michael, Author at West Kent Gastroenterology

One of the most common reasons for referral to a gastroenterologist is the feeling of bloating (abdominal distension). It occurs when gas or fluid accumulate in the abdomen, causing expansion of the small or large intestine. In younger people it is usually a benign and harmless, albeit distressing, symptom but rarely it may be due to an underlying disease.

Bloating is most commonly a feature of irritable bowel syndrome (IBS) but the following conditions may cause bloating and need to be considered:

Small intestinal bacterial overgrowth
Coeliac disease
Chronic infection with G lamblia
Weight gain (especially if the fat accumulates in the abdominal cavity)
Maldigestion or abnormal fermentation of carbohydrates (e.g. lactose or fructose intolerance)

And more rarely:

Abnormal fluid accumulation (ascites)
Large ovarian cyst or uterine fibroid (noncancerous growths of the uterus)

Investigation of Bloating

The cause of bloating may be clear following a careful history and examination by a doctor. The following tests may be undertaken to help with the diagnosis:

Blood test to look for coeliac disease
Stool sample to look for Giardia lambliaantigen
Hydrogen breath tests for carbohydrate intolerances or small intestinal bacterial overgrowth
Faecal calprotectin to exclude inflammation or infection
Ultrasound scanning of the abdomen and pelvis (in a female) to exclude abnormal fluid accumulation or enlarged organs

Treatment of Bloating

This will depend upon the underlying cause. Thus, infection with G lambliais cured by tinidazole. Lactose or fructose intolerance may respond to dietary restriction. Small intestinal bacterial overgrowth may be helped by an antibiotic (e.g. rifamixin) or probiotics. IBS with bloating is often relieved by a low FODMAP diet (avoiding foods rich in short chain carbohydrates that are poorly absorbed in the small intestine and so are rapidly fermented by bacteria in the colon). In patients with a new diagnosis of coeliac disease, a gluten-free diet will need to be followed.

For more information about bloating and potential treatment options, please do not hesitate to contact Dr. Adam Harris.

Irritable Bowel Syndrome (IBS) affects up to 20% of the UK population with women at least twice as likely to be affected as men. Common symptoms include bloating, constipation, diarrhoea and abdominal discomfort.While many help their symptoms by changing diet such as avoiding foods high in FODMAPS, this blog will examine the positive effects that probiotics may have on IBS by modifying the balance, or biodiversity, of the gut bacteria or microbiome. Probiotics are defined as “live microorganisms, which, when administered in adequate amounts, confer a health benefit on the host.”

So, how may a probiotic help to reduce IBS symptoms?

Probiotics may give a boost to the numbers of “friendly bacteria” in the gut. There is some evidence, albeit limited, that the bacterial biodiversity may be altered in individuals with IBS.
An improvement in “friendly bacteria” may help to break down the FODMAPS foods that may exacerbate IBS.
A change in the biodiversity of the gut microbiome may also play a role in modulating the gut’s nervous system, thus reducing the impact of stress on the gut.

Here, I mention 3 probiotics that, to the best of my knowledge, were shown in clinical trials to be significantly better than placebo at relieving symptoms in individuals with IBS.

Symprove is a water-based probiotic that contains four live strains of the ‘friendly bacteria’ lactobacillus available from the internet or directly from the manufacturer. About 70mls of Symprove is drunk at the start of the day, 10 minutes before eating or drinking anything, for 12 weeks. Once a bottle is opened it must be stored in a fridge.

It was shown in a large clinical trial to help IBS. Researchers at London’s King’s College Hospital found that more individuals with moderate-severe IBS achieved remission after a 12 weeks course of Symprove than those taking placebo (an identical looking and tasting supplement but one which didn’t contain any bacteria).

Bio-Kult contains a total of 14 different strains of 5 different bacteria and a minimum of 2 billion live bacteria per capsule. It is taken once or twice daily for at least 28 days and if of benefit, may be used long term. Bio-Kult does not need to be stored in a fridge, is stable at room temperature and has a long shelf-life. The capsules were shown in the laboratory to resist acid or up to 2 hours implying they should survive the acidic environment of the human stomach. A randomized, controlled trial in India found that Bio-Kult was significantly more effective than placebo in individuals with IBS with diarrhoea.

Alflorex, a single strain (Bifidobacterium infantis3564) probiotic is taken once daily in capsule form for a minimum of 28 days. A single Alflorex capsule contains around 1 billion live bacteria. It was shown to be significantly better than placebo in a large study in women with IBS.

For more information about these treatment options, please do not hesitate to contact Dr. Adam Harris.

A healthy liver should contain little to no fat. Having high levels of fat in the liver is associated with an increased risk of serious health problems, from diabetes and high blood pressure to kidney disease. This month’s blog will discuss non-alcoholic fatty liver disease (NAFLD), the term used for excess fat build-up in the liver. As highlighted in the name, this condition isn’t caused by drinking too much alcohol.

