South African Gastroenterology Review - latest Issue

The last edition of this journal for 2018 brings an end to a very beneficial year from an educational point for SAGES. Numerous conferences and standalone symposia in collaboration with the Gastro Foundation has resulted in positive feedback from our members.

Background & objective: Liver transplantation is an established, effective treatment for acute and chronic end stage liver disease. Donors risk factors should be studied in order not to compromise the procedure of transplantation or to lose candidates for transplantation, the study aims to evaluate the effect of variable donor risk factors on the outcome of Living donor liver transplantation regarding the morbidity and mortality.

Methods: the current study conducted on 48 patients who underwent living donor liver transplantation for End stage liver disease caused by chronic HCV. Morbidity and mortality were assessed at three and twelve months. Obtained data were studied in correlation with various donor related risk factors, a score designed to collect these risk factors, correlate them with recipient mortality, and graft rejection.

Results: high rates of graft rejection and recipient mortality was significantly related to older donor age, donor obesity, donorrecipient gender mismatch, hepatic steatosis, and donor graft recipient weight ratio (GRWR) ≤ 0.8. The designed donor risk score of ≥ 7 was expectedly to associate with poor outcome & recipient mortality.

Conclusion: The present study suggested that donor risk score can be a strong predictor of donor related risk factors and its effect on the outcome of Living Donor Liver Transplantation in patients espicially with hepatitis C genotype 4

Background: Ulcerative colitis (UC) is a chronic relapsing inflammation of the colon that sometimes fails standard medical therapy. Escalation of treatment often requires introduction of anti-TNF therapy. Golimumab is a new anti-TNF agent launched in South Africa in 2015 for moderate-severe UC. It is not licensed for Crohn’s disease (CD).

Method: Retrospective analysis of patients with moderate-severe UC requiring golimumab therapy (induction and maintenance therapy) for a 2 year period from September 2016 to August 2018 on the SAGES IBD registry. Patients gave signed informed consent.

Results: A total of 109 patients required induction therapy with biologics during this 2 year period of which 12 (11%) required golimumab. A further 4 patients were already receiving golimumab making it 16 patients in total. Fourteen (87.5%) patients had UC and 2 (12.5%) had CD. Ten (62.5%) of the 16 patients were female with a median age of 46. There was 1 current smoker. A small number (18.8%) were taking corticosteroids at the time of induction with golimumab but they all discontinued steroid therapy during golimumab treatment. All 14 patients with UC was currently or previously exposed to aminosalicylates. Four (28.5%) of them discontinued this treatment due to intolerance or lack of efficacy. None of the patients with CD received aminosalicylates. Fourteen (87.5%) of the 16 patients received immunomodulator therapy. Four (28.5%) patients discontinued this treatment because of side-effects or lack of effect. Eleven (68.8%) patients received both aminosalicylates and immunomodulator therapy concurrently during the study period. Ten (62.5%) of the 16 patients were naïve to biologics and were commenced on golimumab as first line therapy. Nine (90%) of the 10 patients remained on golimumab for the entire duration of the study. Six (37.5%) patients were switched to golimumab after having failed other forms of biologic therapy. Two (12.5%) patients stopped treatment with golimumab altogether during the study period because of treatment failure. Golimumab was well tolerated with good clinical outcome and no side-effects.

Conclusion: The use of golimumab for moderate-severe IBD remained low since its launch. Golimumab therapy was safe and effective in moderate-severe UC and CD, although patient numbers were low. Treatment failure rate was low.

Background: Primary Sclerosing Cholangitis (PSC) is a chronic, progressive cholestatic liver disease of unknown aetiology. Its incidence and prevalence vary considerably in Asian and Western studies.1 The differences in the recorded epidemiological data suggest that the presentation of PSC may vary in different populations. PSC has a strong association with Inflammatory Bowel Disease (IBD). The phenotype in patients with PSC alone can be different to that of patients with both PSC and IBD (PSC-IBD). There is a dearth of information on this topic from African countries in general and more specifically in the Black South African population.

Aim:
1. Describe the features of PSC subjects in terms of demography, clinical features, laboratory findings, radiographic imaging and outcome with an emphasis on the Black South African cohort.
2. Compare the findings in patients with isolated PSC to those with PSC-IBD.

