To the ileum . and beyond Dr. Matt W. Johnson BSc MBBS

1
To the ileum .and beyond

• Dr. Matt W. Johnson BSc MBBS MRCP (??MD!!)
• Consultant Gastroenterologist

2
(No Transcript)
3
1909 Royal Military Asylum
4
(No Transcript)
5
(No Transcript)
6
(No Transcript)
7
1733 Hyde Park
8
1976 - Tooting
9
St. Georges Hospital
10
Achievements

• First Class BSc Degree
• Medical Sciences with Physiology
• Physiology research project Effects of alpha and
  beta sympathetic adrenoreceptors on mucus content
  and quantity.
• MBBS (University of London)
• Eating in every one of the 28 Indian restaurants
  from Tooting Broadway to Tooting Bec

11
HO SHO Posts

• MEDICAL SHO POSTS
• St. Helier Hospital, Gastro and GIM
• Hemel Hempstead Hospital, Gastro, Haem and GIM
• Royal Free Hospital, Specialist Liver Unit and
  GIM
• St. Thomas Hospital, Cardiology
• Lewisham Hospital, Endocrine and GIM
• Lewisham Hospital, Care of the Elderly
• Guys Hospital, Accident and Emergency
• PRE REGISTRATION HOUSE OFFICER
• Mayday Hospital, General Surgery and ENT
• St. Georges Hospital, GIM and Care of the
  Elderly

12
(No Transcript)
13
St. Thomass Hospital
14
South East Thames SpR Rotation

• QUEEN ELIZABETH THE QUEEN MOTHER (MARGATE)
  HOSPITAL
• Dr. A. Piotrowicz, Dr. K. Hills
• DARENT VALLEY HOSPITAL
• Dr. W. Melia, Dr. R. Ede, Dr. P. Mairs
• KINGS COLLEGE HOSPITAL - LIVER UNIT
• General Hepatopancreatobiliary / Liver ITU /
  Transplant Medicine
• Dr. J. OGrady, Dr. M. Heneghan, Dr. J. Devlin,
  Dr. P. Harrison,
• Dr. V. Aluvihare, Dr. K. Agarwal, Dr. E. Sizer,
  Dr. W. Bernal.
• Dr. G. Auzinger, Dr. J. Wendon.
• St. MARKS and St. THOMASS HOSPITAL
• Research Fellowship, Specialist Surgical
  Gastroenterology
• Prof R.J. Nicholls, Prof P.J. Ciclitira and Prof
  A. Forbes
• St. THOMAS and GUYS NHS TRUST
• Sir R. Thompson, Prof P.J. Ciclitira, Dr. J.
  Meenan,
• Dr. J. Sanderson, Dr. T. Wong, Dr. M. Wilkinson,
  Dr. R.Ede
• BROMLEY NHS TRUST
• Dr. J. Hunt, Dr. A. Jenkins, Dr. M. Asante
• ROYAL SURREY COUNTY HOSPITAL
• Dr. M. Smith

15
Specialty Areas of Interest

• Inflammatory Bowel Disease including tertiary
  referral clinics at St. Marks and St. Thomass
  hospitals.
• Surgical Gastroenterology - National Referral
  Unit for ileoanal pouches, faecal incontinence,
  complex anorectal fistula disease at St. Marks
• Small bowel pathology Coeliac disease tertiary
  referral clinics for complicated and
  non-responsive cases.
• Hepatology (General hepatopancreatobiliary
  medicine, Hepatitis clinics, Liver ITU, pre/post
  liver transplant medicine)

