Mistakes in managing perianal disease and how to avoid them

Perianal disease is very common and can impair quality of life significantly. It is crucial to identify the serious causes of these symptoms, but also to reduce the burden of the less dangerous conditions that nevertheless can be debilitating and interfere with an individual’s work and life. 

Perianal disease takes many forms, is very common and can impair quality of life significantly. The symptoms of perianal disease, including pain, bleeding, discharge and pruritus, are common to several conditions that are sometimes difficult to disentangle.

It is crucial to identify the serious causes of perianal symptoms, but also to reduce the burden of the less dangerous conditions that nevertheless can be debilitating and interfere with an individual’s work, social or intimate life. Below we discuss some of the frequent and important mistakes made in the management of perianal disease based, where possible, on evidence, and where not, on clinical experience.

A case of colitis

An unusual presentation of a common problem or a common presentation of an unusual problem?    

A 65-year-old man presents with a 1-week history of increasingly intense and continuous low abdominal pain that does not appear to be exacerbated by eating. The abdominal pain was preceded by exertional chest pain that settled with anti-anginal therapy prescribed by the patient’s GP. Routine blood tests are normal on admission and the patient denies taking an NSAID or paracetamol.

An abdominal CT (image A) is organised followed by a colonoscopy. The colonoscopy detects the presence of ulceration (image B) at the caecum and proximal ascending colon, but the appearance is normal elsewhere. Mucosal samples are taken. Apart from hypertension that is managed with ramipril, the recently started anti-anginal drug nicorandil and low-dose aspirin, the patient is well and able walk several miles without shortness of breath. Unfortunately, the patient deteriorates a couple of days later and becomes septic. A repeat abdominal CT confirms the presence of a perforation at the level of the caecum, and the patient undergoes an emergency hemi-colectomy. Analysis of the resection specimen confirms deep ulceration with a perforation at the centre of an area of ulceration (image C).  WHAT IS THE MOST LIKELY DIAGNOSIS? a)     Ischaemic colitis b)     Aspirin-induced colonic ulceration c)     Ulceration secondary to mucosal biopsy samples taken at colonoscopy d)     Crohn’s disease e)     None of the above

Mistakes in endoscopy and how to avoid them

Diagnostic and therapeutic mistakes discussed in the context of evidence and endoscopic experience.

Upper and lower gastrointestinal endoscopy examinations are performed daily as routine diagnostic procedures in a large number of patients with nonspecific indications, such as heartburn, pain, anaemia, bleeding, workup of portal hypertension and so on.

Most of the examinations will point to a classic diagnosis (e.g. peptic disease, cancer, variceal management), but sometimes we see patients who've had multiple diagnostic endoscopic procedures in the previous few months with nonconclusive findings. The diagnostic mistakes discussed here are those that sprang to mind based on our endoscopic experience and they are discussed in an evidence-based approach. For therapeutic endoscopic procedures (e.g. ERCP and resections), we present the most important mistakes that are often seen in our practice and have major consequences for the patient. We propose, from our experience, a simple approach to avoid these mistakes.

All UEG Week 2016 content is included in the UEG Education Library

In addition to the recordings on UEG Week 24/7, the scientific material of UEG Week 2016 is available in the UEG Education library, including all abstracts, posters and the syllabus of the Postgraduate Teaching Programme.
Select <UEG Week 2016> from conferences

Mistakes in paediatric functional constipation diagnosis and treatment and how to avoid them 

Have a look at the major mistakes that are made when diagnosing and treating children with functional constipation. 

