1. To the ileum ……. and beyond
Dr. Matt W. Johnson BSc MBBS MRCP (??MD!!)
Consultant Gastroenterologist

3. 1909 Royal Military Asylum

7. 1733 – Hyde Park

8. Tooting

9. St. George’s Hospital

10. Achievements First Class BSc Degree MBBS (University of London)
Medical Sciences with Physiology
Physiology research project: Effects of alpha and beta sympathetic adrenoreceptors on mucus content and quantity.
MBBS (University of London)
Eating in every one of the 28 Indian restaurants from Tooting Broadway to Tooting Bec

11. HO + SHO Posts MEDICAL SHO POSTS St. Helier Hospital, Gastro and GIM
Hemel Hempstead Hospital, Gastro, Haem and GIM
Royal Free Hospital, Specialist Liver Unit and GIM
St. Thomas’ Hospital, Cardiology
Lewisham Hospital, Endocrine and GIM
Lewisham Hospital, Care of the Elderly
Guy’s Hospital, Accident and Emergency
PRE REGISTRATION HOUSE OFFICER
Mayday Hospital, General Surgery and ENT
St. George’s Hospital, GIM and Care of the Elderly

13. St. Thomas’s Hospital

14. South East Thames SpR Rotation
QUEEN ELIZABETH THE QUEEN MOTHER (MARGATE) HOSPITAL
Dr. A. Piotrowicz, Dr. K. Hills
DARENT VALLEY HOSPITAL
Dr. W. Melia, Dr. R. Ede, Dr. P. Mairs
KINGS COLLEGE HOSPITAL - LIVER UNIT
General Hepatopancreatobiliary / Liver ITU / Transplant Medicine
Dr. J. O’Grady, Dr. M. Heneghan, Dr. J. Devlin, Dr. P. Harrison,
Dr. V. Aluvihare, Dr. K. Agarwal, Dr. E. Sizer, Dr. W. Bernal.
Dr. G. Auzinger, Dr. J. Wendon.
St. MARK’S and St. THOMAS’S HOSPITAL
Research Fellowship, Specialist Surgical Gastroenterology
Prof R.J. Nicholls, Prof P.J. Ciclitira and Prof A. Forbes
St. THOMAS’ and GUYS’ NHS TRUST
Sir R. Thompson, Prof P.J. Ciclitira, Dr. J. Meenan,
Dr. J. Sanderson, Dr. T. Wong, Dr. M. Wilkinson, Dr. R.Ede
BROMLEY NHS TRUST
Dr. J. Hunt, Dr. A. Jenkins, Dr. M. Asante
ROYAL SURREY COUNTY HOSPITAL
Dr. M. Smith
FRIMLEY PARK HOSPITAL - LAS
Col. Fabricius, Col. Ineson

15. Specialty Areas of Interest
Inflammatory Bowel Disease – including tertiary referral clinics at St. Mark’s and St. Thomas’s hospitals.
Surgical Gastroenterology - National Referral Unit for ileoanal pouches, faecal incontinence, complex anorectal fistula disease at St. Mark’s
Small bowel pathology + Coeliac disease tertiary referral clinics for complicated and non-responsive cases.
Hepatology (General hepatopancreatobiliary medicine, Hepatitis clinics, Liver ITU, pre/post liver transplant medicine)

16. 17 Publications
2009
Coeliac disease in the elderly. Nat Clin Pract Gastroenterol Hepatol Dec; 5(12):
Bacterial community diversity in cultures derived from healthy and inflamed ileal pouches after restorative proctocolectomy. IBD Nov
The bacteriology of pouchitis: A molecular phylogenetic analysis. GUT Dec
The prevalence of osteoporosis and osteopenia in ileal pouch patients post-restorative proctocolectomy. IBD Sept
Prolonged toxic megacolon secondary to Salmonella. [Submitted to Diseases of the Colon and Rectum]
2008
Coeliac disease in the older patient: Are we ageist in our practice. [Awaiting publication in Gastroenterolgy CME Journal]
The medical management of patients with an ileal pouch anal anastomosis after restorative proctocolectomy. EJoGH.
Faecal M2-pyruvate kinase; a novel, non-invasive marker of ileal pouch inflammation. EJoGH
2007
Faecal calprotectin: A non-invasive diagnostic tool and marker of severity in pouchitis. Eur J Gastroentero Hepatol March; 20(3):
2006
Hyperbaric oxygen as a treatment for malabsorption in a radiation damaged short bowel. June 2006; 18(6):
Risk of dysplasia and adenocarcinoma following restorative procto-colectomy for ulcerative colitis. Colorectal Disease. CDI R1. 03/05/06
2005
Use of fecal lactoferrin to diagnose irritable pouch syndrome: A word of caution. Gastroenterology (5):1647-8
Presentation, diagnosis and management of inflammatory bowel disease in older people. CME Geriatric Medicine, 2005; 7(3):
The pathogenesis of coeliac disease. Molecular Aspects of Medicine, Dec 2005: 26 (6);
2004
11th International Symposium on Coeliac Disease: A report. Gastroenterology Today. Summer 2004; 14 (2): 46-7
Clinical toxicity of HMW glutenin subunits of wheat to patients with celiac disease.
Proceedings of the 19th Meeting of the Working Group on the prolamin analysis and toxicity, 2004; III Symposium: 147-9
2002
Malaria: The dilemmas of malarial diagnostics. J R Army Med Corps 2002; 148:

