South African Gastroenterology Review - latest Issue

Given its role in metabolic regulation, the gastrointestinal tract constitutes a significant target in the management of Type 2 Diabetes Mellitus (T2D). Since the landmark paper by Dr. Walter Pories and his research team1, numerous randomized clinical trials over the short and medium term demonstrated that metabolic surgery achieves excellent glycemic control and reduces cardiovascular risk factors. In this issue of Gastro Review Jeanne Lubbe reports on the current evidence and the role of metabolic surgery in South Africa. Given the shocking findings for South Africa in a global obesity study that highlighted the massive problem not only in adults, but also in children with 13% overweight or obese – more than the global average of 5%, it is plausible that this modality will play a significant role in the future management of this problem.2 Traditionally bariatric surgery is primarily viewed as an intervention that reduces the risk of future disease (i.e., to prevent metabolic or cadiovascular complications of severe obesity) rather than an approach to treat established disease.

Significant progress has been made in the understanding of ulcerative colitis and Crohn’s Disease over the last decades. Despite this, the pathogenesis of inflammatory bowel disease (IBD) remains obscure, especially at molecular level. Various contributing factors have been identified so far, but their respective contributions are not entirely clear cut. In this review, we focus on the genetic and environmental factors linked with IBD pathogenesis. We also explore the role of pro-inflammatory cytokines on the molecular pathophysiology of IBD. Conflict of interest: None Funding: None

In 1888, Sir William Osler first described a case of recurrent episodes of painless, non-pruritic swellings that occurred in a 24 year old female. These swellings typically lasted between one and four days and affected various parts of her body – hands, fingers, knees, elbows, face and lips. Whilst most episodes affected the face and limbs, other more severe episodes resulted in abdominal colic, nausea and vomiting. He noted that these episodes would often occur spontaneously, with no specific triggers identified. Osler then obtained a comprehensive family history, which revealed that these symptoms had been present in twenty-eight other family members in the preceding five generations. He then went on to make the following conclusions: 

1. “The occurrence of local swellings in various parts of the body, face, hands, arms, legs, genitals, buttocks, and throat. In one instance, possibly in two, death resulted from a sudden Oedema Glottidis. 

2. Associated with oedema, there is almost invariably gastro-intestinal disturbance: colic, nausea, vomiting and sometimes diarrhoea. 

3. A strongly marked hereditary disposition, the disease having affected members of the family in five generations. “

There is a worldwide steady increase in obesity prevalence, and in South Africa 70% of adult females are classified as overweight (BMI >25 kg/m2), the highest recorded numbers in Sub-Saharan Africa. The morbidity associated with being overweight includes diabetes, hypertension, gastro-esophageal reflux disease, and nonalcoholic fatty liver disease amongst others. Accordingly, life expectancy is decreased. Metabolic surgery is currently the most effective treatment for weight loss and type 2 diabetes, and is being performed increasingly in South African private and public hospitals. Physicians should be aware of indications for, and outcomes and complications after metabolic surgery. This report reviews current evidence and the role of metabolic surgery in South Africa.

Background: Left sided ulcerative colitis is often a severe disease which requires aggressive medical therapy. Rarely, it can result in colectomy. Moreover, it can progress and extent to involve the entire colon. 

Method: Retrospective analysis of patient data on the SAGES IBD database. Patient data with severe left sided ulcerative colitis requiring anti-TNF therapy for the period between September 2016 to August 2017. Patient consent was obtained. 

Results: A total of 149 requests for biologic therapy were received during this period of which 13 had left sided ulcerative colitis. Seven (53.4%) were male and the mean age at diagnosis 33.3 years. Mean age at commencement of biologic therapy was 40.9 years. There were no smokers. One (7.7%) had ulcerative proctitis, 7 (53.8%) had proctosigmoiditis and 5 (38.4%) had left sided colitis. No patient was receiving topical steroids and 2 (15.4%) patients had exposure to topical 5-aminosalicylic acid. All patients had exposure to oral 5-aminosalicylic acid and 9 (69.2%) were receiving ongoing treatment. Ten (76.9%) received azathioprine or 6-mercaptopurine and 5 (38.5%) received methotrexate. Of the 12 patients on immunomodulator therapy, 10 (76.9) were concurrently on 5-aminosalicylic acid. Seven (53.8%) patients received infliximab and 9 (69.2%) patients received adalimumab. No one received golimumab or vedolizumab. All patients received standard dose anti-TNF therapy except 1 (7.7%) patient who received double dose infliximab. Biologic therapy was well tolerated with good clinical outcome and no side-effects. 

Conclusion: The incidence of severe left sided ulcerative colitis was low in this cohort. Severe left sided disease is associated with a high medication burden and cost. Response to biologic therapy was excellent.

Dear Colleagues,

Viral Hepatitis causes an inflammation of the liver due to a viral infection. Most cases of Viral Hepatitis are contracted through one of five viruses including, hepatitis A virus (HAV), hepatitis B virus (HBV), hepatitis C virus (HCV), hepatitis D virus (HDV) and hepatitis E virus (HEV). Of the five hepatitis viruses, all can cause acute hepatitis, however only HBV, HCV, and HDV frequently cause chronic hepatitis which can lead to liver cirrhosis and to liver cancer.

The 8th Liver Interest Group annual meeting was held in Cape Town over the first weekend of December 2017, and this year’s meeting was special with the launch of the Gastroenterology and Hepatology association of Sub - Saharan Africa (GHASSA). The Association will be used to draw up and to publish Gastroenterology and Hepatology guidance for practitioners with regard to issues particularly relevant to Sub-Saharan Africa (SSA).

Whilst contemplating what to do in my retirement, I set off in January to a few places on the African continent courtesy of a variety of funders and surgical and medical gastroenterology past trainees and acquaintances over the years. First stop Khartoum, Sudan the place of the Longest Kiss, the union of the White and the Blue Nile. Another adventure on the good ship Gastro Foundation with the project being to take the best of UEGW 2017 video presentations as a postgraduate programme to their annual congress.

The purpose of the award is to honour the memory of Professor Solly Marks by recognizing clinicians or researchers of distinction in the field of gastroenterology/hepatology on an annual basis. This is an educational grant that is to be used for the upskilling of an individual and that will benefit the general good of gastroenterology in South Africa, as Prof Marks would have wanted. It is not to be used as a top up fund, but rather for a specific endeavour.

For the 9th annual Gastroenterology Foundation Fellows Weekend, 40 fellows and 27 faculty descended upon the Spier Conference Centre 2-4 February 2018. As a visiting medical GI fellow at Groote Schuur from Brown University in the United States, I was fortunate to be included on the Spier roster this year. When I received the invitation, I had no way of knowing it would become the highlight of my month in South Africa. Following introductory comments from Professor Sandie Thomson and Dr. Chris Kassianides Friday morning, we jumped right into the educational activities. The organizers had curated a series of prerecorded UEG (United European Gastroenterology) lectures and endoscopy videos to share with us. This proved to be an effective use of technology to mitigate the vast physical distance between the eager audience at Spier and European experts on topics like Helicobacter pylori and advanced endoscopic procedures in the elderly. Professor Eduard Jonas closed the morning session with an update on epidemiology and treatment of hepatocellular carcinoma, with emphasis on patients in Sub-Saharan Africa.