative period and in the secondary care setting, where specialist input from clinicians experienced in short bowel is often lacking.Normal small bowel length is 275–850 cm.4–7 It is accepted that when the length of small bowel is reduced to less than 200 cm it may be insufficient to enable adequate absorption of fluids and micronutrients. The symptoms of short bowel (often referred to in the literature as short bowel syndrome) are secondary to a reduction in intestinal surface area together with an increased motility of the remaining section of small bowel, with accompanying increased secretion into the lumen. These intestinal secretions vary in their electrolyte content and osmolality depending on the anatomical location, with the highest chloride and potassium loss from gastric secretions and high sodium loss from jejunal secretions.8 Clinically, short bowel manifests itself as a high stomal output or diarrhoea, dehydration and malnutrition. High stomal output or diarrhoea do not, however, necessarily equate immediately to short bowel; conversely, a small bowel longer than 200cm may be insufficient if it is diseased. Here, we discuss some of the pitfalls that are encountered in the recognition and management of short bowel and have suggested an algorithm for assessing and managing patients with a high stomal output. Although some of these pitfalls may appear obvious, they are addressed here because they are commonly encountered in clinical practice (summarised in table 1 at the end of the article).
A case at the crossroads of dermatology and gastroenterology
What next for a middle-aged patient with a condition affecting her skin and mouth?
Several years ago, a middle-aged woman presented with a condition affecting her skin (photograph A) and mouth (photograph B), and she was diagnosed with lichen planus.The patient then presented with dysphagia. A lesion was found high in the oesophagus (photograph C) and biopsy samples were taken (photograph D). Case question 1 WHAT IS THE AETIOLOGY OF THE STRICTURE? a) Benign b) Malignant
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ESGAR/EPC Multidisciplinary pancreatic workshop
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Mistakes in paediatric IBD and how to avoid them
Better clinical outcomes are increasingly being sought in young people with IBD
Around 1 in 10 cases of inflammatory bowel disease (IBD) will present before adulthood, with the median age at presentation being 11–12 years.1 IBD in children and young people is associated with more extensive disease, increased disease activity and a higher rate of complications compared with adult-onset IBD.2 Worldwide, estimates of paediatric IBD prevalence rates are lacking, but data suggest its incidence is increasing.3
Risk factors for paediatric IBD include immigration to high prevalence regions, particularly to countries that have Westernised diets, increasing geographical latitude, and European ancestry (versus belonging to an indigenous population).4 The risk may also be higher in children of certain ethnicities (South Asian, Hispanic, and East Asian).5
While the pathophysiology and clinical presentation of paediatric IBD is well understood, the role of genetics and personalised treatment is currently the focus of a significant amount of international research. Better clinical outcomes—including optimal nutrition, improved growth, better quality of life and increased disease remission rates with decreased occurrence of complications—are increasingly being sought in children and young people with IBD.4
This article discusses mistakes commonly made when identifying, diagnosing and managing children whom are suspected or confirmed to have IBD. The mistakes and discussion are based on published evidence where possible, plus our clinical experience of looking after children with IBD.
Prevention of cancer in the gastrointestinal tract and the liver
Learn how to manage patients with pre-neoplastic disorders.
Mistakes in tissue sampling during endoscopy and how to avoid them
Tissue acquisition is the most common manoeuvre performed during endoscopy.
This is the age of liver biomarkers—let the sunshine in!
We are entering a new age of light for noninvasive biomarkers for liver diseases
Much like in the 1969 hit song “The Age of Aquarius”, we are now entering a new age of light when it comes to noninvasive biomarkers for liver diseases. UEG has embraced this new era with an online course that covers current and upcoming biomarkers of steatosis, steatohepatitis, liver fibrosis, hepatocellular carcinoma (HCC) and biliary diseases.In the field of gastroenterology and hepatology, research into noninvasive diagnostics and biomarker discovery has grown exponentially in the past few years. In particular, numerous breakthroughs in the diagnosis of and prediction of prognosis for various acute and chronic liver diseases are now being witnessed. This focus on chronic liver diseases is justified, because they are an increasing source of medical and public health concern worldwide, much of which is due to the lack of early disease biomarkers. A couple of months ago, I had the pleasure of working with Frank Tacke and Jesús Bañales on a new UEG online course “Biomarkers of liver disease”. Our goal was to summarize current diagnostic modalities for nonalcoholic fatty liver disease (NAFLD), from simple steatosis to fibrotic and cirrhotic nonalcoholic steatohepatitis (NASH), HCC and biliary diseases, discuss their main limitations and