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Constipation is a common condition that is more common in women and is generally defined by infrequent bowel movements (usually less than 3 stools per week) with the passage of hard stools with straining.

The 3 most common causes of constipation are irritable bowel syndrome (IBS-C), functional constipation (IBS without abdominal pain) and slow transit constipation (STC). In STC the colonic movement is abnormally slow whereas in IBS-C and functional constipation the colon moves normally. The best way to differentiate between these conditions is a colonic transit marker study. This is a non-invasive, painless and easy test of the movement of the colon assessed by measuring the number and distribution of tiny radio-opaque markers retained within the colon about 5 days after drinking them. In individuals with IBS-C or functional constipation a minority of markers will be seen on the abdominal X-Ray, whereas in patients with STC most of the markers will be retained.

The following may cause functional constipation or worsen pre-existing IBS-C or STC:

  1. Not eating enough fibre – such as fruit, vegetables and cereals
  2. Not drinking enough fluids
  3. Not exercising or being less active
  4. Ignoring the urge to go to the toilet
  5. Changing your diet or daily routine eg travelling
  6. Stress, anxiety or depression
  7. Drugs eg painkillers

In addition to the use of laxatives such as lactulose, Movicol (Laxido), docusate and senna, over the last few years new treatments have become available for the treatment of IBS-C and STC. I will briefly mention these in turn.

Linaclotide (please read Patient Information Sheet) is the first guanylate cyclase-C agonist available in the UK and may be prescribed to improve symptoms of abdominal pain, bloating and constipation in adults with moderate-to-severe IBS-C. It improves symptoms by decreasing sensitivity to abdominal pain (visceral sensitivity) and by increasing the amount of fluid in the intestines and increasing the speed that waste moves through the colon (accelerates transit). There is good evidence from large, well-conducted trials to suggest that people experience significant decreases in abdominal pain and bloating with improved stool frequency. Unfortunately, diarrhoea is a common side effect.

Another treatment for IBS-C is the pre-biotic called Orafti Inulin. Extracted from chicory root, high in inulin-type fructans, this can be added to food products, providing a high level of fibre and thus addressing one of the primary causes of constipation.

In patients with STC lubiprostone or prucalopride may be tried.

  1. Lubiprostone works by activating chloride channels in cells lining the gut, improving intestinal fluid secretion and increasing movement of the intestine. It leads to an increase in spontaneous bowel movements and decreases abdominal bloating, discomfort and straining.
  2. Prucalopride works by stimulating serotonin receptors in the bowel and increases colonic movement. It increases bowel movements, decreases bloating, discomfort and straining in most patients.

For more information about constipation or any of the above treatments, please do not hesitate to contact Dr. Adam Harris



GORD is a chronic relapsing condition whereby acid produced in the stomach moves up into the lower part of the gullet, or oesophagus, leading to a “burning” discomfort or heartburn. The actual amount of acid is not increased but the acid spends too long in contact with the oesophagus.

This blog will focus on the factors surrounding GORD, examining why the condition is seemingly becoming more common.

Hiatus hernia

The most common cause for GORD is a hiatus hernia. Here the top part of the stomach is pushed, or herniated, through the normal opening (hiatus) in the diaphragm. This defect impairs the clearance of acid from the lower part of the oesophagus and increases the volume of acid reflux from the stomach especially after eating.

A hiatus hernia is most likely to occur in individuals who gain weight, are overweight or obese. An elegant study from Glasgow reported that increasing abdominal pressure with a belt (mimicking excessive weight gain) increased reflux episodes across a hiatus hernia after eating.

Obesity

The prevalence of obesity in the UK is increasing and has reached 27%. It is likely therefore that the increase in GORD reflects, at least in part, the rising BMI in the UK population.

Helicobacter pylori infection

H pylori causes most duodenal & stomach ulcers and, especially in developing countries, is associated with stomach cancer. The infection may however protect against the development of GORD. The prevalence of H pylori is falling whilst GORD is increasing.

Research has suggested that H pylori may, in certain individuals, decrease reflux of acid, the development of Barrett’s oesophagus & possibly protect against some forms of oesophageal cancer.

Lifestyle

Dietary factors such as increased fat content, cigarette smoking & alcohol excess may worsen GORD.

Public Awareness

Public Health England’s campaign to highlight the importance of heartburn as a risk factor for cancer of the oesophagus led to an increase in the diagnosis of GORD.