It’s important to detect and manage this condition as early as possible – Stage 1 NAFLD doesn’t usually cause any serious harm but if it the fat build-up continues, it can lead to serious liver damage including cirrhosis.

There are 4 stages of NAFLD:

simple fatty liver (hepatic steatosis) – most common stage that may affect 1 in 3 adults in the UK
non-alcoholic steatohepatitis (NASH) – a more serious form where the liver has become inflamed, estimated to effect up to 5% of the UK adult population
fibrosis –where persistent inflammation causes scarring, but the liver is still able to function normally
cirrhosis – the most severe stage which occurs after many years of inflammation. The damage is permanent and can lead to liver failure and liver cancer

Individuals are at an increased risk of developing NAFLD if they:

are obese or overweight
have type-2 diabetes
have high blood pressure & cholesterol
are over the age of 50
smoke cigarettes

There aren’t usually any symptoms of the condition in the early stages – it is usually diagnosed following an abnormal result from a liver function test (raised GGT and/or ALT; high ferritin) or after an ultrasound scan. Occasionally, a liver Fibroscan or even a biopsy may be required to establish the stage of the disease.

How is NAFLD treated? While there’s currently no specific medication for the condition, the best management is to lose weight, eat a healthy balanced diet & exercise regularly.

If you have any questions about non-alcoholic fatty liver disease, please do not hesitate to contact Dr. Harris.

The low FODMAP diet is a relatively new concept in the UK. It is recognised by NICE as an effective diet for managing the symptoms of IBS such as abdominal pain, wind and bloating. About 70% of people with IBS who try the diet will achieve an improvement in their gut symptoms.FODMAPS are found in a wide range of foods including: onion, garlic, wheat, lactose, honey, nuts and many fruits and vegetables (apples, pears, broccoli and avocado to name but a few).

Once ingested, some FODMAPs are not absorbed in the small intestine and cause osmotic diarrhoea. As they pass into the large intestine they are fermented by colonic bacteria which may result in gas production and symptoms such as wind, pain and bloating.

Reducing dietary intake of FODMAPS has been shown to improve gut symptoms in most people with functional bowel disorders such as irritable bowel syndrome (IBS).

The low FODMAP diet is a complex approach however and involves a 4-8 week period of restricting FODMAP rich foods. This is followed by the systematic reintroduction of these foods back into the diet. The purpose of this stage is to identify foods that trigger symptoms and ensure a nutritionally balanced diet at the end of the process.

It is important that people who undertake the diet receive good quality advice from a Registered Dietitian on how to follow the different stages of the low FODMAP diet. It isn’t as simple as following a list of ‘foods to eat’ and ‘foods not to eat’. High FODMAP ingredients are often hidden in processed foods. Because the diet is relatively new, the information available on the internet and elsewhere can be misleading and create confusion.

An important point of note is that if the diet isn’t followed properly, it’s unlikely to be effective.

For more information please contact Ali Todd, Registered Dietitian, on 07810 367549 or for an appointment 07757 757571. In addition, further information is available on her website.

Rifaximin is an antibiotic that can be used to treat irritable bowel syndrome without constipation (IBS) and small intestinal bacterial overgrowth (SIBO) and if successful, may relief abdominal pain, bloating and diarrhoea. Individuals with IBS and/or SIBO are thought to have abnormal biodiversity of the gut microbiome. The overgrowth of gut bacteria may lead to excessive gas production and malabsorption of certain carbohydrates (see last month’s blog) leading to symptoms, such as diarrhoea, gas bloating and abdominal pain. Rifaximin may improve the biodiversity and thus improve symptoms.It’s worth noting that the rifaximin is usually well-tolerated and has few side effects, predominantly because less than 0.5% of the oral dose is absorbed from the gut. However, patients may still experience mild symptoms such as nausea, dizziness and fatigue. The drug does not appear to lead to bacterial resistance nor an increase in risk of Clostridium difficile infection (a concern when using broad-spectrum antibiotics).

If used to treat SIBO repeated courses may be required if symptoms return. Recurrence of SIBO may occur after rifaximin treatment in around 15% of patients at 3 months, 30% of patients at 6 months and 40% of patients at 9 months. If this is confirmed by a lactulose hydrogen breath test, further treatment may be required.

Rifaximin comes in tablet form (400mg) and is usually taken 3 times daily for 10 days. It can be taken with or without food. However, the high cost of rifaximin has limited its use; it is not a treatment option as an NHS patient.

If you have any questions about rifaximin or the treatment of IBS or SIBO, please do not hesitate to contact Dr. Harris.