Constipation is a bothersome problem for many children. It may present as one or more of the following: infrequent bowel movements with faecal incontinence, hard and often large stools, painful defecation and abdominal pain. No organic cause of the constipation can be found in approximately 95% of children—these children suffer from functional constipation. The prevalence of functional constipation ranges between 0.7% and 29.6% and it occurs in girls more often than in boys (ratio 2.1:1).1

The diagnosis of functional constipation is based on the paediatric diagnostic Rome criteria for functional gastrointestinal disorders.2,3 Additional investigations are indicated only if the diagnosis is not clear or in order to rule out an underlying organic disease, such as Hirschsprung disease.4 Education, demystification of constipation, following a reward-based toilet program and keeping a daily bowel diary form part of the nonpharmacological management process.4 Disimpaction, maintenance treatment and weaning of medication are all elements of pharmacological treatment.4 Polyethylene glycol (PEG) is the first-choice laxative for both disimpaction and maintenance treatment; however, if PEG is not available or is poorly tolerated, lactulose is recommended. Other laxatives are available as a second-line or additional treatment if treatment with PEG is insufficient. Here we discuss the major mistakes that are made when diagnosing and treating children with functional constipation. The discussion that follows is evidence based in the majority of cases, but where evidence is lacking the discussion is based on the lead author’s clinical experience of more than 20 years in the field as a paediatric gastroenterologist.

Mistakes in irritable bowel syndrome and how to avoid them

Learn more about the mistakes that can be made when diagnosing and managing IBS!

Around 11% of the worldwide population experience irritable bowel syndrome (IBS), making it one of the most frequent gastroenterological diagnoses.1 The symptoms of IBS include abdominal pain associated with unpredictable bowel habits and variable changes in the form and frequency of stool.2

While all patients with IBS suffer from recurrent bouts of abdominal pain, their bowel habits are varied: around one-third suffer predominantly with diarrhoea (IBS-D), one-fifth experience predominantly constipation (IBS-C) and half have an erratic mixed pattern of both diarrhoea and constipation (IBS-M).3 This very heterogeneous condition undoubtedly has multiple causes and an individualized approach to management and treatment is required. Here I discuss the mistakes most frequently made when diagnosing and managing IBS. The mistakes and discussion that follow are based, where possible, on published data and failing that on many years of my own clinical experience.

Clinical Introduction to colorectal polyps

Improve your understanding of colorectal polyps.

Gut microbiota

Learn more about importance of the gut microbiota in many clinical conditions.

Emergency upper gastrointestinal bleeding

Enhance your knowledge of nonvariceal and variceal bleeding.

Mistakes in the management of acute pancreatitis and how to avoid them 

Critical decision-making points & pitfalls

Acute pancreatitis is a common inflammatory disorder of the pancreas and its incidence is increasing among hospitalized patients worldwide.
In 2009, it was the most frequent diagnosis in patients discharged from GI services in the US and the fifth leading cause of in-hospital mortality.1 Because of this high disease burden, acute pancreatitis is also a substantial contributor to healthcare spending, accounting for an estimated annual spend of US$4–7 million per million inhabitants in western countries.2,3

The main symptoms include severe upper abdominal pain (often sudden onset), nausea, vomiting, bloating and the development of ileus. In many cases jaundice will also be present. The diagnosis, as agreed by international consensus, can be established by fulfilling two of the following three criteria: upper abdominal pain of sudden onset, elevation of either serum lipase or amylase activity to greater than three times the upper limit of normal, and imaging findings consistent with inflammation of the pancreas.4–6 By far the most common risk factors for the development of acute pancreatitis are excessive alcohol consumption and gallstone disease. Several mutations have been identified that, in combination with nongenetic factors or alone, can lead to pancreatitis. Certain drugs are known to be associated with the development of pancreatitis and smoking might also increase the probability of it developing. 80–85% of patients diagnosed with the disease will have mild disease and make an uneventful recovery with little more than adequate fluid therapy and analgesia needed to support them. The remaining patients, however, will suffer from moderately severe to severe acute pancreatitis, with the development of pancreatic necrosis, severe sepsis or abdominal compartment syndrome. These patients are at immediate danger of multiorgan failure and death and require multidisciplinary intensive care, organ support and often pancreatic interventions conducted by experienced investigators. Since it is difficult to predict outcomes and complications develop during the disease course, treatment in specialized centres that have a high case load is recommended.4 Here, we discuss critical decision-making points and pitfalls frequently occurring when managing patients with acute pancreatitis. The discussion is based on the medical literature and many years of clinical experience.