For more information about GORD, please do not hesitate to contact Dr. Harris.



During episodes of gastro-oesophageal reflux, the stomach’s contents (containing hydrochloric acid) may rise to the upper oesophagus, beyond the upper oesophageal sphincter (a ring of muscle at the top of the oesophagus) and into the back of the throat. This is known as laryngopharyngeal reflux (LPR) and is a condition that can affect anyone.While Gastro-Oesophageal Reflux disease (GORD), a similar condition, presents with the classical symptom of heartburn (a burning sensation in the lower chest), there is no such predominant symptom for LPR. For this reason, it is sometimes referred to as ‘silent reflux’.Possible symptoms include excessive throat clearing, a persistent cough, hoarseness or trouble swallowing and/or breathing. A diagnosis of LPR is often made by ENT surgeons who may examine the larynx using a small endoscope. Usually, patients will be referred onto a gastroenterologist for further assessment and treatment.

LPR is predominantly treated with acid-lowering medication such as proton pump inhibitors (PPIs) that reduce the production of acid by the stomach. If patients with a hiatus hernia (predisposes to GORD) surgical repair may be considered.

However, a paper recently published in JAMA Otolaryngology (October 2017) has suggested that a plant-based diet and consumption of alkaline water might be as effective as treatment with a PPI. The main outcome of the study was a change in Reflux Symptom Index (RSI) – the 1st group were treated with PPI and standard anti-reflux precautions (PS) and the 2nd group with alkaline water, a plant-based Mediterranean-style diet and standard anti-reflux precautions (AMS). Results from the study showed that the percentage of patients achieving a clinically meaningful reduction in RSI was 54% in PS-treated patients and 63% in AMS-treated patients. While there is still more work to be done, this study shows promising and intriguing results.

For more information about LPR or GORD please do not hesitate to contact Dr. Adam Harris



Over the last 20 years many patients have asked for my advice on losing weight (often following a discussion about hiatus hernia, reflux or fatty liver….). It appears that all diets work (albeit some quicker than others) when people stick to them but once they end, the fat tends to re-accumulate. Some diets involve spending money on special foods or drinks or attending regular sessions. For some busy people this can be challenging and may get in the way of starting or continuing a diet.When Dr Michael Mosley and his colleagues first highlighted the 5:2 diet on BBC2’s Horizon programmes (February 2015) I was most interested as the diet was easy to follow (once the calorie content of food and drinks was established), very cost-effective and would be relatively easy for many of my working patients to follow. It is much easier to comply with a diet that only asks you to restrict your calorie intake occasionally (and allow for social or work-related lunches or dinners).

So what is the basis of the 5:2 diet? This diet involves restricting your calorie consumption to 25% of your energy (calorie) needs, two (consecutive or non-consecutive) days a week, and eating normally the rest of the time.

During the ‘fasting’ days, men should consume no more than 600 calories per day and women no more than 500 calories. The 500/600 calories can be consumed throughout the day as snacks, or as one or two meals. It is recommended that good foods to eat on a ‘fasting’ day are foods high in protein and fibre which tend to fill you up more – so foods like fish, meat and vegetables.

Further information about the diet may be found at https://thefastdiet.co.uk/

The proposed health effects of the 5:2 diet include weight loss, improvement in life expectancy, possible protection against certain cancers and diseases including heart disease, stroke, Alzheimer’s, diabetes and dementia. Many also report improved results in health tests like blood pressure and cholesterol testing, alongside significant, and sustainable, weight loss.

However, it is important to note that the evidence supporting the 5:2 diet is currently limited. More research is needed to look at the long-term risks and benefits. For example, I suggest that once the desired amount of weight loss has been achieved that my patients continue with a “6:1 diet” to maintain it.

For more information about the 5:2 diet as well as potential benefits/drawbacks, please do not hesitate to contact Dr. Adam Harris.



IBS is a chronic disorder consisting of abdominal pain or discomfort associated with defaecation and/or accompanied by a change in stool form and frequency (constipation or diarrhoea or both). Usually, the abdominal pain or discomfort is either relieved by defaecation or associated with altered bowel frequency or stool form. Other common symptoms include altered stool passage (straining, urgency, incomplete evacuation); abdominal bloating, passage of mucus, lethargy and low backache.

