Ulrike Kapp-Popov


T  +43 (0) 699 1997 16 16


E  e-learning@ueg.eu

 

 

Ruby Sutton


T  +43 699 1997 16 18


r.sutton@ueg.eu

 

Ready to put your GI knowledge to the test?

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 

RCD is subdivided into two main clinical subsets—primary and secondary. Patients with primary RCD show no improvement on a GFD, whereas those with secondary RCD experience symptom relapse after a variable period of wellbeing.1–3 RCD can be also classified as type 1 and type 2 (table 1). RCD type 1 and 2 have a similar incidence (0.04% to 1.5%) and age at diagnosis (generally after the age of 50 years);6 however, they differ significantly in terms of complications, prognosis and treatment options, making correct diagnosis essential.7–13  
The diagnostic approach to RCD includes assessment of dietary adherence to a GFD and revision of the initial coeliac disease diagnosis. Re-evaluation of duodenal histopathology is mandatory, with immunohistochemical characterization aimed at identifying aberrant intraepithelial lymphocytes (IELs) and TCRℽ chain clonality (regarded as pre- or low-grade lymphoma). Videocapsule endoscopy (VCE) is necessary to determine the extent of the lesions, whereas double balloon enteroscopy (DBE) can be useful for obtaining biopsy samples from distal lesions previously identified by imaging (i.e. entero-MR and entero-CT).8,9 A practical algorithm summarizing the diagnostic process for RCD type 1 and 2 is shown in figure 1.
In this article, we discuss the mistakes most frequently made in patients who have suspected RCD, based on the available evidence and our clinical experience in the field. 
Figure 1 | Diagnosis of refractory coeliac disease. A practical algorithm that we developed to summarize the diagnostic process for refractory coeliac disease (RCD) type 1 and 2 compared with slow responding coeliac disease, nonresponsive coeliac disease and other nongluten-dependent enteropathies. EGDS, esophagogastroduodenal endoscopy; GFD, gluten-free diet; TCRℽ, T-cell receptor ℽ. 

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.
  1. 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.

  2. 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.

  3. 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.
Best of luck!

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 Fockens

Although 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 Zaninotto

Surgical 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. 

With the number of redrawn figures steadily rising, we decided to collect them together and make them available as a new resource - the UEG Image Hub - which can be freely accessed via the UEG Library. The images themselves can also be freely downloaded and used without needing to obtain permission. Should you wish to reuse any of the images, all we ask is that you give the appropriate credit (including the artist’s name) and cite the image source - information on how to do this is provided with the image files. If you modify any of the images, we ask that you give credit, cite the image source and state clearly that the image has been modified.
To browse all images in the UEG Image Hub, simply visit the UEG Library and select “Image Hub” as the “Format” filter in the right-hand navigation bar. Further filtering of the images can be done by “Category”. 
We do hope you find this new resource to be of value and will make use of the images provided. New images will be added as they become available, so be sure to keep visiting the UEG Image Hub in the future!

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 

Fermentation products are thought to cause symptoms of bloating, abdominal pain, diarrhoea and nausea;8 however, the role of the intestine in the pathogenesis of such symptoms is unclear in both adults and children.9–11 Indeed, an important discrepancy between the degree of malabsorption and symptom severity has been established.12,13 
Here, we discuss mistakes that are made when managing patients who have bloating, abdominal pain, diarrhoea and nausea, in whom carbohydrate malabsorption or intolerance have been diagnosed or are thought to contribute to the condition. The discussion focuses on lactose malabsorption, because of its well-known pathophysiology and high prevalence; however, similar mechanisms apply for intolerances to other poorly-absorbed fermentable, oligosaccharides, disaccharides, monosaccharides and polyols (sugar alcohols) (FODMAPs) and related artificial sweeteners. As treatment focuses on symptom relief, evaluation of complaints that are presumably related to carbohydrate ingestion has to place emphasis on symptom assessment.14 

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 1

WHAT IS THE HISTOLOGICAL DIAGNOSIS? A.     MALT lymphoma B.     H. pylori-associated chronic gastritis C.     Granulomatous gastritis D.    Gastric adenocarcinoma E.     Collagenous gastritis

Case Question 2      

IN 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 3

HOW 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.

