Gastroenterology teamBMJ 2016; 352 doi: https://doi.org/10.1136/bmj.i1592 (Published 23 March 2016) Cite this as: BMJ 2016;352:i1592
Dietary management of irritable bowel syndrome
“In the past, managing irritable bowel syndrome by controlling the diet has been seen as a wacky idea—one for those who aren’t science driven,” admits Miranda Lomer, senior consultant dietician at Guy’s and St Thomas’ NHS Foundation Trust in London. But many minds have been changed by the success of a dietary regimen originally developed in Australia.
Better care is certainly needed. Irritable bowel syndrome affects 10-15% of adults and causes pain, bloating, and other symptoms. Most patients should be manageable in primary care, Lomer says, yet the condition accounts for 40-60% of gastroenterology referrals. Many patients require repeated follow-ups and less than half benefit from changes in diet.
Enter the low FODMAP (Fermentable Oligo-Di-Monosaccharides and Polyols) diet. FODMAPs are carbohydrates: fructose, lactose, fructans, galactans, and polyols. With help from an Australian dietician, the low FODMAP diet was modified for UK conditions and tested on patients. Satisfaction with symptom improvement rose to 76%, far higher than with other diets. A randomised controlled trial followed, and it showed that 68% of patients had adequate symptom relief compared with 23% continuing their normal diet.
Implementing low FODMAP diets is not simple. “People who try to do it on their own after searching on the internet tend to omit too many foods,” she says. But as the trust’s success became more widely known it was inundated with referrals. So a system of group rather than individual education was devised, with groups of 12 patients doing two sessions, each of 1.5 to 2 hours. “As soon as one patient opens up, they all talk,” she says. “It creates a great self help network.” The low FODMAP diet is now incorporated into official guidelines, 600 dieticians have been trained, and 70 000 UK patients have had access to the resources generated.
IBD Passport travel resource
Inflammatory bowel disease is rising in incidence, affecting between 0.5% and 1% of the population. It can be managed but not cured, and periods of feeling fine can end with a relapse. “There’s no predictable pattern to these flare-ups,” says Kay Greveson, a clinical nurse specialist at Royal Free Hospital in London. “Symptoms include diarrhoea, bleeding, fatigue, and generally feeling unwell.”
Unsurprisingly, people fearing such a flare-up may be reluctant to travel. “Some are on immunosuppressive drugs and, although these have an 80% success rate, patients are tied to a hospital since they need an admission every eight weeks for the drugs to be administered,” she says. “Young patients who might like to take a gap year abroad can’t go. It didn’t seem fair.”
Clinical advice is that patients can travel but need to plan carefully. What was lacking was a single source of reliable information, designed for this particular group. A survey of patients and health professionals showed that less than a quarter of patients sought advice before travelling, and half of those taking immunomodulatory therapy were unaware that they should avoid live vaccines. More than a quarter of healthcare professionals lacked confidence about giving travel advice.
Greveson set up a dedicated website, IBD Passport, on her own initiative and largely at her own cost. Intended as a global resource, its content was peer reviewed and aims to provide accurate and up-to-date advice. “I was aiming to produce an all encompassing website that would tell people everything they needed to know about travelling with IBD,” she says. “There was nothing like this before. There are sources like NHS Fit for Travel, but they are generic websites that don’t go into the intricacies of the do’s and don’ts.”
Feedback has been strongly positive. There are plans for translations into languages other than English, and the idea could be extended to other chronic conditions.
Faecal calprotectin testing in primary care
Patients who go to their GPs with bowel problems create a dilemma: do they have irritable bowel syndrome (IBS) or the less common but more serious inflammatory bowel disease (IBD)? “Symptoms on presentation can be vague,” says Janet Wilson, a public health principal in Wakefield who divides her time between the local authority and Wakefield Clinical Commissioning Group.
“Some people were going to the GP five or six times a year, and the GPs were unsure whether it was IBS. Some GPs were referring because they were nervous. What we wanted to do was to streamline the pathway. If there was a test to distinguish IBS from IBD, we would be able to avoid a number of these patients even going to the hospital and having to undergo invasive procedures.”
The team identified the faecal calprotectin test, which detects inflammatory markers in stool samples. While the business case for its use was being developed the National Institute for Health and Care Excellence published guidance recommending it. The test was introduced with a threshold score: patients below the threshold would have IBS diagnosed, and those above might require further action, such as a repeat test, before deciding on referral.
The initiative has proved successful and experience has enabled the threshold to be raised without risk of diagnostic error. In 2014-15, 652 patients fell below the threshold, of whom 80% would before have been sent for endoscopy—so 521 endoscopies were avoided. As well as reducing anxiety to patients, the new pathway has cut pressure on clinics and saved money. Nor was there any evidence that patients who really needed endoscopies were not getting them. “We took a sample of patients who had scored very high in the tests, tracked them back, and found that all of them had been referred within two weeks and had got an endoscopy,” Wilson says.