IBS most often affects people between 16 and 30 years and is at least twice as common in women as in men. It is the most common functional disorder which means that the symptoms are absolutely genuine but are not due to an identifiable disease process or detectable abnormality on investigation. It is thought that IBS affects between 10% and 20% of the general population.

So what causes IBS? The short answer is that nobody knows but there are a few theories. IBS may follow an infection or an episode of food poisoning in about 20% of cases (so-called post-infective IBS) and it is thought therefore that this “insult” may change gut bacteria (microbiota) or alter nerve pathways in the gut. IBS may also be worse at times of stress by altering nerve transmitter (serotonin) levels or lowering the threshold at which individuals are aware of symptoms.

What treatments are available? Well, there are many different treatment options, dependent on the predominant symptom and an individual’s preference.

  1. Diet

Many people with diarrhoea and abdominal bloating will respond to a low FODMAP (Fermentable, Oligosaccharides, Disaccharides, Monosaccharides And Polyols) diet or restricting the amount of gluten (non-coeliac gluten sensitivity IBS) or dairy products.

  1. Drugs

 May be used to treat pain (mebeverine, alverine, hyoscine, peppermint oil), to relieve constipation (eg lactose) or decrease diarrhoea (eg loperamide). In subjects with more severe IBS with constipation, linaclotide may be tried. Citalopram, that affects serotonin levels, is particularly effective if pain and bloating are the main symptoms.

  1. Probiotic

Treatment with a probiotic such as Symprove may help individuals with IBS but may take many weeks to do so.

  1. Antibiotics

 Rifaximin (550mg tds for 2 weeks) led to a marked improvement in bloating, abdominal pain, and loose or watery stools compared with placebo. Most likely mode of action of rifaximin is a reduction in overall bacterial load and bacterial fermentation.

  1. Others

 In those whom are unkeen on drugs or fail to respond to dietary measures may respond to cognitive therapy or hypnotherapy. According to NICE, the use of acupuncture and reflexology should not be encouraged for the treatment of IBS.

For more information regarding IBS and treatment options, please do not hesitate to contact Dr. Harris.

 Note from Author – This piece was published, in full, in the November edition of So Tunbridge Wells magazine.



There are billions of bacteria in the human gut and they are referred to as the gut microbiome. Its role in health and disease is the subject of extensive research. Imbalance of the normal gut microbiota, or dysbiosis, is thought to be related, at least in part, to inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS) as well as some non-gut related conditions such as obesity, type 2 diabetes and allergic disorders.

Bacteria are unevenly distributed along the length of the gut with the lowest numbers in the stomach (due to acid) then increasing in the small intestine, and rising to very large amounts in the the large intestine. In addition the type of bacteria (biodiversity) varies: there are relatively more firmicutes in the small intestine and relatively more bacteroides in the large intestine.

Diet may alter the composition of the gut microbiome for example switching from a meat-based to a plant-based diet. The significance of more monotonous diet is unclear but it appears that loss of diversity of the microbiota may be associated with an increase in risk of infections and inflammation.

In IBD there appears to be a decrease in the amount and diversity of firmicutes. This may be important as these bacteria produce short chain fatty acids that are thought to have anti-inflammatory properties.

In IBS there may be a relative increase in firmicutes compared with bacteroides leading to altered colonic fermentation. It is possible than a low FODMAP diet or even probiotics, may alter the gut microbiota under these circumstances and hence improve symptoms.

A lot of research is underway investigating our gut microbiota both in health and disease to see if changing the biodiversity can prevent or treat various conditions or diseases.

For more information, please do not hesitate to contact Dr. Harris.



Gut Reaction #15: The LINX procedure for Gastro-Oesophageal Reflux Disease (GORD)

Gastro-Oesophageal Reflux Disease, or GORD, is a chronic relapsing condition whereby stomach acid refluxes back into the lower part of the gullet, or oesophagus, due to a weak muscle or sphincter where the top part of the stomach joins the bottom end of the oesophagus. The most common symptom is “heartburn”. Treatment options for GORD vary widely depending on the frequency and severity of the symptoms.

There are currently 3 main treatment options:

·        Lifestyle changes such as weight loss, smoking cessation, decreasing alcohol intake and dietary modifications. While these steps help to reduce the symptoms associated with infrequent reflux, patients with more frequent or severe symptoms may find that lifestyle changes alone may not be enough.

