South African Gastroenterology Review - latest Issue

The World Health Organization (WHO) published a report in 2016 towards combating hepatitis B and C to reach elimination by 2030. Viral hepatitis is a leading cause of death worldwide and in 2013, 1.46 million deaths were attributed to this disease – more than 90% due to complications of hepatitis B and C. Shockingly, less than 0.3 % of patients with HBV infection gets diagnosed in the WHO African region. This combined with the fact that fewer than 1% receives treatment, greatly contributes to the spread of the disease.

• Liver fibrosis assessment is key to rapid decision making with respect to treatment and prognosis in liver disease
• Liver biopsy remains the gold standard for assessing fibrosis and pattern of injury but is invasive, costly, relatively unavailable and is unsuited to the rapid and efficient upscaling of treatment to those in need of care e.g. viral hepatitis
• Non invasive technologies are supplanting liver biopsy as the primary means of assessing liver fibrosis
• Transient elastography (FibroScan^® ) – first introduced in 2003 – has evolved as a reliable and validated noninvasive technology for assessing liver fibrosis
• The technique is simple and requires easily transferrable operator skills
• A minimum of 10 readings are required to be valid 
• Substantial data supports its validity in a variety of chronic liver diseases with AUROC scores that range between 0.85 and 0.95
• FibroScan^® has the added benefit of assessing fatty change in the liver via the CAP (Controlled Attenuation Parameter) assessment score
• Potential users of this technology should acquire the requisite upskilling to operate Transient Elastography (FibroScan^® )
• To achieve the objectives of the National Viral Hepatitis Elimination Strategy in South Africa, such technology will be needed in the public sector
• The cost effectiveness of this technology with appropriate allocation of funding codes is required for the private sector

International Sustainable Development Goals set ambitious elimination targets for hepatitis B virus (HBV) infection by 2030. We here set out to review barriers, challenges and opportunities for progress towards these goals, with a particular focus on South Africa. Although many African populations still have a high prevalence of HBV infection (defined as ≥8%), interventions and planning have been hampered by limited data. The majority of HBV infections (>90%) currently remain undiagnosed, and - even when a diagnosis is made - cases are not well stratified to determine prognosis, risk of transmission, and treatment eligibility. Nucleos(t)ide analogues can be successful in suppressing the virus but must generally be taken life-long, and there are concerns around the possible emergence of drug and vaccine resistance. Poor funding, lack of advocacy and education, and the stigma associated with infection represent further barriers. Despite these diverse challenges, we are in an era of opportunity to advance South Africa’s progress towards elimination goals. Widespread deployment of the HBV vaccine in infancy has already markedly reduced paediatric infection, and birth dose vaccinations will further reduce the risk of vertical transmission. South Africa can capitalise on the laboratory and clinical infrastructure that already supports HIV diagnosis and treatment, by expansion of services to include HBV. HBV treatment and diagnostics are now on WHO lists of essential drugs and equipment. In the decade ahead, South Africa can make significant advances, but this will require sustained attention and investment from stakeholders in policy, public health, clinical care, and basic science.

The substantial burden of colorectal cancer and its propensity to affect certain groups preferentially exposes a need to understand the mechanisms by which these malignancies develop. Several dietary and lifestyle factors have been implicated in the development of colorectal cancer, possibly through the intricate metabolic and inflammatory mechanisms. Likewise, as a key metabolic and immune regulator, the gut microbiota has been recognized to play an important role in colorectal tumorigenesis. Environmental factors are seemingly determinants for the gut microbial composition and function, alterations of which induce changes in the host gene expression, metabolic regulation, and local and systemic immune response, thereby influencing cancer development. This review highlights the epidemiologic and mechanistic evidence regarding the links between diet and lifestyle and the gut microbiota in the development of colorectal cancer. A focus is placed on factors for which substantial data supports their importance for colorectal cancer and their potential role in the gut microbiota, including dietary patterns, fibre, red and processed meat, fat consumption, obesity and physical activity. As the level of data surrounding the importance of the microbiome and environment in colorectal carcinogenesis develops, it is hoped that this will lead to development and clinical translation of potential microbiota-based strategies for cancer prevention.

Background: Schistosomiasis, previously thought to be a rural problem, is a common parasitic disease caused by flukes (trematodes) of the genus Schistosoma. More than 207 million people, 85% of whom live in Africa, are infected with schistosomiasis, and an estimated 700 million people are at risk of infection in 76 countries where the disease is considered endemic because agricultural work, domestic chores, and recreational activities expose them to infested water. The infection manifests itself as a variety of different pathologies, depending on the location of the parasite and its ova in the body.

Like other developing countries, schistosomiasis is endemic in certain regions of South Africa. Rapid urbanization as a result of mass rural-urban migration has led to the appearance of many informal settlements, with its associated socioeconomic problems, near major metropolitan areas. Schistosomiasis can therefore no longer be considered as a rural disease.

Schistosomiasis of the appendix, though first described more than a century ago, had remained a rare surgical manifestation of the disease with an overall prevalence of 0.024%, even in areas where the disease is reported to be endemic. A recent study in Nelspruit by Botes et al, however, showed a prevalence of 10% among all appendix samples over a 4-year period.

A case of appendiceal schistosomiasis presenting with recurring abdominal pain, is reported. Consent was sought from patient before publication.

IgG4-related disease (IgG4-RD) is a newly recognized disorder characterized by increased level of IgG4 and tumefaction or tissue infiltration by IgG4+ plasma cells.1,2 IgG4-RD can affect multiple organ systems. In this case report, we describe a patient who presented with portal vein thrombosis complicated with portal hypertension and esophageal varices. To our knowledge, this complication of IgG4-RD has not yet been described in the medical literature.

An opportunity was afforded me to consolidate the technical and theoretical knowledge, learning and experience garnered during my two-year Witwatersrand University HPB Fellowship by being awarded an International Travel Fellowship by the courtesy of the sponsorship of the Oscar Norwich Foundation, together with the unwavering support and encouragement of the Gastro Foundation South Africa, organisations to whom I am profoundly grateful. The Travelling Fellowship enabled me to spend a period of 10 weeks in Mumbai, India at the Global Hospitals Mumbai and the Tata Memorial Hospital from October to December 2018.

On the 1st of February, a pristine day at Spier in the Cape ushered in the 10th annual Gastro Foundation Fellows meeting. The preceding meetings promised and delivered not only invaluable academic preparation for fellows sitting for the exit exams in various fields of gastroenterology, but the opportunity to network and form enduring friendships. This meeting would prove no different.

I was invited to an interest group meeting at Inanda Club, Sandton that was hosted by the Gastro Foundation. It was a beautiful sunny Saturday morning and the room was filled with familiar faces. What better way to spend a Saturday morning: great food, excellent company and brilliant discussions.