Recommended Read (May 2014)

Education committee is happy to circulate another edition of ‘recommended read ‘to our members.

  Ángel Arias et al has published a systematic review and meta analysis of Efficacy of Dietary Interventions for Inducing Histologic Remission in Patients With Eosinophilic Esophagitis (EoE) in Gastroenterology this month http://dx.doi.org/10.1053/j.gastro.2014.02.006 . The authors have analysed data from 1317 patients with EoE (1128 children and 189 adults) who received different dietary treatments. Elemental diets were effective for 90.8% of cases, Six Food Elimination Diet (SFED- avoiding milk protein, soy, eggs, wheat, peanuts/treenuts, and seafood) for 72.1% and allergy test result–directed food elimination for 45.5% of cases.  Dietary interventions are effective in producing histologic remission in patients with EoE. Elemental diets and SFEDs were the most effective, achieving <15 eosinophils/high-power field in 90.8% and 72.1% of patients, respectively. Authors conclude that ‘’their research has demonstrated that dietary modifications are an effective treatment alternative for inducing histologic remission of EoE, reinforcing the idea that this strategy should be considered as a first-line therapy in both children and adults affected by the disease’’. They also recommend research in many aspects related to dietary treatment that require clarification, including the sustained effect of dietary restriction in maintaining EoE remission, changes in oesophageal fibrosis, aspects associated with adherence to the diet, and quality of life issues.

Please note that this article (open access) will be open for discussion from 8pm next Thursday in our new activity ‘Journal club on Twitter’ #PGHANJC

  In most IBD centres, vitamin B12 levels will be checked from time to time in patients with Crohn’s disease. Do all patients with ileal Crohn’s disease or ileal resection will develop vitamin B12 deficiency? Battat R et al have published a systematic review in the journal of Inflammatory Bowel Disease Inflamm Bowel Dis. 2014 Jun;20(6):1120-8. doi: 10.1097/MIB.0000000000000024.  After reviewing about 3700 patient details, the authors have reported that Crohn's disease without ileal resection, regardless of disease location in the ileum, did not increase the risk for B12 deficiency. Ileal resections greater than 30 cm were associated with B12 deficiency in Crohn's disease, whereas those less than 20 cm were not. The effects of 20 to 30 cm resections were inconsistent. Ulcerative colitis did not predispose to B12 deficiency. It would be good to look at the UK data on this in paediatric IBD. A point to ponder for the IBD working group.

  When you see your next patient with coeliac disease, have a think whether he or she is ‘tougher’ than your patient with IBD.  I was surprised to see that patients with coeliac disease rated the burden of their treatment at or greater than the level experienced by individuals who needed dialysis, insulin injections, and other chronic medical treatments (Shah S et al to be published in Am J Gastroenterology). Compliance with the gluten-free diet could be challenging due to many factors, including the taste and texture of non-gluten alternatives, social reasons, peer pressure, and the inconvenience and expense of obtaining gluten-free foods. A significant proportion of patients with coeliac disease who are following a gluten-free diet may have persistent symptoms. The potential causes include continued gluten ingestion, often from trace ingredients not readily recognized as sources of gluten in food and from so-called hidden sources in non-food products such as medications and toothpaste.   Persistent coeliac disease activity with elevated coeliac disease–specific autoantibodies, inflammation, and/or villous atrophy is not unusual in patients taking strict gluten-free diet.  There are conflicting reports regarding whether such persistent mucosal injury is associated with increased mortality in patients with coeliac disease. Considering all these issues, other strategies beyond a strict gluten-free diet alone are highly sought after by patients with coeliac disease. Lähdeaho, M.L et al have published their findings of a randomized, controlled, phase II clinical trial of ALV003, an oral mixture of 2 recombinant gluten-specific proteases in adult patients with biopsy-proven coeliac disease http://dx.doi.org/10.1053/j.gastro.2014.02.031. ALV003 contains a prolyl endopeptidase from Sphingomonas capsulate, in combination with another endopeptidase from germinating barley. Adult patients with biopsy-proven coeliac disease were randomized 1-to-1 to receive ALV003 or placebo drug along with the daily gluten challenge. Twenty received the study drug and twenty one received placebo. The gluten challenge led to mucosal injury in the placebo group; no significant mucosal changes were noted in the study drug group. Over the 6-week trial, there were significant differences in the morphologic changes that occurred between the 2 groups of subjects. No changes in coeliac disease serology were seen between the 2 groups. Gastrointestinal symptoms secondary to gluten ingestion were significantly greater in the placebo group compared with those receiving active treatment. This study has significance in providing another treatment option to patients with coeliac disease. This could also potentially alter the recent recommendations that the diagnosis of coeliac disease can be achieved without performing small intestinal biopsies. National regulators like NICE may reserve endopeptidases to patients with biopsy proven coeliac disease.