·        Medical therapy with drugs that either lower stomach acid production (such as H2 Blockers and Proton Pump Inhibitors) or “coat” the refluxate (such as Alginates). While these treatments often help to control symptoms, they will not prevent reflux and may require taking drugs daily for many years.

·        Surgical treatment to repair or augment the lower oesophageal sphincter such as Nissen fundoplication or the new LINX procedure. These procedures will prevent reflux from occurring and thereby help symptoms. Fundoplication involves “wrapping” the top part of the stomach around the bottom of the oesophagus to improve the sphincter pressure; the LINX procedure raises the pressure by placing a flexible band of magnetic beads on the outside of the lowest part of the oesophagus without disturbing the stomach. Both these surgical procedures are performed using keyhole surgery, by experienced surgeons and often as day-cases.  As with all surgical procedures there are potential risks and complications.

For more information about the management of GORD, please do not hesitate to contact Dr. Harris.



Gut Reaction #14: Risankizumab – Targeting interleukin 23 for Crohn’s disease

The Lancet recently published results from a study which assessed the efficacy and safety of risankizumab, a monoclonal antibody that targets interleukin-23 only (ustekinumab targets interleukin-21 and 23), in patients with moderate-to-severe Crohn’s disease.

In this large study, patients were enrolled across 36 different sites in North America, Europe and southeast Asia. They were given either 200mg, 600mg or placebo.

At week 12, 31% of those given risankizumab entered clinical remission (compared with 15% given placebo). The most common side effect was nausea.

This short-term study displays encouraging results – risankizumab was more effective than placebo for inducing clinical remission in patients with active Crohn’s disease. Therefore, the selective blockade of interleukin-23 might be a viable therapeutic option in this challenging disease.

For more information about this treatment option or Crohn’s disease, please do not hesitate to contact Dr. Harris.



Functional disorders concern both mind and body – a patient’s emotional and psychological state can affect, or create, physical symptoms. These symptoms are absolutely genuine but are not due to an underlying physical abnormality or disease.

Therefore patients may display dramatic symptoms – abdominal pain, bloating, diarrhoea, headaches and chronic fatigue – but these are symptoms related to no identified disease or physical cause. Irritable Bowel Syndrome (IBS) has long been considered a functional disorder due to a perceived impact of social and psychological factors on the somatic disease process. Decades of research has shown that stress can be an aggravating factor for IBS. 

Suzanne O’Sullivan’s book, It’s All In Your Head, examines functional disorders, showing it to be a ‘serious disease of modern society: misunderstood, misdiagnosed and surrounded by fire’. Doctor O’Sullivan, a consultant neurologist of over 10 years, wrote the book to shine a light on functional disorders, illuminating how common they are in a bid to raise awareness and to help patients to understand their symptoms. Fundamentally, her findings were that symptoms stemming from functional disorders must be treated as seriously as issues rooted in physical illness. 

Dr. O’Sullivan states that as a society we must all accept the power of the mind over the body and understand that there is no quick or single solution for this form of illness: “To look for one is akin to looking for the cure of unhappiness. There is no single answer because there is no single cause.” 

For more information about functional disorders or Irritable Bowel Syndrome, please do not hesitate to contact Dr. Harris.



Filgotinib is a Janus kinase 1 (JAK1) inhibitor, that was reported in The Lancet to show positive results in patients with Crohn’s disease. Filgotinib is a “small molecule drug” that is taken by mouth & unlike the existing treatments for Crohn’s disease (biological agents such as infliximab & adalimumab) does not directly affect TNF but inhibits the activity of JAK1 & thereby reduces the inflammation causing Crohn’s disease.

 In the study, 175 patients with moderate-to-severe Crohn’s disease were randomised to receive 200 mg filgotinib or placebo (a similar looking but inactive tablet). Filgotinib induced clinical remission in 48% of the patients, compared with 23% of the patients given placebo. In addition, more patients given filgotinib had an improvement in their quality of life (34%) than those given placebo (18%).

 While there is still much work ahead, this Phase 2 study highlights filgotinib’s potential as an oral treatment for the treatment of Crohn’s disease.

 For more information about this treatment option or Crohn’s disease, please do not hesitate to contact Dr. Harris.



At West Kent Gastroenterology, we work hard to provide our patients with top-class care. You will enjoy friendly, fast and modern treatment by a highly experienced gastroenterologist. We carefully review patient satisfaction and feedback, and at West Kent Gastroenterology we are continuously making improvements to our services, ensuring the highest level of care possible.

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