Methods: 
Retrospective chart review of 305 patients with PSC and/or IBD, with the focus on patients with PSC and PSC-IBD. The study conducted at the Gastroenterology clinic at Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) from 1 January 2008 to 31 May 2014. The data was extracted and captured in Microsoft Excel and analysed using Statistical Product and Service Solutions (SPSS).

Statistical analysis: 
Descriptive statistics were used to summarize the demographic data – presented as counts and percentages. Parametric data are expressed as mean and standard deviation (SD). The Chi-square test was used to assess whether there were any association between PSC and the following factors: gender; ethnicity and a history of smoking.

Inclusion criteria: Patients aged 14 years and older with PSC or IBD, selected and identified using hospital medical records. The diagnosis of PSC was based on the presence of characteristic features on radiographic imaging (ERCP or MRCP) or on liver biopsy. The diagnosis of IBD was based on the clinical presentation as well as colonoscopyy, radiologic and pathological findings.

Exclusion criteria:
• Patients in whom the diagnostic procedures were done at an outside institution.
• Patients with liver abnormalities that could be attributed to drug induced liver injury.
• Patients who have other aetiologies which could account for the PSC- like features e.g. HIV

Results:
o The study population composed of 305 subjects, including 119 Black African patients.
• The PSC cohort consisted of 69 patients.
• There were 35 patients with PSC alone o 22 patients were Black African
• There were 34 patients with PSC-IBD
• 25 patients were Black African Summary of the demographic data presented in Figure 1.

Introduction
Cytomegalovirus (CMV) is a member of the Herpes virus group. It is a double stranded DNA virus and is known as Human Herpes Virus 5 in human hosts. CMV seropositivity is frequent in Western populations with a seroprevalence of 58% being reported in the U.S.¹ In Africa, pooled prevalence studies demonstrate rates as high as 81.8% amongst HIV uninfected adults. Amongst the HIV infected population prevalence rates of 81.9% and 94.8% were seen in AIDS and asymptomatic HIV positive patients respectively.² This is likely a reflection of impaired humoral immunity amongst those with AIDS. In a rural South African cohort, a 100% seroprevalence was demonstrated amongst HIV positive treatment naïve patients with a negative association noted between CD4 counts and IgG titres.³

Introduction
Common variable immunodeficiency (CVID) is a rare form of severe immunodeficiency manifested by recurrent bacterial infections with several gastrointestinal manifestations. Herein we describe an unusual presentation of CVID.

The idyllic Vineyard Hotel, with its beautiful backdrop of Table Mountain, played host to the 11th Gastroenterology Foundation of Sub-Saharan Africa Inflammatory Bowel Disease [IBD] Interest Group Meeting held on 27 October 2018. The meeting was well attended by local Capetonian gastroenterologists and others with an interest in IBD.

On a beautiful Saturday morning, I made my way to the Radisson Blu Gautrain hotel in Sandton for the 9th annual liver interest meeting. After a quick cup of coffee to catch up with colleagues, we made our way into the modern and stylish conference centre to begin the talks of the day.

The Gastroenterology Foundation of SSA once again visited Ghana and contributed to the 4th GASSLID meeting in Accra with a pre-congress Endoscopy Workshop, the first of its kind. The South African Faculty supported this Gastro Foundation pilot endoscopy course with the intention of hosting similar courses in several SSA countries. The SA faculty included Professor’s Sandie Thomson and Eduard Jonas from the University of Cape Town Gastroenterology Unit and Professor Chris Kassianides, Chairman of the GFSSA.

A lot of doctors and nurses of the South African gastroenterology community used the opportunity to join this live-streamed event from Hamburg. On Friday 2 November, 2500 delegates joined Prof Thomas Rösch (President 2018) and his team in Hamburg to help deliver EndoClubNord, the largest live Endoscopy meeting in the World.

SAGES 2018 prizes

The 56th annual SAGES conference held at The Forum in Sandton between 8th and 11th August 2018, featured a number of post graduate programs hosted by the Gastroenterology Foundation of SSA.