Directaccess colonoscopy and sigmoidoscopy
East London has among the worst bowel cancer survival statistics in England, and some of the lowest colonoscopy rates. But the obvious solution of simply referring more suspect cases would risk saturating the clinics and lengthening waiting times. The answer found by City and Hackney Clinical Commissioning Group and Homerton University Hospital was to streamline the process, dispensing with the initial appointment and referring patients directly from general practice to colonoscopy.
Robert Palmer, a GP with a special interest in gastroenterology, says: “Many younger patients have rectal bleeding, and what they need is a diagnosis—they’re worried they may have cancer, and so are their GPs. The traditional pathway was to refer them all to a colorectal surgeon in clinic, who’d say, ‘Yes, you’d better have a sigmoidoscopy’ and would make an appointment, and six or eight weeks later they’d have it. We thought this is crazy. So in 2012 we set up direct access sigmoidoscopy for patients aged 18-55 with rectal bleeding who didn’t fulfil the two week wait criteria.”
This eliminated the hospital triage step. In 2014 the idea was extended to colonoscopy, for those aged 40-70 meeting defined criteria. General practitioners make the appointments using Choose and Book.
“It’s gone well,” Palmer says. When cancers are detected, they are found earlier and the patients who do not have cancer get reassurance more quickly. The sigmoidoscopy service is now open to patients nationally, with referrals coming from neighbouring boroughs and one from as far away as Bristol. The colonoscopy service remains restricted to Hackney only.
Had this service been available London-wide over the same period, Palmer estimates that diagnostic delays would have been reduced, and stage at diagnosis improved, for 81 young patients with colorectal cancer.
Novelsmall bowel endoscopy
The arrival at the turn of the 21st century of capsule endoscopy—use of a tiny swallowable camera that takes pictures as it moves through the digestive tract—has opened up a window on the small bowel that was previously beyond the endoscopist’s range. More than 11 000 capsule endoscopies are now performed every year in the UK. “It’s certainly not a niche specialty,” says David Sanders, consultant gastroenterologist at Sheffield Teaching Hospitals NHS Foundation Trust.
“We could see everything, but we couldn’t do anything,” he says. “So this led to the development of a new technique, double balloon enteroscopy, where you can ‘concertina’ the small bowel on to the enteroscope, marching down the bowel with the aid of a balloon on the scope and a second balloon on the overtube surrounding it. But it takes more than an hour, and it’s very uncomfortable for the patient.”
Talking to patients it was clear that many found the procedure intolerable and the pain relief inadequate, despite high doses of sedation. “This brought us to propofol, which controls pain much better. In the United States and Australia it’s commonplace because endoscopy units there are manned by anaesthetists.
“So we lobbied for it to be given an HRG [Healthcare Resource Group] code so the NHS would pay for it, and thought ‘why don’t we do the propofol in the endoscopy room, rather than in theatre?’ because if we do that we save on all the overheads. It also gives us increased turnover of cases. We were able to show savings of £100 000 a year by having it in an out-of-theatre setting.”
The Sheffield team has shared its expertise and trained more than 40% of the small bowel units nationally in its use. “It’s been so successful that at Sheffield they’ve started using it in urology too. It’s transferable to anybody who’s doing minimally invasive procedures in theatre,” he says. “The patients’ pain ratings are down from eight (on a zero to 10 scale where 10 is intolerable) to zero. It’s wonderful.”
Cytosponge: find cancer early
Cancer of the oesophagus is rising and despite advances in treatment, five year survival is only 13%. The biggest risk factor is acid reflux, but most patients who go to their GPs with this complaint are not sent for endoscopy. Given how many there are, that’s hardly practicable. A much simpler diagnostic tool that can be used in primary care is needed, says Rebecca Fitzgerald, professor of cancer prevention at Cambridge.
Her answer is the Cytosponge—a swab on a string that is swallowed by the patient, remains in place for a few minutes for the gelatin-like coating to dissolve, and is then retrieved with only minor discomfort. The cells it has collected are tested for the presence of a protein, Trefoil factor 3 (TFF3), which is a marker for Barrett’s oesophagus, a common precursor of cancer.
“The test has a very high negative predictive factor, 99%, to eliminate the largest possible number of patients from the need for further investigation,” she says. In a series of four studies the Cytosponge has proved suitable for use in primary care, accurate in diagnosing Barrett’s, and acceptable to patients. The technology has been licensed to Medtronic.
“We’re now launching a final study in primary care to make sure the health economics add up,” she says. “Then we’ll be in a position to take it to the National Institute for Health and Care Excellence.”
There is a risk that use of the test might generate such a need for follow-up that endoscopy departments would be flooded. “We’re aware of that, so now we’re working on going one step further,” she says. “You get a lot of cells off this sponge, so you can look for other biomarkers, going one step further and instead of saying, ‘Is there Barrett’s or not?’ we could say, ‘Is this worrying?’ Does the patient need an endoscopy or could they simply come back for monitoring in one or two years’ time?”
The Gastroenterology Team of the Year award is sponsored by Takeda and Crohn’s and Colitis UK. The awards ceremony takes place on 5 May at the Park Plaza Hotel, Westminster. To find out more go to www.thebmjawards.com.