Carbohydrates are commonly consumed as part of a typical Western diet. This blog will highlight some of the problems that carbohydrates may pose if there are problems with digestion or absorption.Carbohydrate digestion starts in the upper part of the small intestine where enzymes (e.g. lactase) break down the larger carbohydrates (polysaccharides or starches) into smaller monosaccharides which are absorbed into the blood stream. If this process is incomplete (maldigestion or malabsorption) excess carbohydrates may reach the colon where fermentation by bacteria can lead to the production of excess gas (hydrogen, carbon dioxide and methane) and fatty acids (butyrate and propionate) leading to abdominal cramps, flatulence, bloating and diarrhoea.

Symptoms related to carbohydrate malabsorption or maldigestion may occur in patients with irritable bowel syndrome, small intestine bacterial overgrowth, coeliac or Crohn’s disease or after surgery or radiotherapy to the gut. In addition, some people may have a relative lack of enzymes, such as lactase or fructase, leading to an inability to breakdown and absorb lactose- or fructose-containing foods such as dairy products or fruits.

Carbohydrate malabsorption or maldigestion may be suspected during consultation with a gastroenterologist or dietician. Hydrogen breath tests may be undertaken to confirm lactose intolerance or fructose intolerance. If confirmed, symptoms may be helped by reducing lactose or fructose containing food items. A lactulose hydrogen breath test may be performed to look for SIBO and if abnormal, individuals may respond to dietary changes, an antibiotic or probiotic.

The link between ingested carbohydrates and IBS was identified some years ago by Australian doctors who developed the low FODMAP diet whereby fermentable oligosaccharides, disaccharides, monosaccharides and polyols are reduced or eliminated from the diet. These carbohydrates include fructose (found in certain fruits like apples, mangoes, watermelon and dried fruits), lactose (found in milk and milk products), fructans (found in wheat, garlic and onions), galactans (found in legumes) and polyols (found in fruits such as peaches and certain vegetables such as mushrooms and cauliflower). The low FODMAP diet is challenging to follow and ideally should be supervised by a dietician.

In summary, in individuals with symptoms related to ingestion of carbohydrates, assessment by a gastroenterologist or dietician, hydrogen breath testing and dietary manipulation may be of benefit.

If you have any questions about carbohydrates and maldigestion, please do not hesitate to contact Dr. Harris.

This month’s blog will focus on STW5 (or Iberogast), a herbal product used for many years to treat functional dyspepsia (a chronic disorder of sensation and movement in the upper digestive tract – read more here).

What is it?

Iberogast is a liquid formulation of nine herbs, developed in Germany in 1961 and named after the genus (Iberis) of one of its ingredients. It consists of a mixture of extracts from bitter candytuft, angelica root, milk thistle fruit, celandine herb, caraway fruit, liquorice root, peppermint herb, balm leaf and chamomile flower. It contains no sugar, salt, yeast, wheat, gluten, corn, soy, dairy products, artificial colouring, artificial flavouring, or preservatives but does contain a small amount of alcohol.

Is it safe?

Used throughout Europe and other parts of the world for more than forty years, Iberogast has been used by over 20,000,000 patients with only 18 reported adverse events over the years. It appears therefore safe to use.

How does it work?

It is thought to affect various different functional processes in a complimentary, synergistic way. Thus it has been shown to affect the movement and tone of the stomach; alter the mucus lining the stomach; help reduce gas formation; decrease sensitivity to pain and possibly alter the gut microbiome.

Does it work?

A recent study found that patients with functional dyspepsia taking Iberogast had significantly reduced gastrointestinal symptoms compared to the control group who were taking placebo. Of patients taking Iberogast, 86% reported a therapeutic effect after four weeks of treatment. Results from a meta-analysis in 2013, which combined data from multiple, varied, small trials performed over the past decade, reinforced these findings of significantly more effectiveness than placebo in providing symptomatic relief to patients with functional dyspepsia. The researchers compiling the data agreed that although the cumulative total of patients in this meta-analysis was relatively limited, it was still large enough to demonstrate efficacy, even though they did suggest more research.

How it is taken?

Each Iberogast bottle has a built-in drop dispenser – shake the bottle before use, hold the bottle at a 45 degree angle and shake the required number of drops into a small glass of water (or liquid of your choice e.g. juice or warm tea) and drink, 3 times a day.

The recommended dose of Iberogast is 20 drops (1 mL), 3 times a day.

Where can I get some?

Iberogast can be bought over the counter at your local Health Food shop or online.

With last month’s blog having focused on CMA’s article 22, enforcing transparency and trust within the private healthcare system, this month’s blog will follow up by discussing the GDPR and the measures WKG takes to protect your information.

