Recommended Read November 2013

If you have attended the TiPGHAN-AM meeting last month, you would have heard that how wonderful Ursodeoxycholic acid (UDCA) in the setting of intestinal failure associated liver disease and cystic fibrosis associated liver disease. UDCA is also used in primary sclerosing cholangitis (PSC). Approximately 80% of patients with PSC have concomitant inflammatory bowel disease (IBD), conversely only 5% patients with IBD have PSC.  Eaton et al in their study published in American Journal of Gastroenterology (The American Journal of Gastroenterology 106, 1638-1645 doi:10.1038/ajg.2011.156) had looked at the impact of UDCA in the development of colorectal neoplasia in patients with PSC and concomitant ulcerative colitis (UC). They performed a nested cohort study among 56 out of 150 subjects enrolled in the high dose UDCA trial who had UC. 25 patients were randomised to UDCA and were followed up for a mean period of 4 years and 31 had been randomised to placebo and were followed up for a mean of 4.3 years. Patients in both groups had a median of 4 surveillance colonoscopies in this period. 9 out of 25 (36%) in the UDCA group developed colorectal neoplasia whereas 3 out of 31 (10%) in the placebo group developed colorectal neoplasia. The higher incidence of colorectal neoplasia in the UDCA persisted after adjustments of potential confounders like smoking and duration of UC. The authors conclude that long term use of high dose Ursodeoxycholic acid is associated with increased risk of colorectal neoplasia in patients with PSC and UC. It may be worth considering changing our practice to use UDCA only for cholestatic patients with PSC.

I trust that most of our members are entering their patients into the national IBD biologics audit. The audit organisers have sent out the annual report earlier this year and I have noted that they were ‘’disappointed’’ to see that most paediatric gastroenterology centres are not screening children with Crohn’s disease for Hepatitis B virus (HBV) prior to starting on biologics treatment. Is there any evidence for screening asymptomatic children with normal liver function tests for Hepatitis B, especially in low endemic countries like the UK? A quick internet search reveals that few national and international organisations advise to ‘consider’ Hepatitis B screening, but no specific advice for children or advice for screening based on risk stratification. Van der Hove et al assessed the cost effectiveness of HBV screening prior to initiation of TNF-alfa inhibitors treatment in Crohn’s disease (Van der Hove et al Dig Dis Sci Doi 101007/s10620-013-2820-9).  Direct medical costs were assessed and discounted following a third party payer perspective. The main outcome was the incremental cost effectiveness ratio (ICER). HBV screening became cost effective only if HBV reactivation or HBV related mortality is higher than 37 and 62% respectively. Authors concluded that extensive HBV screening is not cost effective compared to no HBV screening and screening high risk group of patients are likely to become cost effective. National Institute of Clinical Excellence (NICE) has commented on this topic recently as part of their guideline Hepatitis B (chronic): Diagnosis and management of chronic hepatitis B in children, young people and adults CG 165 http://publications.nice.org.uk/hepatitis-b-chronic-cg165.  NICE guidelines state that ‘’Further research should be undertaken to determine whether long-term use of mild immunosuppressive agents for autoimmune and allergic problems presents a risk for reactivation of HBV infection in people with previous or current chronic hepatitis B, including occult HBV infection. The cost effectiveness of routine tests for HBV in this population, including HBV DNA for occult HBV infection, and the need for prophylactic treatment with nucleoside or nucleotide analogues needs further evaluation. Prospective studies are needed to assess the risk of HBV reactivation in people receiving mild immunosuppressants or biological treatment for autoimmune diseases, to identify risk factors that predict HBV reactivation in this population, and evaluate treatment or pre-emptive strategies using existing nucleoside and nucleotide analogues.’’. It looks like that biologics audit committee have no reason to be disappointed; instead they should be applauding the paediatric gastroenterologists for practicing evidence based medicine.

It is not a big surprise to learn that Italians love their food and this affinity has now transcended to their scientific publications. Antonia Affnita et al have given an irresistible title to their paper ‘’Breakfast: a multidisciplinary approach’’ and analysed breakfast related issues rather unsurprisingly in a multidisciplinary way (Affnita et al Italian Journal of Paediatrics 2013, 39:44). They have summarised that ‘’the historical, bio physiological and educational value of breakfast in our culture is extremely important and should be recognised and stressed by scientific community. Efforts should be done to promote this practice for the individual health and wellbeing.’’  Breakfast loving members of BSPGHAN should not ignore this article and may wish to follow the healthful example of 18th century Italians and ‘’ go to the fields at sunrise to have breakfast with the whole family; they take dry food, salted meats, cheese fruit and wine, throw a tablecloth on the grass and have hearty meal near a stream or fountain, breathing in the flower scented air’’.  This is not something I would be doing in Birmingham, but would be very keen to hear the breakfast experience of our members from different parts of the country.

We know that feeding fructose in unlimited quantities to non- human primates; they get fatty livers within 6 weeks. The effect of fructose rich beverages on human adolescents is much difficult to assess, given that you cannot cage teenagers and feed them on a controlled diet- even though you may wish to do so sometimes. However we have the answer now to this question thanks to a study published in American Journal of Nutrition by Ambrosini et al (10.3945/ajcn.112.051383). Food diaries kept by 1433 adolescents in Western Australia were reviewed and their body mass index, waist circumference, blood pressure, fasting lipid, glucose and insulin were all measured and overall cardio-metabolic risk was estimated. Authors have found that high sugar sweetened beverage intake has strong correlation with risk of obesity and adverse cardio-metabolic factors.

Wars have not done much good to anyone other than probably for arms traders.  However history shows that few thin children in the Dutch Hunger Winter of 1944-45 got better when deprived of bread by Nazi occupiers. There after coeliac disease was recognised as paediatric disease and later it was found that adults as well can be affected by coeliac disease. However introduction of reliable serology testing had shown that coeliac disease is not as uncommon as previously thought. Lisa Whyte and Huw Jenkins have looked at the clinical presentation of children with coeliac disease in South Wales over the last 28 years (Arch Dis Child 2013;98(6):405-7). 163 patients were diagnosed from 2005 to 2011, 50 patients from 1999 to 2004, 21 patients from 1990 and 1998 and 11 patients from 1983-89. They have also found that over 50% patients exhibited few or no symptoms and 36% patients were diagnosed after targeted screening. This increase in asymptomatic patients needs to be kept in mind when we try to implement the new BSPGHAN guidelines on coeliac disease which puts its emphasis on coeliac serology in symptomatic children. It is also reassuring that gluten free diet as per medical advice was the mainstay of the treatment of these children in the last 24 years rather than Dr Jenkins and colleagues have to rely on any forces to occupy and deny bread to children in South Wales!

Most of these articles can be obtained by your Athens account and I would encourage our trainee members to read these articles in full. Please send your feedback to Carla.
Yours sincerely,

Rafeeq
Chair of Education committee
October 2013