16
17 Publications

• 2009
• Coeliac disease in the elderly. Nat Clin Pract
  Gastroenterol Hepatol. 2008 Dec 5(12) 697-706
• Bacterial community diversity in cultures derived
  from healthy and inflamed ileal pouches after
  restorative proctocolectomy. IBD. 2009 Nov
• The bacteriology of pouchitis A molecular
  phylogenetic analysis. GUT. 2009. Dec
• The prevalence of osteoporosis and osteopenia in
  ileal pouch patients post-restorative
  proctocolectomy. IBD. 2009. Sept
• Prolonged toxic megacolon secondary to
  Salmonella. Submitted to Diseases of the Colon
  and Rectum
• 2008
• Coeliac disease in the older patient Are we
  ageist in our practice. Awaiting publication in
  Gastroenterolgy CME Journal
• The medical management of patients with an ileal
  pouch anal anastomosis after restorative
  proctocolectomy. EJoGH.
• Faecal M2-pyruvate kinase a novel, non-invasive
  marker of ileal pouch inflammation. EJoGH
• 2007
• Faecal calprotectin A non-invasive diagnostic
  tool and marker of severity in pouchitis. Eur J
  Gastroentero Hepatol. 2008 March 20(3) 174-179
• 2006
• Hyperbaric oxygen as a treatment for
  malabsorption in a radiation damaged short bowel.
  June 2006 18(6)685-688
• Risk of dysplasia and adenocarcinoma following
  restorative procto-colectomy for ulcerative
  colitis. Colorectal Disease. CDI-00256-2005.R1.
  03/05/06

17
Research Fellowship

• St. Marks and St. Thomas Hospital
• The Bacterial Pathogenesis of Pouchitis and
  Development of Novel Probiotic Therapies
• Prof PJ. Ciclitira, Prof RJ. Nicholls and Prof A.
  Forbes
• MD Awaiting Examination

18
(No Transcript)
19
(No Transcript)
20
Aims

• IBD Centre of Excellence
• SBCE
• HRM
• EUS

21
Luminology
22
(No Transcript)
23
To the ileum and beyond
24

• Oesophagus

25
High Resolution Manometry

• Spatiotemoral plots derived from gt36 closely
  spaced pressure sensors
• Reveals complex functional anatomy
• Increased our understanding of dysmotility
• Looks beautiful

26
Normal
27
Achalasia
28
Mid-oesophageal submucosal Ca
29
Herniation of Lap Wrap
30

• Stomach

31
Management of Dyspepsia BSG Guidelines
1996Updated 2002

• By
• Matt Johnson
• St. Thomass and East Surrey

32
Dyspepsia Introduction

• Prevalence 23 41 in UK
• 4 of GP consultations
• 10 of these are referred to hospital
• 2 of entire adult population receive either an
  OGD or a barium meal each year

33
Rationing of Endoscopy

• Morbidity 11,000 (Haemorrhage)
• Death 110,000 (Perforation)
• OGD is recommended in all patients gt55y D
• with new onset uncomplicated dyspepsia
• for gt 1/12 duration
• lt 55y with alarm symptoms C

34
Alarm Symptoms

• These include dyspeptic patients with
• Unintentional weight loss
• GI Bleeding
• Previous gastric surgery
• Epigastric mass
• Previous gastric ulcer
• Unexplained Fe deficiency
• Dysphagia or Odynophagia
• Persistent continous vomiting
• Suspicious barium meal

35

Investigation of dyspepsia in patients lt55
years NICE guidelines www.nice.org CG17 Test
and treat Helicobacter Empirical PPI therapy
Reduce role of endoscopy in the lt55 yrs Manage
uninvestigated reflux as dyspepsia Alarm symptoms
via TWW
February Surrey and Sussex
Healthcare 2008 NHS Trust
36
Investigation of dyspepsia in patients lt55 years
724 endoscopies performed 54 normal 13 major
abnormalities 33 minor abnormalities 42
recommended PPI therapy 8.1 helicobacter
eradication resulting 1 oesophageal cancer
discovered (aged 52)
37
Investigation of dyspepsia in patients lt55 years
Conclusions Three weeks out of year spend
endoscoping this group Findings in line with
other studies Very low prevalence of cancer in
this group Minimal evidence of change in
management
38
Iron Deficiency Anaemia
39
Causes of Fe deficiency Anaemia

