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What is it?

Colonic diverticulosis is the condition whereby diverticula, or pockets, form from the lining of the colon. These protrusions of the colon lining occur at sites of weakness in the muscle wall possibly due to increased pressure from muscle contractions.
Diverticulitis is an inflammatory process that causes acute symptoms and may be associated with serious complications.

What may cause it?

Potential risk factors include increasing age; diets low in fibre, high in red meat and refined carbohydrates; obesity.
There is no evidence that seeds or nuts cause diverticulitis.
Changes in the biodiversity of the colonic bacteria

What are the symptoms?

Diverticulosis is often asymptomatic and found on investigation by colonoscopy or CT scanning. It may be associated with low abdominal cramping, bloating or constipation.
Diverticulitis, due to infection or inflammation of the diverticula, may cause localized lower left sided abdominal pain with either diarrhoea or constipation and fever. Bleeding may occur.

How common is it?

Classically, this is a disease process that predominantly affects people over the age of 70 years and is more common in developed countries. It is however getting more common in younger people possibly related to obesity.

What tests are needed to diagnose it?

A colonoscopy enables the gastroenterologist to examine the lining of the colon to confirm diverticulosis and to exclude colon cancer or inflammatory bowel disease.
An abdominal CT scan is a radiological test used to diagnose diverticulitis and to look for complications.
A blood test may be performed to look for any signs of infection or inflammation within the colon.

How do you treat it?

Individuals with diverticulosis are advised to eat a healthy and balanced diet, avoid too much red meat and to lose weight if obese. Use of a prebiotic and/or a probiotic may be of benefit but at present this is an evidence-free zone.
Mild diverticulitis is usually treated with oral antibiotics. A recent placebo-controlled trial however did not show, in the outpatient setting, that antibiotics were any better than placebo.
Patients with complications of acute severe diverticulitis such as an abscess (collection of pus) or perforation (a hole in the colon) require emergency admission to hospital for intravenous antibiotics and sometimes urgent surgery.
Long-standing severe diverticulosis or following recurrent attacks of diverticulitis the colon may get narrowed (stricture formation) and surgery may be required to avoid obstruction.

If you have any questions, please do not hesitate to contact Dr. Harris.

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.

Studies conducted in recent years have explored the relationship between the gut microbiota, consisting of around 800 different bacteria species, and metabolism. It has been suggested that specific intestinal microbial compositions can either protect from, or contribute to, obesity and other metabolic diseases.

First, I would like to discuss short-chain fatty acids (SCFA) and the vital role they play in influencing gut health. SCFA are produced by bacteria from fermentation of dietary products, mostly fibre, within the colon. Their primary role is to serve as a source of energy for cells within the colon and to stimulate repair and replacement. Of potential interest, butyrate may influence how energy (including glucose) is metabolised in the body and so hold a possible protective effect against metabolic disease and obesity.

The potential relationship between gut microbiota and obesity was analysed in this excellent 2017 study when faecal microbiota from both lean and obese subjects was transferred into mice, which then changed their feeding behaviour and subsequently their body mass to reflect the human source. The researchers suggested that butyrate positively influences energy balance and thus protects from diet-induced obesity.

Subsequent research has shown a broad variety of possible effects of butyrate on metabolism including an increase in mitochondrial activity, preventing metabolic endotoxemia, improving insulin sensitivity, increasing intestinal barrier function and protecting against diet-induced obesity.

These fascinating findings suggest a relationship between the gut microbiota and human metabolism. Further research is needed in humans to extend the experimental findings in mice and to establish if the gut microbiome may be changed (by prebiotics, probiotics, antibiotics or even faecal transplantation) to help reduce obesity and even, diabetes.

If you have any questions about gut microbiota and its relationship to obesity, please do not hesitate to contact Dr. Harris

In the 19^th edition of the Gut Reaction series, I suggested that patients with Laryngo-Pharyngeal Reflux (LPR) may consider an alkaline water & plant-based Mediterranean style diet. As discussed in that blog, a paper published in JAMA Otolaryngology (October 2017) suggested that 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 1^st group were treated with PPI and standard anti-reflux precautions (PS) and the 2^nd 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.

How alkaline water and dietary change help the symptoms of LPR is unclear but it may change the biodiversity of the gut bacteria (microbiome) in the oro-pharynx, gullet (oesophagus) and stomach.

In this blog, I will provide some further information regarding alkaline water and what the Mediterranean-style diet involves.

First of all, the “alkaline” in alkaline water refers to its pH level. The pH level is a number that measures how acidic or alkaline a substance is on a scale of 0 to 14. Alkaline water has a higher pH level than regular drinking water. Because of this, some advocates of alkaline water believe it can help maintain balance by neutralising the acid in your body. Drinking water generally has a neutral pH of 7 while alkaline water typically has a pH 8-9.

It is relatively straightforward to make your own alkaline water at home. Here is a suggested recipe:

Pour a half-gallon of the filtered water (preferable to tap water) into a gallon jug with a lid. If using tap water, a filtration system is recommended.
Add one teaspoon each of baking soda, sea salt and coral calcium powder to the container.
Wash a lemon and slice it in half. Squeeze the juice into a small bowl.
Pour the juice into the water/baking soda/coral calcium mix.
Secure the container lid and then shake it vigorously to thoroughly mix all the ingredients.
Add the rest of the distilled water to the container, being sure to leave an inch of space at the top of the container for air.
Close the container tightly and shake it to mix the water.
Use pH strips to test the water to see the level, ideally around level 8 or 9. If that is not the case, add another ¼ teaspoon of baking soda and mix again until the proper pH level is reached.

Equally, many supermarkets stock alkaline water along with other specialty waters in the bottle water aisle. It can also be ordered online from a number of retailers.

Here is some basic information about the plant-based Mediterranean style diet:

Eating primarily plant-based foods, such as fruits and vegetables, whole grains, legumes and nuts.
Replace butter and other dairy with healthy fats such as olive oil and canola oil.
Use herbs and spices instead of salt to flavour foods.
Limit red meat to consume no more than a few times a month.
Eat fish and poultry at least twice a week.

If you have any questions about alkaline water or a plant-based Mediterranean style diet, 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.

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:

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

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.
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

Newer Posts

Older Posts

Gut Reaction #30: Colonic Diverticulosis and Diverticulitis

Gut Reaction #29: Rifaximin in IBS and SIBO

Gut Reaction #28: Carbohydrates, maldigestion and malabsorption

Gut Reaction #27: The possible relationship between gut microbiota and obesity

Gut Reaction #26: Alkaline Water & Plant-Based Mediterranean Style Diet

Gut Reaction #25: STW5 (Iberogast)

Gut Reaction #24: GDPR

Gut Reaction #23 CMA Article 22 – Consultant Fee Disclosure

Gut Reaction #22: Probiotics and Prebiotics

Gut Reaction #21: Constipation

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