A growing body of evidence suggests an interesting overlap between the gut, the brain and emotional state. Chronic digestive disorders such as IBS are thought to occur when the enteric nervous system (gut) and the central nervous system (brain) do not ‘communicate’ properly with each other. Serotonin is a neurotransmitter (a chemical messenger) which impacts mood, sleep and appetite. Interestingly, almost all of the body’s serotonin can be found in the gut and the rest is found in the brain. Emotional state is therefore connected in some way to the gut.

A recent study found that a majority of patients with functional Gut conditions also had coexisting psychological conditions (eg anxiety and depression). Another found that patients with chronic digestive disorders (such as IBS) have higher levels of psychological distress and experience a lower quality of life than the general population. 

Individuals with IBS may become particularly anxious about Gut-related events (eg bowel movements, abdominal cramps and mealtimes), also known as Gut symptom-specific anxiety. Because an individual may become hypervigilant to their symptoms, they may experience increased fear and arousal in relation to them. Thinking about symptoms becomes a trigger for anxiety, and the body’s resulting stress response can either make symptoms appear or make them worse. This thought cycle therefore becomes a self-fulfilling prophecy. As a result, gastroenterologists might aim to manage IBS by using psychological therapies in an attempt to reduce symptoms by lowering the body’s stress response.

Psychogastroenterology is the term used to describe the science of applying psychological principles, techniques and therapies to help manage chronic digestive disorders, such as IBS. Its aim is to help patients better manage their symptoms, and may be used in combination with other treatments, such as medication. The main techniques used are cognitive behavioural therapy (CBT), relaxation therapy and hypnosis. 

CBT aims to modify certain thoughts and behaviours so that they are more conducive towards achieving a positive psychological state. Sessions are carried out with a qualified healthcare professional and typically require a regular commitment over a set period of time. New data suggests that remote CBT using video or telephone consultation may be superior to office-based therapy in patients with moderate-severe IBS.

Relaxation therapy involves diaphragmatic breathing exercises and progressive muscle relaxation to help calm the body’s stress response. If the body’s stress response can be reduced then hopefully this can decrease the severity of symptoms an individual experiences and therefore decrease Gut symptom-specific anxiety. 

Hypnosis, despite being a controversial subject in the medical community (due to an historical lack of controlled evidence), has shown to be an effective treatment for IBS for some individuals. Sessions challenge patients to progressively relax their thoughts on IBS symptoms by using calming imagery and sensations. It can bring about improvements in physical and mental wellbeing. 

Although we do not know whether psychological distress is the cause of IBS or indeed a symptom of IBS, it is clear that there is good reason for gastroenterologists to address the psychological aspect of IBS when considering a patient’s treatment plan. 

For more information, please contact Dr Adam Harris. 

Coeliac disease is an autoimmune condition where the small intestine is chronically inflamed, and nutrients from food may not be absorbed properly. This is due to a permanent allergy to gluten in the diet (present in wheat, barley and rye), which activates an abnormal mucosal immune response. Coeliac disease is treated effectively in the majority of patients by sticking to a 100% gluten-free diet indefinitely. Although a gluten-free diet is an effective treatment in most patients, a significant minority develop persistent or recurrent symptoms. Difficulties sticking to such a diet have led to the development of non-dietary therapies, several of which are undergoing trials in human beings.

Coeliac disease is common: in the UK, 1 in 100 people have it, and numbers are rising. It is more common in individuals with a first-degree relative (ie a parent or sibling) with the condition and in people from or with close relatives from Ireland and Finland. Patients with conditions such as type 1 diabetes, microscopic colitis, autoimmune thyroid disease, Down’s syndrome and Turner syndrome are at a higher risk of having coeliac disease.

The diagnosis may be considered in people with iron deficiency anaemia, low folate or vitamin D, chronic fatigue, in pre-menopausal women with osteoporosis, or in those with recurrent abdominal bloating, loose stools, constipation or weight loss. 