• Occult GI Blood Loss
• Aspirin/NSAID use 1015
• Colonic carcinoma 510
• Gastric carcinoma 5
• Gastric ulceration 5
• Angiodysplasia 5
• Oesophagitis 24
• Oesophageal Ca 12
• GAVE (ectasia) 12
• Small bowel tumours 12
• Ampullary Ca. lt1
• Ancylomasta duodenale lt1

• Malabsorption
• Coeliac disease 46
• Gastrectomy lt5
• H. pylori colonisation lt5
• Gut resection lt1
• Bacterial overgrowth lt1
• Non-GI blood loss
• Menstruation 2030
• Blood donation 5
• Haematuria 1
• Epistaxis lt1

40
Iron Deficiency Anaemia

• Haemoglobin lt12 or lt13 nmg/L
• MCV lt76
• Ferritin lt15nmg/L
• Coeliac serology
• TFT
• Sickle cell and Thalassaemia screen
• Non-vegetarian
• No menorrhoea

41

• Small Bowel

42
COELIAC DISEASE

• Matt Johnson David Dewar
• Professor Paul Ciclitira
• St Thomass Hospital, London

43
Prevalence of coeliac disease

• Sweden 167 antibody positive
• Ireland 1100
• England 1150
• Europe 1300
• N America 1300
• Australia 1300

44
DERMATITIS HERPETIFORMIS
45
Associations

• Dermatitis herpetiformis
• IgA deficiency 2-3
• SBBO 8 of NRCD
• Hyposplenism ?80
• Microcytic colitis 5
• Autoimmune conditions 25
• Thyroid disease
• Type 1 diabetes
• Addisons
• Sjogrens syndrome

46
AD and age at diagnosis

• Group Prevalence AD
• A1 agelt2yrs 5.1
• A2 age 2-10yrs 17
• A3 agegt10yrs 23.6
• Prevalence of autoimmune disease is related to
  duration of gluten exposure

Ventura A (1999) Gastroenterology 117297-303
47
Osteoporosis

• 47 women lt 50 men on GFD have osteopenia /
  osteoporosisa
• Improvement 1 year post treatmentb

aMcFarlane (1995) Gut 36710-14 bValdimarsson
(1996) Gut 38322-7
48
Mortality

• Almost all mortality in CD is due to malignancy
• gt50 due to EATCL
• Other tumours mouth, oesophagus, sb,lb
• Mortality 1.9-3.4x control population
• Holmes et al 2x control pop1
• Mortality normal after 5 yrs on GFD2

1Holmes GK et al (1976) Gut 17(8) 612-9 2Holmes
GK et al (1989) Gut 30(3) 333-8
49
(No Transcript)
50
Ulcerative jejunitis

• Rare (6th decade) pre-malignant state
• Related to Enteropathy-associated T cell lymphoma
  (EATL)
• T Cell receptor PCR monoclonality
• UCL Prof. Isaacson
• Atypical gTcell receptor abnormalities
• Steroids, nutritional support, close observation

51
Treatment of coeliac disease

• Gluten-free diet
• Avoidance of wheat, rye and barley
• Oats (probably OK)
• Dietician
• Codex Alimentarius
• Coeliac societies handbook
• BUT NOT CORNFLAKES

52
Using Serology to Monitor Patients

• IgA gliadin and TTG normalise on a strict GFD
  after 3-6/12
• Must have pre-treatment levels
• IgG gliadin can be used but takes longer to
  normalise
• IgA endomyseal is costly and more difficult to
  quantify

53
Dewar D, Johnson MW, Ciclitira PJ, GUT 2005
54
Small Bowel

• UGI tract 0.8m
• LGI tract 1m
• Sb 5.6m
• 95 absorption capacity

55
Capsule Endoscope
A small disposable capsule about the size of a
jelly bean. Has own light source and video
camera. Suitable for adults and older
children. Transmits data to recorder worn at
waist. Patient swallows capsule with glass of
water after a simple overnight fast. Carries
on with normal activities and returns data
recorder after 8 hours.
56
BSG Indications for SBCEGuidelines April 2008 