The GDPR (General Data Protection Regulation) becomes law on May 15^th 2018, overhauling how businesses process and handle data. The GDPR is Europe’s new framework for data production laws, replacing the previous 1995 data protection directive, which current UK law is based upon.

In the full text of GDPR there are 99 articles setting out the rights of individuals and obligations placed on organisations covered by the regulation. Therefore, companies covered by the GDPR will be more accountable for their handling of people’s personal information. This can include having data protection policies, data protection impact assessments and having relevant documents on how data is processed.

West Kent Gastro has already met, and in some cases exceeded, the requirements of the GDPR – patients will already be aware that all communications between the GP and the patients is now encrypted.

WKG’s measures, in accordance with the GDPR, include:

WKG no longer sends information via fax.
All email correspondence is now encrypted and additional attachments now password-protected.
All confidential waste disposed of accordingly with confidential waste bins.

If you have any questions about the GDPR and WKG’s measures, please do not hesitate to contact Dr. Harris.

This month’s blog will take an alternative approach to the usual format, focusing not on the patient but instead the practitioner.

In 2012, the Competition and Markets Authority (CMA) opened its investigation into the private healthcare market. The key finding of the subsequent report (please find here), published in 2014, found that there was a lack of publicly available fee information on consultants. The CMA concluded that this was anti-competitive because it prevented patients from exercising effective choice while reducing price competition between consultants.

The solution, article 22 of the 2014 Order, stated that consultants were required to disclose fee (and related) information to patients and established a new patient-orientated information organization – the Private Healthcare Information Network (PHIN). This came into effect between January-March 2018 ensuring that patients were made aware of consultant fees prior to their outpatient appointment and follow-up treatment as well as confirming their understanding of their insurance cover.

What does the CMA Order cover?

Consultant fees for initial and follow-up outpatient appointments
Consultant fees for follow-up treatment or tests
Consultant financial interests in medical facility/equipment
List of insurers that recognize the consultant

It is worth noting that this Article does not cover hospital fees.

Consultants are therefore required to:

Send letters to patients containing the necessary information prior to their outpatient appointments as well as before any follow-up tests or treatment
Give patients the necessary information verbally if the appointment is at short notice/urgent

This CMA Order was implemented for both the patient and practitioner, enforcing transparency and trust in the private healthcare system.

West Kent Gastroenterology Ltd is compliant with all the recommendations of Article 22.

Probiotics and prebiotics, both of which assist in maintaining a healthy gut, are often confused for one another. This blog will set out the definitions and differentiations between the two.

Probiotics are defined as “live microorganisms, which, when administered in adequate amounts, confer a health benefit on the host.” A probiotic treatment can therefore be consumed to give a boost to the roughly 400 types friendly bacteria already in the gut, working to prevent digestive discomfort and other gastrointestinal problems.

Despite the definition there is a relative paucity of high quality evidence to support a health benefit. The one that I recommend in my patients with irritable bowel syndrome (IBS) is called Symprove. This is a water-based probiotic (each dose contains more than 10 billion live, active bacteria) that was shown in a high-quality trial to be significantly more effective than placebo in subjects with IBS. Individuals noted an improvement in abdominal pain and bowel function after 4 weeks treatment.

On the other hand, prebiotics are not ‘live microorganisms’, but “a non-digestible food ingredient that beneficially affects the host by selective stimulating the growth and/or activity of one or a limited number of bacteria in the colon and thus improves health”. While probiotics introduce good bacteria into the gut, prebiotics act as a fertilizer for the ‘friendly’ bacteria that are already there.

Once again there are few good studies to confirm the health benefits of prebiotic but one that caught my eye involved chicory-derived Orafti inulin. A well-conducted trial in healthy volunteers with constipation showed that taking 12g of chicory-derived Orafti inulin daily led to a significant improvement in stool frequency. This clinical improvement was associated with an increase in Bifidobacteria. This species of colonic bacteria is thought to promote health by producing antimicrobial substances including lactic acid that limits pathogen (“bad bacteria”) growth while stimulating growth of “good bacteria” that may be associated with health-promoting effects.

For more information on probiotics or prebiotics, please do not hesitate to contact Dr. Adam Harris.

Older Posts

Blog

Gut Reaction #34: Bloating

Gut Reaction #33: Probiotics for irritable bowel syndrome (updated version)

Gut Reaction #32: Non-alcoholic fatty liver disease

Gut Reaction #31: The Low FODMAP Diet (Guest Blog)

Gut Reaction #29: Rifaximin in IBS and SIBO

Gut Reaction #28: Carbohydrates, maldigestion and malabsorption

Gut Reaction #25: STW5 (Iberogast)

Gut Reaction #24: GDPR

Gut Reaction #23 CMA Article 22 – Consultant Fee Disclosure

Gut Reaction #22: Probiotics and Prebiotics

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