NAFLD and diabetes—are they symptoms of gut dysbiosis?

Connecting changes in gut microbiota to metabolic and hepatic diseases

The idea that obesity is a direct consequence of changes in gut microbiota structure and function that lead to enhanced extraction of energy from the host diet has been discussed for some years. Studies now suggest that associated diseases such as non-alcoholic fatty liver disease (NAFLD) and diabetes may also be considered consequences of intestinal dysbiosis.

A leading cause of liver transplantation, NAFLD may now top the list of the most common liver diseases in developed countries. In an article published in Gastroenterology earlier this year, Betrapally and colleagues argue that “…the development and progression of fatty liver, alcoholic fatty liver disease, and NAFLD all appear to be influenced by the composition of the [gut] microbiota.”1 The way the gut microbiota influences the progression of these diseases appears to be complex, potentially involving diet-induced changes in bacterial metabolomes and microbial interactions with, for instance, bile acids and gut hormones such as glucagon-like peptide 1 (GLP1).1,2 An incretin secreted by enteroendocrine L cells, GLP1 induces pancreatic β-cell proliferation, maintains glucose-dependent insulin secretion and inhibits glucagon release, gastric emptying and food intake. Short-chain fatty acids (SCFAs) synthesized by certain bacteria activate the G-protein-coupled receptors GPR41 and GPR43, promoting secretion of GLP1.1 This was exemplified in a randomized controlled trial (RCT), in which Alisi and colleagues investigated the effect of the probiotic VSL#3, a mixture of eight probiotic strains (Streptococcus thermophilus, bifidobacteria [B. breve, B. infantis, B. longum], Lactobacillus acidophilus, L. plantarum, L. paracasei, and L. delbrueckii subsp. bulgaricus) in children with NAFLD, using changes in the severity of the fatty liver disease as the primary outcome.2 They found that a 4-month supplement of VSL#3 significantly improved NAFLD, probably through VSL#3-dependent reversal of dysbiosis. Of note, however, is the fact that no data were included on gut microbiota profiling prior to or after intervention. Nevertheless, the authors speculated that restoration of normal gut flora led to reduced intestinal permeability, increased production of SCFAs and anorexogenic gut hormones, including GLP1, as well as enhanced insulin sensitivity. The effect of consuming 300g of probiotic yoghurt containing Lactobacillus acidophilus La5 and Bifidobacterium lactis Bb12 every day for 8 weeks on selected metabolic parameters was studied in an RCT comprising 72 NAFLD patients.3 Patients consuming the probiotic yoghurt exhibited a reduction in the levels of serum hepatic enzymes (alanine aminotransferase and aspartate aminotransferase), serum total cholesterol, and low-density lipoprotein cholesterol. Again, no microbiota profiling was performed in order to try to link the findings with potential restoration of gut eubiosis. Meanwhile, other studies—although not intervention studies—have taken to investigating the gut microbiota profiles of patients with NAFLD lesions such as non-alcoholic steatohepatosis and fibrosis. These studies have identified independent associations between the predominance of certain bacterial groups and the presence of fatty liver disease.4,5 The fact remains, however, that we still need intervention studies that include pre-intervention and post-intervention gut microbiota profiling, preferably including data on the gut metabolome as well. And, as pointed out by Wieland and colleagues,6 we still need data in order to be able to delineate causality and obtain a mechanistic understanding of how in fact obesity and related metabolic and hepatic disease might reflect changes in gut microbiota structure and function.

We still need intervention studies that include pre-intervention and post-intervention gut microbiota profiling