In patients with symptoms suggestive of coeliac disease a blood sample may be taken to look for special proteins or antibodies (anti-transglutaminase) that develop in patients with untreated coeliac disease. These are accurate in most cases (about 90%) but the “gold standard” diagnosis requires taking small samples (biopsies) from the small intestine at upper gi endoscopy and looking at these under a microscope to look for the characteristic signs of villous atrophy and an excess of inflammatory cells (lymphocytes). This test may be needed in patients who do respond to a gluten-free diet.

Coeliac disease is not to be confused with non-coeliac gluten sensitivity, which may present with similar symptoms but in the presence of normal blood tests and small intestine, and may improve on a gluten-free diet. Interestingly, a recent study found a subset of individuals with chronic fatigue syndrome may have sensitivity to wheat and related cereals in the absence of coeliac disease and may respond to dietary restrictions. There is still research to be done.

Advice on gluten free diet and what alternative foods can be eaten to maintain a balanced diet is best obtained from a state-registered dietician with experience in coeliac disease. Your GP (or a consultant gastroenterologist) will be able to make a referral for this advice if required.

For more information, please contact Dr Adam Harris.

Following a month of indulgence, many decide to make lifestyle changes in January. Some try dietary restriction (eg ’Veganuary’) or reduce their total caloric intake, while others abstain from alcohol (eg ‘Dry January’) or jumpstart new exercise regimes. There are even some heroes among us making several changes at once. While it is advised that individuals take proper care of themselves year round, it is appreciated that this does not always happen.

Of topical interest therefore is that intermittent fasting proves beneficial for weight loss in both animal and human studies. As humans, we have not evolved to consume three large evenly-spaced meals throughout the day (plus snacks). This is a symptom of modern life and is due to an abundance of resources. Rather, we went for short stretches of time without food. We still needed to perform, to hunt prey and escape predators, but we did so in a fasted state.

Two methods of intermittent fasting in humans provide evidence-based weight loss, specifically the 5:2 regime (fasting 2 days per week), and daily time-restricted feeding (leaving, for example 18 hours between dinner and breakfast the next day, ie a 6-hour eating period). Comparatively, intermittent fasting seems to provide greater health benefits than a simple reduction in daily caloric intake, and might be considered the method of choice for effective weight control, metabolism of energy, and improved health across the lifespan.

Healthcare professionals may not understand how to prescribe intermittent fasting regimes. Patients may also be unwilling to start one. This may be due to several unpleasant short-term effects, such as increased levels of hunger and irritability, and decreased concentration. Ideally, a patient would ease into the plan over a number of months, in order to minimise any unpleasant effects. This allows time for the body to adjust. The following plans can be considered for 5:2 intermittent fasting and daily time-restricted feeding, respectively:

5:2 Intermittent Fasting

• • For month 1: 1000 calories 1 day per week
  • For month 2: 1000 calories 2 days per week
  • For month 3: 750 calories 2 days per week
  • For month 4: 500 calories 2 days per week

Daily Time-Restricted Feeding

• • For month 1: 10 hour feeding period 5 days per week
  • For month 2: 8 hour feeding period 5 days per week
  • For month 3: 6 hour feeding period 5 days per week
  • For month 4: 6 hour feeding period 7 days per week

A new year provides a convenient opportunity for a fresh start, and widespread participation and media coverage provides a sense of camaraderie between friends, family and colleagues. This may increase the odds of success, and if nothing else, at least everyone is miserable together. If you still find yourself feeling unsatisfied with any lifestyle changes you may have made in January, then what about trying ‘Fasting February’?

For more information, please contact Dr Adam Harris.

This is a very common bacterial infection of the stomach lining. It was first discovered by Drs Warren and Marshall (subsequently awarded Nobel prizes for their amazing finding). It is thought to be caught in childhood and is very common in developing countries. In about 10% of infected individuals the bacterium may lead to a significant increase in the amount of acid produced by the stomach and this may lead to a duodenal ulcer or in older people, a stomach ulcer. Curing the infection (called eradication) will heal the ulcer and prevent it recurring.

Most people with H. pylori infection will be unaware of the infection or may develop intermittent indigestion (dyspepsia); the benefit of eradication therapy in such cases is less clear cut.