introduce novel, prospective biomarkers for disease triggering, staging and monitoring. Imaging assessment techniques are well established as noninvasive biomarkers, mitigating the need for an invasive liver biopsy. Our UEG online course covers the imaging tools and technologies already employed for diagnosis and monitoring of NAFLD and, particularly, fibrosis, where they may also have potential for the longitudinal assessment of therapeutic responses.1 It should be noted, however, that having tools that allow diagnosis of NAFLD in its earliest stages is of utmost importance, given the high likelihood of progression to more severe stages, including fibrosis itself. In this regard, the possibility of using extracellular vesicles (EVs) and microRNAs (miRNAs) as novel biomarkers of liver disease is particularly appealing, as the EV cargo, which includes miRNAs, represents a snapshot of the parental liver cell at the time of release and changes immediately according to the pathophysiological status of the liver.2,3 Several miRNAs and EV-related proteins present in serum, bile or urine also display high sensitivity and specificity for the diagnosis of different cholangiopathies. These novel biomarkers may, therefore, be of further use for the early detection of cholangiocarcinoma (CCA),4 particularly considering that, at the moment, only nonspecific biochemical (and/or histological) markers are used in combination with clinical and radiological data for the diagnosis of CCA, according to the expert consensus document recently published by the European Network for the Study of Cholangiocarcinoma.5 As for HCC, diagnosis relies mainly on imaging methods. In fact, only ultrasonography is recommended by the European Association for the Study of the Liver (EASL) and European Organisation for Research and Treatment of Cancer (EORTC) clinical practice guidelines on the management of HCC.6 As such, early HCC diagnosis needs to be improved, as does the ability to identify subgroups of patients who have a different prognosis and response to treatment,7 which could be achieved through EV-based and miRNA-based assays. For instance, specific tumour-associated microparticles (taMPs) have very recently been proposed as novel biomarkers of HCC and CCA.8 As 5 years have passed since the EASL–EORTC guidelines on HCC were published, the next revised version is expected to discuss these and other recent advances in the biomarker field. As a final note, it should be highlighted that the use of EVs and miRNAs as liver disease biomarkers is not without its challenges. Standardization of sample collection, data normalization and analysis, as well as large, independent comprehensive studies in well-characterized patient populations, are needed to help speed its translation to clinical practice. And this is exactly where the sunshine is finally being let in—several large consortiums supported by the European Commission are now addressing these issues, including EPOS (Elucidating Pathways of Steatohepatitis) [http://www.epos-nafld.eu] and, most recently, LITMUS (Liver Investigation: Testing marker Utility in Steatohepatitis) [http://www.litmus-project.eu]. In particular, the primary aim of LITMUS is to bring new diagnostic tests to NAFLD patients and identify those most at risk of developing severe inflammation and liver scarring, by discovering, validating and qualifying better biomarkers. By closing the gap between patients, researchers and industry, such consortiums will undoubtedly have a key role in firmly establishing EVs and microRNAs as noninvasive biomarkers of liver disease in the clinical setting. I do hope this brief summary and the video shared here will motivate you to have a look and try UEG’s new online course “Biomarkers of liver disease”. As for all UEG online courses, access is free when you sign in to your myUEG account. Enjoy! References
- Baues M, Dasgupta A, Ehling J, et al. Fibrosis imaging: Current concepts and future directions. Adv Drug Deliv Rev 2017. Epub ahead of print 3 November 2017. DOI: 10.1016/j.addr.2017.10.013
- Szabo G and Momen-Heravi F. Extracellular vesicles in liver disease and potential as biomarkers and therapeutic targets. Nat Rev Gastroenterol Hepatol 2017; 14: 455–466.
- Afonso MB, Rodrigues PM, Simão AL and Castro RE. Circulating microRNAs as potential biomarkers in non-alcoholic fatty liver disease and hepatocellular carcinoma. J Clin Med 2016; 5. pii: E30
- Arbelaiz A, Azkargorta M, Krawczyk M, et al. Serum extracellular vesicles contain protein biomarkers for primary sclerosing cholangitis and cholangiocarcinoma. Hepatology 2017; 66: 1125–1143
- Banales JM, Cardinale V, Carpino G, et al. Expert consensus document: Cholangiocarcinoma: current knowledge and future perspectives consensus statement from the European Network for the Study of Cholangiocarcinoma (ENS-CCA). Nat Rev Gastroenterol Hepatol 2016; 13: 261–280.
- European Association for the Study of the Liver and European Organisation for Research and Treatment of Cancer. EASL-EORTC clinical practice guidelines: management of hepatocellular carcinoma. J Hepatol 2012; 56: 908–943.
- Gerbes A, Zoulim F, Tilg H, et al. Gut roundtable meeting paper: selected recent advances in hepatocellular carcinoma. Gut Pub ahead of print 17 November 2017. DOI: 10.1136/gutjnl-2017-315068.
- Julich-Haertel H, Urban SK, Krawczyk M, et al. Cancer-associated circulating large extracellular vesicles in cholangiocarcinoma and hepatocellular carcinoma. J Hepatol 2017; 67: 282–292.