On a different—yet related—note, a study has just been published in Nature identifying Prevotella copri as a driver of insulin resistance and potentially the development of type-2 diabetes.7 Mice fed P. copri developed increased serum levels of branched-chain amino acids, insulin resistance and reduced glucose tolerance. Hence, P. copri was identified as one of the bacterial species most critical to the development of insulin resistance. This finding suggests that type-2 diabetes is effectively the result of intestinal dysbiosis with predominance of certain bacteria such as P. copri. The results of future research will reveal the extent to which obesity and associated metabolic and hepatic diseases may be alleviated and perhaps even treated via gut microbiota manipulation with prebiotics, probiotics, synbiotics, antibiotics or other compounds such as SCFAs.8 If you are interested in the role of the gut microbiota in the development of NAFLD, especially changes in SCFA metabolism, I highly recommend perusing the review by Leung and colleagues in Nature Reviews Gastroenterology & Hepatology.9 For even more information on microbiota-associated pathogenesis of liver disease and its complications, I suggest reading the reviews by Schnabel and Brenner,10 Boursier and Diehl,11 Quigley and Monsour,12 and Abdou and colleagues.13 To find out more about the use of probiotics in the therapy of NAFLD, the reviews by Putignani et al.14 and Tarantino and Finelli15 are also worth consulting. References
  1. Betrapally NS, Gillevet PM and Bajaj JS. Changes in the intestinal microbioma and alcoholic and nonalcoholic liver diseases: Causes of effects? Gastroenterology 2016; 150: 1745–1755. 
  2. Alisi A, Bedogni G, Beviera G, et al. Randomised clinical trial: the beneficial effects of VSL#3 in obese children with non-alcoholic steatohepatitis. Aliment Pharmacol Ther 2014; 39: 1276–1285. 
  3. Nabavi S, Rafraf M, Somi MH, et al. Effects of probiotic yogurt consumption on metabolic factors in individuals with nonalcoholic fatty liver disease. J Dairy Sci 2014; 97: 7386–7393. 
  4. Boursier J, Mueller O, Barret M, et al. The severity of nonalcoholic fatty liver disease is associated with gut dysbiosis and shift in the metabolic function of the gut microbiota. Hepatology 2016; 63: 764–775. 
  5. Jiang W, Wu N, Wang X, et al. Dysbiosis gut microbiota associated with inflammation and impaired mucosal immune function in intestine of humans with non-alcoholic fatty liver disease. Sci Rep 2015; 5: 8096. 
  6. Wieland A, Frank DN, Harnke B, et al. Systematic review: microbial dysbiosis and non-alcoholic fatty liver disease. Aliment Pharmacol Ther 2015; 42: 1051–1063. 
  7. Pedersen HK, Gudmundsdottir V, Nielsen HB, et al. Human gut microbes impact hos serum metabolome and insulin sensitivity. Nature 2016; 535: 376–381. 
  8. Jin CJ, Sellmann C, Engstler AJ, et al. Supplementation of sodium butyrate protects mice from the development of non-alcoholic steatohepatitis (NASH). Br J Nutr 2015; 114: 1745–1755. 
  9. Leung C, Rivera L, Furness JB, et al. The role of the gut microbiota in NAFLD. Nat Rev Gastroenterol Hepatol 2016; 13: 412–425. 
  10. Schnabl B and Brenner DA. Interactions between the intestinal microbiome and liver diseases. Gastroenterology 2014; 146: 1513–1524.
  11. Boursier J and Diehl AM. Implication of gut microbiota in nonalcoholic fatty liver disease. PLoS Pathog 2015; 11: e1004559. 
  12. Quigley EM and Monsour HP. The gut microbiota and nonalcoholic fatty liver disease. Semin Liver Dis 2015; 35: 262–269. 
  13. Abdou RM, Zhu L, Baker RD, et al. Gut microbiota of nonalcoholic fatty liver disease. Dig Dis Sci 2016; 61: 1268–1281.
  14. Putignani L, Alisi A and Nobili V. Pediatric NAFLD: the future role of patient-tailored probiotics therapy. J Pediatr Gastroenterol Nutr 2016; 63 Suppl 1: S6–8. 
  15. Tarantino G and Finelli C. Systematic review on intervention with prebiotics/probiotics in patients with obesity-related nonalcoholic fatty liver disease. Future Microbiol 2015; 10: 889–902. 

The ABC of E-learning

How UEG E-learning fills a gap in Continuing Medical Education and how you can get the most out of our Online Education offer. 