  An academic equivalent of a boxing match is happening in the field of gut microbiota and immunology over the relevance of Faecalibacterium prausnitzii in Crohn’s disease. Harry Sokol and colleagues from France has reported that a reduction of a major member of  Faecalibacterium prausnitzii is associated with a higher risk of postoperative recurrence of ileal CD doi: 10.1073/pnas.0804812105. A lower proportion of F. prausnitzii on resected ileal Crohn’s disease mucosa also was associated with endoscopic recurrence at 6 months. They have observed that oral administration of either live F. prausnitzii or its supernatant markedly reduced the severity of TNBS colitis and tended to correct the dysbiosis associated with TNBS colitis. They have proposed that counterbalancing dysbiosis using F. prausnitzii as a probiotic is a promising strategy in CD treatment. Richard Hansen and colleagues from Aberdeen have looked at the microbial changes in children with IBD at diagnosis by biopsying the colonic mucosa of 37 children: 25 with newly presenting, untreated IBD with active colitis (13 patients with Crohn’s disease and 12 children with ulcerative colitis), and 12 paediatric controls with a macroscopically and microscopically normal colon (Am J Gastroenterol 2012; 107:1913–1922; doi:10.1038/ajg.2012.335) . They have noted an increase in Faecalibacterium in patients with Crohn’s disease compared with controls. They have proposed that we need to challenge the current model of a protective role for F. prausnitzii in CD. In the recent study published in the journal of IBD (doi: 10.1097/MIB.0000000000000023), Gerasidimis and colleagues from Scotland  reported that Faecalibacterium prausnitzii  concentration significantly decreased after 30 days on exclusive enteral nutrition in children with Crohn’s disease  and in patients who responded to exclusive enteral nutrition treatment, the magnitude of the observed changes was greater. These findings go against the principle that Faecalibacterium prausnitzii is always protective in patients with Crohn’s disease.  I do not believe that we have heard final word on this matter. Please keep your eye out for more developments in this field and we will update you as well.

  A bodily function frequently mentioned in the gastroenterology consulting room is the passage of wind and its relationship to diet and disease.  Professor Azpiroz and colleagues from Barcelona (Gut 2014;63:401-408 doi:10.1136/gutjnl-2012-303013) have bravely set out to unravel the association between the colonic microbiota and flatulence in a study comparing people complaining of flatulence with healthy volunteers. In order to avoid Anglo-Saxon crudity, the authors refer to their outcome measure as ‘’gas passed per anus’’ which should not be confused with gas passed ‘’per annum’’ which would be very tricky to measure. The authors reported that ‘when challenged with flatulogenic diet, patients’ microbiota developed instability in composition, exhibiting variations in the main phyla and reduction of microbial diversity, whereas healthy subjects’ microbiota were stable. Taxa from Bacteroides fragilis orBilophila wadsworthia correlated with number of gas evacuations or volume of gas evacuated, respectively’’. A simple conclusion- people complaining of flatulence have a poor tolerance of intestinal gas.

Most of these articles could be accessed by your Athens account. Please do send your feedback to education@bspghan.org.uk . Please also use twitter account of BSPGHAN to share your views.

Yours sincerely,

Rafeeq
Education Committee
May 2014