2nd London Neurogastroenterology Course
Tracey Moran MSc Chief I GI Physiologist
Patricia Lawlor MSc Chief II GI Physiologist
The 2nd London Symposium was delivered via Zoom and ran over a three-day period. The opening lecture covered Functional GI Disorders (FGID’S). For those unfamiliar with FGID’S, they encompass gastrointestinal disorders such as Irritable Bowel Syndrome, Dyspepsia, Post Prandial Distress Syndrome, Epigastric Pain Syndrome, Functional Anorectal Disorders and Centrally Mediated Abdominal Pain Syndrome. They are not caused by structural tumours or masses or biochemical abnormalities but as a consequence of a disordered GUT-Brain axis. The preferred title for patients with these problems is now known as Disorder of Brain- Gut Interaction. Prof Imran Aziz from the University of Sheffield gave an impressive overview of this complex area. He highlighted the importance of providing a multidisciplinary and patient centred approach to care, including psychotherapists, specialising in Cognitive Behavioural therapy. This is proving successful in the management of these patients in combination with medical therapy.
Eosinophilic Oesophagitis (EOE) was the next topic which is an allergic inflammatory disease of the oesophagus. The main presenting symptom is dysphagia (difficulty swallowing). This disorder is on the increase and we are now seeing more of these patients for investigation with High Resolution Manometry (HRM) in our unit. EOE is diagnosed with biopsy taken at endoscopy and defined as the presence of 15 eosinophils per high power field. If left untreated can it can lead to severe stricturing of the oesophagus.
The topic then turned to the common causes of dysphagia and investigation of same this was led by Prof Rami Sweis. His strongest take home message for the GI physiologist, was to make sure you have the time to prolong an investigation of a patient with swallowing difficulty to try and identify the cause of their symptoms. The study may start off looking quite normal but provocation with bread and rapid drink challenges may begin to reveal abnormalities as the test progresses. This is already the policy in our unit and it is great to see the successful standardisation of HRM testing across the board.
Dysphagia and Gastro-oesophageal reflux disease was also covered and it was highlighted how the GI Physiology service can often times be abused with patients sent for 24-hour pH Monitoring unnecessarily. He outlined both the time scale and cost of carrying out HRM and 24-hour pH testing on each patient. Preparation, testing and analysis of results are time consuming and therefore testing should be reserved for patients in which a clinical need is identified. Though he was talking from the UK perspective, this issue is something we have also encountered in our unit and it was good to hear a consultant bring this up as learning opportunity.
Rumination and supra-gastric belching was covered by Prof Daniel Sifrim, who specialises in this area. Rumination syndrome is defined by the ROME IV criteria as repetitive, effortless regurgitation of recently digested food. This can be followed by re-chewing and swallowing of the food bolus or expulsion of the bolus. Patients are not consciously aware that they are doing this and often mistake it for ‘vomiting after meals’ or ‘Acid indigestion.’ They can often end up being inappropriately treated with Proton Pump Inhibitors (PPI) or anti-reflux surgery. Prolonged Impedance HRM including a meal, followed by Impedance pH was strongly recommended for suspected rumination. The overlap between supra-gastric belching or ‘air-sucking’ as it is also known and rumination is thought to be more common than previously thought. Therefore, careful analysis of pH Impedance for the presence of supra-gastric belching prior to episodes of rumination are required. Treatment for these patients includes Cognitive Behavioural Therapy and diaphragmatic breathing.
Another interesting topic covered was Avoidant Restrictive Food Intake Disorder (ARFID). Like anorexia this disorder is about the elimination of particular types of food to an excessive extent. It differs from anorexia in that it is not related the patient’s perception of their size or weight. The disorder can have severe consequences on the patient’s mental and physical wellbeing.
The early afternoon session discussed such areas as anxiety and vomiting disorders, and the interaction of Brain- Gut impairment in the patient diagnosis. They discussed how to manage functional gastrointestinal disorders using a systematic, evidence based biopsychosocial approach, and the importance of communicating effectively with this co-hort of patient.
Attention then turned to Ehlers-Danlos Syndrome (EDS) and the manifestation of GI disorders in this patient group. EDS is a group of hereditary connective tissue disorders which weakens joints and tendons, creates hypermobility and stretchy velvety skin. There are many phenotypes but the most commonly encountered are Joint Hypermobility EDS and Vascular EDS. The burden of GI symptoms in EDS quite stark. Common GI symptoms encountered include: dysphagia 11-63%, GORD 12-69%, Dyspepsia 34-76% and 54% have Ano-rectal symptoms, predominantly constipation. Again we are seeing an increase in referrals of EDS patients, as up to now the impact of the disorder on the GI tract has been largely underestimated.
Day 2, Dr Simreu gave an in-depth talk on Small Intestinal Bacterial Overgrowth (SIBO). The discussion was around how rare SIBO is, it’s causes and treatments. The inappropriate use of Hydrogen Breath Testing was highlighted and this has been an issue for many GI investigation units. It can be an unnecessary drain on resources and again something we have encountered over our years providing this service.
The topics covered on this day were all along the same lines with a look at Bile Acid Malabsorption and the treatment of intractable diarrhoea. Food allergies and Mast Cell Activation Syndrome were also covered and how patients with FGID’s have a particular susceptibility to allergies. Dietary approaches to IBS took an in-depth look at FODMAPS (Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols). The FODMAPs are a group of short chain carbohydrates, that have been found to cause intestinal irritation in this group. With the help of highly trained dietitians, they have found great improvement in IBS symptoms, particularly in IBS patients with diarrhoea as their predominant symptom.
Day 3 was a look at interesting case studies in both upper and lower GI modalities with Prof Sifrim carrying out an analysis of HRM and 24 Impedance study on a rumination patient and those with distal oesophageal spasm. Dr Mark Scott gave a very interesting lecture on the treatment pathway for patients with Faecal incontinence or Chronic constipation. He emphasised the importance of using Ano-rectal High resolution Manometry in conjunction with other investigations such as Endo-Anal Ultrasound, defecography, Pelvic Floor Ultra sound, neurophysiological and sensory testing.
Lower GI case studies looked at examples of Ano-Rectal High Resolution Manometry traces in Faecal incontinence and constipation. The Endo-Anal Ultrasound cases mainly covered obstetric tears or disruption of the anal sphincters after surgery leading to incontinence.
Overall the 3 days of talks were very insightful and informative. Though we could only be there virtually it was still very enjoyable with plenty of opportunity to ask questions and join in on polls etc. It is reassuring that we are all following the same standards and protocols for procedures and analysis. The standard of the lectures was very high with some of the key leaders in Neurogastroenterology delivering the content. Functional Gut Disorders are increasing in the Irish population and are a significant burden on the health care system, more Gastroenterologists with an interest in Neurogastroenterology will be needed to meet this growing demand.
We would like to thank the IICMS for the bursary to allow us to attend this meeting. Normally this ia s meeting that we could attend due to expensive registration fees, London accommodation, flights etc., however, due to Covid restrictions the virtual zoom meeting drastically reduced the registration fees. Hopefully next year, a combined hybrid meeting will allow the option of virtual attendance by other GI Physiologists, and we would strongly recommend attendance at this Neurogastroenterology Course.