Mistakes in endoscopic retrograde cholangiopancreatography and how to avoid them

Endoscopic retrograde cholangiopancreatography (ERCP) is a widespread technique used for the treatment of different diseases of the bile and pancreatic ducts.

Endoscopic retrograde cholangiopancreatography (ERCP) is a widespread technique used for the treatment of different diseases of the bile and pancreatic ducts. The technique is, however, associated with rare but potentially severe morbidity.

Some of the adverse events associated with ERCP are directly linked to commonly made mistakes and can, therefore, be prevented. Here, we discuss 10 common and/or high-impact mistakes that are made during ERCP and how they can be avoided. 

Updates on calprotectin and IBD—where to look?

Endoscopy with biopsy is the gold standard for detection and monitoring of intestinal inflammation. 

Endoscopy with biopsy is the gold standard for detection and monitoring of intestinal inflammation. Meanwhile, the use of surrogate markers (biomarkers) enables gastroenterologists to reduce costs and inconvenience in the management of intestinal disorders by eliminating the need for invasive procedures. Hence, efficient application of biomarkers for disease detection and assessment of treatment response is critical to cost-effective control of gastrointestinal disease. In this setting, elevated levels of C-reactive protein are a general sign of inflammation and widely used in combination with faecal calprotectin for the detection and monitoring of inflammatory bowel disease (IBD).

Calprotectin is a protein found particularly in neutrophils but also in monocytes. Neutrophil disruption results in the release of calprotectin, although some of it is actively secreted.1 Detection of calprotectin in stool indicates neutrophil migration and infiltration in the intestinal tract, including the gut mucosa. Resisting enzymatic degradation, calprotectin is highly stable and can be detected in stool kept at room temperature for at least 7 days.2 Calprotectin levels in stool (usually expressed as µg/g of faeces) correlate well with endoscopic scoring systems for IBD, such as the ulcerative colitis endoscopic index of severity (UCEIS) and Crohn’s disease endoscopic index of severity (CDEIS), and may even perform better than the Crohn’s Disease Activity Index (CDAI).2 In his comprehensive Gastroenterology review on biomarkers of inflammation in IBD, Bruce Sands summarized the applicability and relevance of using faecal calprotectin to distinguish between IBD and irritable bowel syndrome, and also for categorizing IBD activity, ascertaining response to treatment and predicting clinical relapse.3 Reviews in leading journals are, of course, an excellent tool for updating yourself on state-of-the-art knowledge within a given area; however, the plethora of material present in the UEG Education Library may also prove highly useful. For example, searching the library for calprotectin currently returns no fewer than 338 hits, including 214 conference abstracts, 64 presentations, 55 posters, and 4 syllabus contributions submitted by leading gastroenterologists and rising stars. Among the four syllabus contributions, there is one specifically focused on calprotectin by Christoph Beglinger; for this particular syllabus contribution you have the option to read the pdf or view the associated presentation from UEG Week 2013.4 If you’re looking for the latest progress on the use of calprotectin, filtering your 338 hits by year narrows the results to 59 items for 2015. Among these hits, there are three abstracts from UEG Week 2015 on a smartphone-based calprotectin home test—a technology that was developed to try to eliminate the need for patients to bring stool samples to the clinic for analysis and to allow them to play a more active role in their disease management. Another great place to search for relevant information is in the ‘Standards and Guidelines’ that are also now available via the UEG Education Library. There are currently 17 IBD standards and guidelines available for you to access. One of these articles is “Second European evidence-based consensus on the diagnosis and management of ulcerative colitis Part 1: Definitions and diagnosis”, which you can use to update yourself on consensus opinion on the application of calprotectin.5 Finally, the UEG 24/7 pathway gives you access to all core scientific lectures from UEG Week 2015 in Barcelona. Here, you have the option to select the IBD pathway or you can narrow the results by entering the word biomarker in the filter by title’ search box. Any interesting hits? References:
  1. Ikhtaire S, et al. Fecal calprotectin: its scope and utility in the management of inflammatory bowel disease. J Gastroenterol 2016; 51: 434–446. 
  2. Dhar A. Faecal calprotectin—ready for prime time? Frontline Gastroenterol 2015; 6: 11–13. 
  3. Sands BE. Biomarkers of inflammation in inflammatory bowel disease. Gastroenterology 2015; 149: 1275–1285. 
  4. “Utility of faecal markers in IBD clinical practice” syllabus contribution at UEG Week 2013 
  5. Dignass A, et al. Second European evidence-based consensus on the diagnosis and management of ulcerative colitis Part 1: Definitions and diagnosis. J Crohn’s Colitis 2012; 6: 965–990. 