Ever wondered how a UEG star online course is born? Well, with the availability of a UEG Online Course Activity Grant, it could involve a rising ‘Lady Gaga’ (minus the drama) pairing with an expert ‘Bradley Cooper’ (minus the alcohol) to deliver a non-shallow, Oscar-winning performance.
I've been working with the UEG E-Learning team since early 2014 and feel tremendously proud of how much we have grown in terms of producing online courses. Basically, we just love doing them! But more importantly, the number of users enrolling in our (free!) online courses has risen immensely, and the feedback we've been getting is tremendously positive. Now, to expand the number and breadth of online courses available, UEG is offering an Activity Grant to fund the development and publication of high-quality online courses by individuals or societies. Here's why you, as a young gastroenterologist, should apply:
First, UEG's online courses are primarily taken by young GI specialists, so it makes sense that you get involved in their development. We also know that young GIs are great at coming up with the innovative, fresh and out-of-the-box ideas, which are needed to keep our online courses relevant and appealing.
Second, developing an online course is not as complicated as you may think. There are guidelines and criteria that need to be considered, but we have put a lot of effort in trying to make everything clear and simple. So, why not enjoy a 5-minute coffee break and go through the documents? You'll see that all the material is easy to follow and pretty straightforward, and that we have resources available to help you along the way (e.g. access to our art editor and recording studio). Plus, you can always contact the E-Learning team with any questions or for advice—we are here to help throughout the whole process.
So, where to start? Pick a ‘song’ that’s missing from our ‘playlist’ and find your ‘Bradley Cooper’. Indeed, I am sure a lot of you already have a specific topic in mind, something covered by the ESBGH Blue Book that is perhaps underrepresented in UEG’s Education Library, particularly in the form of an online course. Now all you have to do is think of a recognised expert on that topic with whom you would like to work, contact her or him and start the journey! I invite you to check our latest course on Autoimmune Pancreatitis to get a general idea of one possible format. We would love to hear what other ideas you have in mind! 
Please note that the Activity Grant application deadline of April 5th refers only to submission of the application form  (general concept for the course), a summary of planned costs, and CVs of the lead author and co-author(s). So, as you can see, there is really no excuse for not applying! In any case, for further information you should refer to the "Application for support of Online Courses” section on the Activity Grants page. We look forward to receiving your application!

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). 

Palliation of dysphagia caused by a malignant tumour is the most common indication for stent placement in the oesophagus. However, benign oesophageal strictures are occasionally also treated by stenting because circular ulceration can result in the formation of additional oesophageal strictures and dysphagia.2 Other oesophageal indications include perforations, fistulas, and anastomotic leaks or strictures that can arise after oesophagectomy or bariatric surgery.3 Stent placement in the distal stomach or duodenum is frequently performed for palliation of malignant gastric outlet obstruction. In Western countries, gastric outlet obstruction is most frequently caused by pancreatic cancer, whereas in Asia it occurs more often in patients who have gastric cancer.4–6 Regarding colonic stent placement, it is important to realize that 8–13% of colorectal cancer patients present with acute intestinal obstruction, which in the past was always treated with emergency surgery.7 As multiple studies demonstrated high mortality and morbidity rates after such emergency surgery, colonic stent placement was introduced as a bridge to elective tumour resection.8–11 Finally, for nonoperable patients who have an ileus caused by colonic cancer, stents are also used for palliation. 
Although similar-looking stents are used in the oesophagus, distal stomach/duodenum and colon, it should be emphasized that the diseases occurring in these locations are different entities and should be treated in different ways. Here, we discuss frequent mistakes that can be made during gastrointestinal stent placement, based on the literature and the authors’ clinical experience.
Figure 1 | Oesophageal stent obstruction. a | Stent obstruction caused by food stasis. b | Stent obstruction caused by distal migration of an oesophageal stent. Images courtesy of Amsterdam UMC, University of Amsterdam.
Figure 2 | Duodenal stent placement. a and b | Placement of a stent in the duodenum of a patient with gastric outlet obstruction caused by an irresectable pancreatic cancer. Images courtesy of Amsterdam UMC, University of Amsterdam. 
Figure 3 | Colonic stent placement. a and b | Placement of a stent in the colon of a patient with an obstructing colonic cancer. Images courtesy of Amsterdam UMC, University of Amsterdam. 

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. 

Autoimmune Pancreatitis

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. 

He realised that young GIs all face similar challenges, and explains how attending UEG Week every year and participating in the Young GI Network can help to overcome these. Back home, Mohammed supports his co-workers by sharing the new knowledge and serving as a role model. He encourages his colleagues from all over the world, but especially those from less prosperous countries, to submit their abstracts to UEG Week. All abstracts are peer reviewed and authors will get the chance to present their work, as well as receive abstract related awards and travel grants. 

Follow Mohammed’s example and submit your abstract to UEG Week by April 26, 2019. 
Register for UEG Week and participate in the Young GI Network activities!
Interviewer: Radislav Nakov

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.

Radislav Nakov, member of the YTG and the Education Committee explains what’s happening at UEG’s classroom courses and who should attend them.

These educational events are perfect opportunities to increase your GI knowledge but also to expand your professional network.  Find out more about the courses and how to apply. 
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