17. Research Fellowship St. Marks’ and St. Thomas’ Hospital
The Bacterial Pathogenesis of Pouchitis and Development of Novel Probiotic Therapies
Prof PJ. Ciclitira, Prof RJ. Nicholls and Prof A. Forbes
MD – Awaiting Examination

20. Aims
IBD Centre of Excellence
SBCE
HRM
EUS

21. Luminology

23. To the ileum …and beyond

24. Oesophagus

25. High Resolution Manometry
Spatiotemoral plots derived from >36 closely spaced pressure sensors
Reveals complex functional anatomy
Increased our understanding of dysmotility
Looks beautiful

26. Normal

27. Achalasia

28. Mid-oesophageal submucosal Ca

29. Herniation of Lap Wrap

30. Stomach

31. Management of Dyspepsia BSG Guidelines 1996 Updated 2002By
Matt Johnson
St. Thomas’s and East Surrey

32. Dyspepsia Introduction
Prevalence = 23 – 41% in UK
4% of GP consultations
10% of these are referred to hospital
2% of entire adult population receive either an OGD or a barium meal each year

33. Rationing of Endoscopy
Morbidity = 1:1,000 (Haemorrhage)
Death = 1:10,000 (Perforation)
OGD is recommended in all patients >55y D
with new onset uncomplicated dyspepsia
for > 1/12 duration
< 55y with “alarm symptoms” C

34. Alarm Symptoms These include dyspeptic patients with:
Unintentional weight loss
GI Bleeding
Previous gastric surgery
Epigastric mass
Previous gastric ulcer
Unexplained Fe deficiency
Dysphagia or Odynophagia
Persistent continous vomiting
Suspicious barium meal

35. Investigation of dyspepsia in patients <55 years
NICE guidelines CG17
Test and treat Helicobacter
Empirical PPI therapy
Reduce role of endoscopy in the <55 yrs
Manage uninvestigated reflux as dyspepsia
Alarm symptoms via TWW
February Surrey and Sussex Healthcare NHS Trust

36. Investigation of dyspepsia in patients <55 years
724 endoscopies performed
54% normal
13% major abnormalities
33% minor abnormalities
42% recommended PPI therapy
8.1% helicobacter eradication resulting
1 oesophageal cancer discovered (aged 52) *

37. Investigation of dyspepsia in patients <55 years
Conclusions:
Three weeks out of year spend endoscoping this group
Findings in line with other studies
Very low prevalence of cancer in this group
Minimal evidence of change in management

38. Iron Deficiency Anaemia

39. Causes of Fe deficiency Anaemia
Occult GI Blood Loss
Aspirin/NSAID use –15%
Colonic carcinoma –10%
Gastric carcinoma %
Gastric ulceration %
Angiodysplasia %
Oesophagitis –4%
Oesophageal Ca –2%
GAVE (ectasia) –2%
Small bowel tumours 1–2%
Ampullary Ca <1%
Ancylomasta duodenale <1%
Malabsorption
Coeliac disease –6%
Gastrectomy <5%
H. pylori colonisation <5%
Gut resection <1%
Bacterial overgrowth <1%
Non-GI blood loss
Menstruation –30%
Blood donation %
Haematuria %
Epistaxis <1%

40. Iron Deficiency Anaemia
Haemoglobin <12 or <13 nmg/L
MCV <76
Ferritin <15nmg/L
Coeliac serology
TFT
Sickle cell and Thalassaemia screen
Non-vegetarian
No menorrhoea

41. Small Bowel

42. COELIAC DISEASE Matt Johnson + David Dewar Professor Paul Ciclitira
St Thomas’s Hospital, London

43. Prevalence of coeliac disease
Sweden 1:67 antibody positive
Ireland 1:100
England 1:150
Europe 1:300
N America 1:300
Australia 1:300

44. DERMATITIS HERPETIFORMIS

45. Associations Dermatitis herpetiformis IgA deficiency 2-3%
SBBO 8% of NRCD
Hyposplenism ?80%
Microcytic colitis 5%
Autoimmune conditions 25%
Thyroid disease
Type 1 diabetes
Addison’s
Sjogrens syndrome