Recordings covering hot topics in experimental GI cancer

Highlight recordings from the Basic Science Course 2016 in Munich are now online.

Mistakes in IBD and reproduction and how to avoid them

Find out more about the major mistakes and misperceptions!

Inflammatory bowel disease (IBD) is a chronic relapsing gastrointestinal disease, often affecting young people during their fertile years. The chronic character of IBD means that lifelong medical treatment is often required. As such, it is not surprising that questions often arise about fertility and pregnancy in patients with IBD.

The most important risk factor for adverse pregnancy outcomes in IBD patients is the presence of disease activity during pregnancy. Indeed, negative pregnancy outcomes (e.g. spontaneous abortion, preterm delivery and low birth weight) are associated with disease activity at the time of conception and during pregnancy.1–4 The majority of pregnancies in women with quiescent IBD are uncomplicated. This demonstrates the importance of maintaining remission by continuing medication during pregnancy. Counselling patients before pregnancy on the effects of IBD drugs and disease activity on the child in utero is, therefore, of utmost importance. Although much is known about reproduction and IBD, misbeliefs regarding pregnancy and IBD still persist. Here, we present 10 major mistakes and misperceptions that are made when treating IBD patients who wish to reproduce. The list and discussion are evidence based and integrated in our clinical practice.

Get access to recorded lectures 

This intense course for trainees and early career medical professionals can now be attended from home. 
Find out more

Get access to recorded lectures from Summer School Prague 2016.

This intense clinical-based weekend course is perfect for trainees and early career medical professionals and can now be attended from home. 

EDS Surgery Course Recordings

Discover the highlights of the 10th EDS Postgraduate Course featuring a large variety of surgical state-of-the-art lectures.

Mistakes in upper gastrointestinal bleeding and how to avoid them 

Discover more about the most frequent mistakes!    

Dealing with upper gastrointestinal (UGI) bleeding is fraught with pitfalls, not least because spotting those patients who are suffering significant bleeding can be difficult amongst the majority of referrals who are ill and hypotensive for other reasons. Despite diagnostic difficulties and the increasing age and comorbidities of our patients, the mortality rate from UGI bleeding has remained stable over the past 30 years.1–4 The variable mortality rates in published series can be explained by the inclusion of a proportion of healthier patients without a significant bleeding site. For this reason, the best way to assess emergency UGI bleeding outcomes is probably to exclude cases in which there is no significant finding, and only include patients with bleeding ulcers and varices into the calculated 30-day mortality rate. In Leeds we have examined the mortality rate in all patients with bleeding ulcers and varices over a 5-year period and found a 30-day mortality rate of 22%.5 In the absence of non-invasive means to identify patients with genuine bleeding, the benchmark for patients with emergency GI bleeding is to offer an emergency gastroscopy within 24 hours. In the UK, even this permissive benchmark is not always achieved. In a UK National audit,6 only 50% of patients underwent endoscopy within 24 hours of presentation, compared with 76% of patients in a Canadian audit.7 For patients with UGI bleeding, we know that early endoscopy is safe, reduces length of hospital stay and reduces the need for emergency surgery.8–12 However, we have no strong evidence that an early endoscopy saves lives.11–13 This may be as most series are small and largely composed of patients who do not have significant bleeding. Naturally, carrying out an emergency endoscopy in a patient who develops vomiting after commencing antibiotics for a bronchopneumonia is unlikely to make any difference to mortality. Here, I draw on many years clinical experience to discuss the mistakes most frequently made when dealing with UGI bleeding. 
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