Gastrointestinal symptoms and nutritional issues in patients with hypermobility disorders: assessment, diagnosis and management

In this issue Lam and colleagues review the assessment and management of gastrointestinal symptoms and nutritional issues in patients with hypermobility disorders. Presentation to secondary and tertiary care centres is increasing. There is a lack of specific guidance and management can be challenging including the potential for iatrogenic harm. Key points include – the true prevalence of hypermobility disorders is unknown; gut symptomatology is often due to disorders of gut brain interaction and in the absence of objective evidence of dysmotility or other dysfunction, a biopsychosocial model of treating symptoms can be the most effective; postural tachycardia syndrome has been demonstrated in around 30%; over 70% of patients have psychological symptoms (primary or secondary); patients often have a high medication burden; eating related symptoms are common leading to reduced oral intake and/or food avoidance; oral diet and oral nutrition supplements should be optimised first; the evidence for clinically assisted nutrition and hydration is for objectively demonstrated malnutrition or electrolyte disturbance only. The authors describe evidence-based strategies for management, with an emphasis on reducing the risk of iatrogenic harm and improving multidisciplinary team care. The article is helpful, practical and pragmatic - Editor’s Choice this month (See page 68) .

Understanding and managing psychological disorders in patients with inflammatory bowel disease: a practical guide

Although it is well known to clinicians that anxiety and depression are common in patients with inflammatory bowel disease it is less clear how best to impact. Clinical teams should include a psychologist although this isn’t always the case.In this issue Bel Kok and collegues discuss the evidence base and practical management and provide a stepwise approach to psychological care in patients with IBD which all members of the MDT can use. This includes an overview of the management options for optimising mental well-being ranging from lifestyle measures to a combination of psychological therapy and antidepressants. There is an excellent accompanying figure (figure one), summary of mental health support available in the UK (table two) and guide to the prescribing of antidepressants (table three). Essential reading. Listen to the accompanying podcast (See page 78).

Positioning intestinal ultrasound in a UK tertiary centre: significant estimated clinical role and cost savings

There is increasing interest in the use of intestinal ultrasound in the diagnosis and monitoring of Inflammatory Bowel Disease including detection of complications. In this issue Luber and colleagues report from their centre on the proportion of colonoscopies and small bowel MRI examinations that could have been saved if intestinal ultrasound was performed as an alternative. This was by retrospective case note review. In summary the authors concluded 73 of the 260 colonoscopies and 58 of 105 small bowel MRI’s could have been avoided. No significant pathology would have been missed. These findings suggest a signficant potential cost saving although there are the issues of case selection, equipment, training, skills of the operator and suchlike to adress if intestinal ultrasound is going to become a widely available point of care test (See page 52).

Survey of UK clinicians’ approaches to decision making in neonatal intestinal failure

The outcome for neonatal intestinal failure has improved considerably over the past two decades with patients surviving long term on parenteral nutrition. In this issue Cairns and colleagues explore clinician approaches to decision making in neonatal intestinal failure particularly when the outcome is likely to be long term dependence on parenteral nutrition or gut transplantation. Participants – neonatologist, paediatric surgeons and paediatric gastroenterologists were surveyed electronically and asked if they would recommend active or palliative care or allow the parents to decide in several specific scenarios. Of 147 respondents 81% of gastroenterologist would recommend active care for a term infant with total gut Hirschsprung compared with 46% and 33% of surgeons and neonatologist respectively. No gastroenterologist recommended palliation while 23% of both neonatologist and surgeons would. There were further scenarios presented including that of a 28 week gestation infant with bilateral parenchymal haemorrhages and short bowel syndrome with equally variant recommendations. There was similarly variance in prognostic estimates with better survival prediction for neonatal intestinal failure at 5 years by gastroenterologists than surgeons or neonatologists. This significant variance in knowledge base and advice given emphasises the importance of multidisciplinary assessment and discussion in this difficult setting including, the authors suggest, a national ethical framework to help guide early decision making. There is an excellent accompanying commentary - Neonatal Intestinal Failure - Improved Outcomes (See page 13).

Lessons from an audit of exclusive enteral nutrition in adult inpatients and outpatients with active Crohn’s disease: a single-centre experience

Exclusive enteral nutrition is well recognised as a highly effective first line treatment for paediatric Crohn’s disease. It is less well used an adult practice. In this issue Melton and colleagues review their experience. In summary exclusive enteral nutrition was initiated in 60 patients over a 2.5 year period. Of the 49 in whom the goal was induction of remission 28 completed the course and 24 achieved a reasonable response if not clinical remission. 21 withdrew either for intolerance or disease related factors. Completion of the course was associated with effective disease control and high self reported adherence with improvement in nutritional status and weight gain. The key issue for patients who were not able to tolerate exclusive enteral nutrition was the inability to accept the total avoidance of non formula food. This study is important. It provides further evidence for the use of exclusive enteral nutrition but also highlights the research priority which is to try and help develop effective strategies to support patients compliance and enable them to complete the full course. There is an excellent accompanying commentary - Let food be thy medicine (See page 6) .

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