46. AD and age at diagnosis:
Group Prevalence AD
A1 – age<2yrs %
A2 – age 2-10yrs 17%
A3 – age>10yrs %
Prevalence of autoimmune disease is related to duration of gluten exposure
Ventura A (1999) Gastroenterology 117:

47. Osteoporosis
47% women < 50% men on GFD have osteopenia / osteoporosisa
Improvement 1 year post treatmentb
aMcFarlane (1995) Gut 36:710-14
bValdimarsson (1996) Gut 38:322-7

48. Mortality Almost all mortality in CD is due to malignancy
>50% due to EATCL
Other tumours = mouth, oesophagus, sb,lb
Mortality x control population
Holmes et al : 2x control pop1
Mortality normal after 5 yrs on GFD2
1Holmes GK et al (1976) Gut 17(8): 612-9
2Holmes GK et al (1989) Gut 30(3): 333-8

50. Ulcerative jejunitis Rare (6th decade) pre-malignant state
Related to Enteropathy-associated T cell lymphoma (EATL)
T Cell receptor PCR monoclonality
UCL – Prof. Isaacson
Atypical gTcell receptor abnormalities
Steroids, nutritional support, close observation

51. Treatment of coeliac disease
Gluten-free diet
Avoidance of wheat, rye and barley
Oats (probably OK)
Dietician
Codex Alimentarius
Coeliac societies handbook
BUT NOT CORNFLAKES

52. Using Serology to Monitor Patients
IgA gliadin and TTG normalise on a strict GFD after 3-6/12
Must have pre-treatment levels
IgG gliadin can be used but takes longer to normalise
IgA endomyseal is costly and more difficult to quantify

53. Dewar D, Johnson MW, Ciclitira PJ, GUT 2005

54. Small Bowel UGI tract 0.8m LGI tract 1m Sb 5.6m
95% absorption capacity

55. Capsule Endoscope
A small disposable capsule about the size of a jelly bean.
Has own light source and video camera.
Suitable for adults and older children.
Transmits data to recorder worn at waist.
Patient swallows capsule with glass of water after a simple overnight fast.
Carries on with normal activities and returns data recorder after 8 hours.
At the
American College of Gastroenterology (ACG) 2004 meeting, Drs Jamie Barkin and
Gregory Schwartz (USA) reported that patients with SBT had an average of 4.6
procedures before definitive diagnosis with capsule endoscopy.

56. BSG Indications for SBCE Guidelines April 2008
1) Obscure gastrointestinal bleeding
2) Suspected sb Crohn’s disease
3) Assessment of Coeliac disease
4) Screening for Polyps / FAP
Suspected small bowel malignancy
Evaluation of side-effects of NSAIDs

57. Dartford SBCE Service
A review of the first 37 small bowel capsule enteroscopies performed at Darent Valley Hospital.
Stomach
Gastritis (5)
Erosions (6)
Angiectasia (4)
Polyps (1)
Small bowel
NSAID induced enteropathy (9)
Angiodysplasia (2)
Coeliac disease (7) - UCH pre-malignant ulcerative jejunitis
Gastrointestinal stromal tumours (GISTs) (2) - 2x St. Mark’ for D-balloon enteroscopy
Crohn’s disease (5)
Juvenile polyposis (1) - GOS
Bacterial overgrowth secondary to small bowel diverticulae (1)
Parasitic infestation (1)
Multiple cystic lymphangiectasia (1)

58. Coeliac Disease
Celiac disease is an immune-mediated disorder that primarily affects the GI tract. It is characterized by chronic inflammation of the small intestine mucosa that may result in atrophy of intestinal villi, malabsorption, and a variety of clinical manifestations, which may begin in either childhood or adult life.
Patients with celiac disease may also have diabetes, anemia, osteoporosis, neurological problems, malignancies, and show behavioral changes.
Family members may also be positive for celiac disease
Sero + (EMA or tTG) patients unwilling or unable to undergo upper GI endoscopy
Sero + (EMA or tTG) patients with negative histology to rule out patchy disease
For alarm symptoms in known CD patients on a strict GFD (risk of malignancy)
Obstruction
Weight loss
Bleeding
Pain
Fever

59. Using SBCE in Crohn’s 10-30% sb only 66% ileocaecal disease
20% colonic
Wireless capsule endoscopy and Crohn’s disease. P Swain
Gut: March 2005 vol 54 no 3
Costamagna Gastroenterology 2002;123:

60. Suspected Crohn’s

61. Obscure Intestinal Bleeding 5% of all UGI haemorrhages Benefits
Safe, well tolerated, able to view entire small bowel, clarity of image + Share images; patient preference;
Reduced diagnostic cost and utilization
If bleeding source identified = Less need for transfusions
Reduced treatment cost and utilization
The first main use of SBCE was in the investigation of patients with obscure intestinal bleeding. So called because patient’s had chronic anaemia or obvious bleeding but the gastroscopy and colonoscopy were normal.
CE is a valuable tool in the diagnostic tool kit
Key advantages of CE include: ability to review and share images; patient preference; safety profile; ability to conduct in variety of settings; clarity of image comparable to other endoscopy; ability to image entire small bowel
Bleeding stops/anemia resolves
Less need for transfusions
Reduced diagnostic cost and utilization
Reduced treatment cost and utilization
Patient satisfaction and quality of life (QoL)
Improved outcome of earlier diagnosed tumors in the small bowel

62. Small bowel malignancies
Prior to SBCE sb tumours = 1 - 2% of all GI malignancies
Now it is thought to compromise 5%
PillCam™ Trial = incidence of small bowel tumors among 1,235 patients – 6% - 9% (Corbin, Bailey, Keuchel)
60% of SBTs are malignant
- adenocarcinomas, carcinomas, melanomas, lymphomas and sarcomas
40% of SBTs are benign
GISTs, hemangiomas, hamartomas, and adenomas
Prior to capsule endoscopy SB tumors comprise 1% - 2% of GI malignancies
PillCam™ incidence of small bowel tumors among 1,235 patients – 6% - 9% (Corbin, Bailey, Keuchel)
Malignant tumors of small bowel (poor prognosis)
Metastases % - 75%
Unresectable % - 50%
Often diagnosed late in course or incidentally at laparotomy or biopsy
If a lesion leads to symptoms, presentation depends on the pathology of the neoplasm and location
At least 50% of benign lesions remain asymptomatic, while approximately 80% of malignant lesions are associated with symptoms
Not clear if symptoms or signs are specific for either benign or malignant tumors
The most common indication for PillCam™ endoscopy in patients with SBTs was obscure GI bleeding/anemia (80%)
PillCam™ endoscopy detected SBTs after patients had undergone an average of 4.6 negative procedures
The majority of SBTs were malignant (60%), consisting of adenocarcinomas, carcinomas, melanomas, lymphomas, and sarcomas
The benign SBTs (40%) were GISTs, hemangiomas, hamartomas, and adenomas

63. Small Bowel malignancies
Often diagnosed late or incidentally at laparotomy
Malignant tumors of small bowel (poor prognosis)
Metastases % - 75%
Unresectable % - 50%
80% of SBTs undergoing SBCE present with obscure GI bleeding/anemia
Improved outcome of earlier diagnosed tumors in the small bowel
On average patients with SBTs who present for SBCEs have already undergone detected SBTs after patients had undergone an average of 4.6 negative endoscopic procedures
PillCam™ Trial (Corbin, Bailey, Keuchel)
If a lesion leads to symptoms, presentation depends on the pathology of the neoplasm and location
At least 50% of benign lesions remain asymptomatic, while approximately 80% of malignant lesions are associated with symptoms
Not clear if symptoms or signs are specific for either benign or malignant tumors
The most common indication for PillCam™ endoscopy in patients with SBTs was obscure GI bleeding/anemia (80%)
PillCam™ endoscopy detected SBTs after patients had undergone an average of 4.6 negative procedures
The majority of SBTs were malignant (60%), consisting of adenocarcinomas, carcinomas, melanomas, lymphomas, and sarcomas
The benign SBTs (40%) were GISTs, hemangiomas, hamartomas, and adenomas

64. Final points Safe + Well tolerated
Cost-effective in economic analysis.
This is now standard practice throughout UK
Watford, Stevenage, Wellen Garden City, Cambridge, ?Aylesbury
Presently the paediatricians refer to GOS
Adult medicine is under-referring St.Mark’s
External referral = £
Cost of service = £13,000
Cost of capsule = £340

65. Colon

66. Operative Picture

67. Complications Obstruction Bleeding Inflammation “itis” Fistula Sepsis
Perforation
May co-exist with IBD
Specimen showing blood in diverticulae

71. Criteria for Toxic Megacolon (Jalan et al)
1) Radiographic evidence
Total or segmental non-obstructive colonic dilatation of > 6cm
2) 3 or more of:
Fever > 38 C
PR > 120 / min
Neutrophils > 10.5
Hb <12.5
3) At least 1 of:
Dehydration
Hypotension
Electrolyte imbalance
Altered consciousness

73. Probiotics are sooo outdated
Prebiotics = “functional foods”
Inulin / Fructo-oligosaccharides / Lactulose Transgalacto-oilgosaccharides
Chicory (boiled root = 90% inulin)
Jerusalem artichoke
Onion
Leek
Garlic
Asparagus
Banana
(cereals eg. Oatmeal)