• 1) Obscure gastrointestinal bleeding
• 2) Suspected sb Crohns disease
• 3) Assessment of Coeliac disease
• 4) Screening for Polyps / FAP
• Suspected small bowel malignancy
• Evaluation of side-effects of NSAIDs

57
Dartford SBCE Service

• A review of the first 37 small bowel capsule
  enteroscopies performed at Darent Valley
  Hospital.
• Stomach
• Gastritis (5)
• Erosions (6)
• Angiectasia (4)
• Polyps (1)
• Small bowel
• NSAID induced enteropathy (9)
• Angiodysplasia (2)
• Coeliac disease (7) - UCH pre-malignant
  ulcerative jejunitis
• Gastrointestinal stromal tumours (GISTs) (2) -
  2x St. Mark for D-balloon enteroscopy
• Crohns disease (5)
• Juvenile polyposis (1) - GOS
• Bacterial overgrowth secondary to small bowel
  diverticulae (1)
• Parasitic infestation (1)
• Multiple cystic lymphangiectasia (1)

58
Coeliac Disease

59
Using SBCE in Crohns

• 10-30 sb only
• 66 ileocaecal disease
• 20 colonic
• Wireless capsule endoscopy and Crohns disease. P
  Swain
• Gut March 2005 vol 54 no 3

60
Suspected Crohns
61
Obscure Intestinal Bleeding
5 of all UGI haemorrhages Benefits Safe, well
tolerated, able to view entire small bowel,
clarity of image Share images patient
preference Reduced diagnostic cost and
utilization If bleeding source identified Less
need for transfusions Reduced treatment cost and
utilization
62
Small bowel malignancies
Prior to SBCE sb tumours 1 - 2 of all GI
malignancies Now it is thought to compromise
5 PillCam Trial incidence of small bowel
tumors among 1,235 patients 6 - 9 (Corbin,
Bailey, Keuchel) 60 of SBTs are malignant -
adenocarcinomas, carcinomas, melanomas,
lymphomas and sarcomas 40 of SBTs are benign
GISTs, hemangiomas, hamartomas, and adenomas
63
Small Bowel malignancies
Often diagnosed late or incidentally at
laparotomy Malignant tumors of small bowel (poor
prognosis) Metastases - 45 -
75 Unresectable - 20 - 50 80 of SBTs
undergoing SBCE present with obscure GI
bleeding/anemia Improved outcome of earlier
diagnosed tumors in the small bowel On average
patients with SBTs who present for SBCEs have
already undergone detected SBTs after patients
had undergone an average of 4.6 negative
endoscopic procedures PillCam Trial (Corbin,
Bailey, Keuchel)
64
Final points

• Safe Well tolerated
• Cost-effective in economic analysis.
• This is now standard practice throughout UK
• Watford, Stevenage, Wellen Garden City,
  Cambridge, ?Aylesbury
• Presently the paediatricians refer to GOS
• Adult medicine is under-referring St.Marks
• External referral 800-1200
• Cost of service 13,000
• Cost of capsule 340

65

• Colon

66
Operative Picture
67
Complications

• Obstruction
• Bleeding
• Inflammation itis
• Fistula
• Sepsis
• Perforation
• May co-exist with IBD

68
(No Transcript)
69
(No Transcript)
70
(No Transcript)
71
Criteria for Toxic Megacolon (Jalan et al)

• 1) Radiographic evidence
• Total or segmental non-obstructive colonic
  dilatation of gt 6cm
• 2) 3 or more of
• Fever gt 38 C
• PR gt 120 / min
• Neutrophils gt 10.5
• Hb lt12.5
• 3) At least 1 of
• Dehydration
• Hypotension
• Electrolyte imbalance
• Altered consciousness

72
(No Transcript)
73
Probiotics are sooo outdated

• Prebiotics functional foods
• Inulin / Fructo-oligosaccharides / Lactulose
  Transgalacto-oilgosaccharides
• Chicory (boiled root 90 inulin)
• Jerusalem artichoke
• Onion
• Leek
• Garlic
• Asparagus
• Banana
• (cereals eg. Oatmeal)