There is an association between long standing infection with H. pylori and an increase in the risk of developing cancer of the stomach. The latter condition is however getting less and less common in the UK and this is probably related, at least in part, to the decrease in the number of people infected with H pylori.  Large studies in South East Asia and more recently from Sweden, have shown a decrease in stomach cancer after eradication of the infection.

The infection has evolved with humans and some believe that is may confer a health benefit in some people (ie in those where it doesn’t cause an ulcer or stomach cancer). Thus, recent data found a possible protective role against Barrett’s oesophagus, eosinophilic oesophagitis (a chronic inflammatory disease of the oesophagus) and inflammatory bowel disease (a chronic inflammatory disease of the colon).

Patients who see their GP with indigestion (dyspepsia) may be checked (by a blood, stool or breath test) to see if they are infected with H. pylori and if so, offered treatment to cure the infection to see if the dyspepsia improves. This improvement in symptoms is most likely if the dyspepsia was due to a duodenal or stomach ulcer caused by the bacterial infection. Success or failure may be determined either by improvement in symptoms or by performing a special breath test (can be prescribed by your GP and undertaken either at home or in the GP surgery).

Curing (or eradicating) infection with H. pylori is more difficult than treating other infections. It requires treatment with 2 antibiotics (eg metronidazole, amoxicillin or clarithromycin) and an acid-lowering drug (eg omeprazole or lansoprazole) all taken twice or three times daily for 7-10 days. This treatment will work in about 80-90% of cases. In an era of growing antibiotic resistance, there is no evidence-based treatment for H. pylori patients with penicillin allergy and prior exposure to clarithromycin.

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

A hiatus hernia is when part of the stomach is pushed (herniated) into the lowest part of the chest through an opening (the hiatus) in the diaphragm. In most cases, the portion of stomach is pushed across the hiatus in a vertical direction and may move up and down producing a sliding hiatus hernia. In less than 10% of cases the stomach may herniate next to the gullet or oesophagus leading to a rolling or para-oesophageal hernia. Hiatus hernias can affect anyone, but they are more common in people who are over 50 years of age, overweight or during pregnancy.

Many people with a hiatus hernia are unaware of it but it may be associated with gastro-oesophageal reflux disease (GORD) due to the movement (reflux) of stomach acid into the gullet. The commonest symptom of GORD is heartburn; other symptoms may include food regurgitation, a bitter or sour taste, bad breath and prolonged coughing. These symptoms occur because the hiatus hernia weakens the barrier between the top of the stomach and the bottom of the gullet (lower oesophageal sphincter complex)

In some patients with GORD and a hiatus hernia, the oesophagus is exposed to long periods of acid induced inflammation that may lead to erosive oesophagitis or even, Barrett’s oesophagus, a condition whereby the lining of the gullet changes its appearance in response to long-standing and regular acid-induced damage.

So how can this all be diagnosed? Most commonly a patient will have an  Upper GI endoscopy whereby a flexible tube is guided carefully and slowly through the mouth and into the stomach and duodenum. This allows the gastroenterologist to examine the lining of the oesophagus, stomach and duodenum (first portion of the small intestine). Alternatively, a barium swallow may be undertaken in the XR department.

How can this condition be treated? Lifestyle changes and medications are the preferred treatments. Lifestyle suggestions include:

• Adapting eating habits, eating smaller meals more frequently
• Avoiding lying down for 3 hours after eating or drinking
• Removing any foods or drinks from your diet that make symptoms worse

There are two classes of medication that supress acid secretion – histamine-2 receptor antagonists (H₂RAs) and proton pump inhibitors (PPIs). H₂RAs work by blocking the effect of food on acid secretion whereas PPIs block the enzyme making acid. PPIs have emerged as the most effective therapy for relieving symptoms and improving quality of life, as well as healing and preventing damage to the oesophagus.

If patients fail to respond to PPIs or are intolerant of them, surgical repair of the hiatus hernia may be helpful such as laparoscopic fundoplication or lower oesophageal sphincter augmentation (LINX system). Surgery is particularly effective in patients with a hiatus hernia with regurgitation.

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