Review article: the diagnosis and management of food allergy and food intolerances.

BACKGROUND: Adverse reactions to food include immune mediated food allergies and non-immune mediated food intolerances. Food allergies and intolerances are often confused by health professionals, patients and the public. AIM: To critically review the data relating to diagnosis and management of food allergy and food intolerance in adults and children. METHODS: MEDLINE, EMBASE and the Cochrane Database were searched up until May 2014, using search terms related to food allergy and intolerance. RESULTS: An estimated one-fifth of the population believe that they have adverse reactions to food. Estimates of true IgE-mediated food allergy vary, but in some countries it may be as prevalent as 4-7% of preschool children. The most common food allergens are cow's milk, egg, peanut, tree nuts, soy, shellfish and finned fish. Reactions vary from urticaria to anaphylaxis and death. Tolerance for many foods including milk and egg develops with age, but is far less likely with peanut allergy. Estimates of IgE-mediated food allergy in adults are closer to 1-2%. Non-IgE-mediated food allergies such as Food Protein-Induced Enterocolitis Syndrome are rarer and predominantly recognised in childhood. Eosinophilic gastrointestinal disorders including eosinophilic oesophagitis are mixed IgE- and non-IgE-mediated food allergic conditions, and are improved by dietary exclusions. By contrast food intolerances are nonspecific, and the resultant symptoms resemble other common medically unexplained complaints, often overlapping with symptoms found in functional disorders such as irritable bowel syndrome. Improved dietary treatments for the irritable bowel syndrome have recently been described. CONCLUSIONS: Food allergies are more common in children, can be life-threatening and are distinct from food intolerances. Food intolerances may pose little risk but since functional disorders are so prevalent, greater efforts to understand adverse effects of foods in functional disorders are warranted.

Mental incapacity in hospitalised patients undergoing percutaneous endoscopic gastrostomy insertion.

BACKGROUND & AIMS: Decisions to insert percutaneous endoscopic gastrostomy (PEG) tubes may be difficult because patients have serious underlying disease, and the procedure has associated risks. Patients may also lack mental capacity to consent to PEG insertion. This study aimed to prospectively determine the prevalence of mental incapacity in hospitalised patients undergoing PEG insertion. METHODS: Mental capacity was assessed using the MacArthur Competence Assessment Tool for Treatment (MacCAT-T) in 72 consecutive inpatients referred for PEG insertion. Cognitive function was measured using the Mini-Mental State Examination (MMSE). Sixty eight inpatients and 69 outpatients having diagnostic upper gastrointestinal (UGI) endoscopy were similarly studied. RESULTS: Thirty nine of the PEG patients had suffered stroke, and none had a primary diagnosis of dementia. Seventy four % (53/72) of inpatients referred for PEG, 22% (15/68) of inpatients having UGI endoscopy, and 3% (2/69) of outpatients having UGI endoscopy, lacked mental capacity, p < 0.001. MMSE scores were normal in just 18% of inpatients having PEG, in 72% of inpatients having UGI endoscopy, and in 91% of outpatients having UGI endoscopy, p < 0.001. CONCLUSION: Amongst inpatients undergoing PEG insertion there is a high prevalence (three-quarters patients) of mental incapacity to consent to this important intervention. Decisions have to be made on behalf of most inpatients referred for PEG insertion.

Changing patterns of coeliac serology requests.

BACKGROUND: Accurate serological tests have revolutionized the diagnosis of coeliac disease. AIM: To quantify the volume of coeliac serology requests at a district hospital over a decade, identify their origin, assess positivity rates and subsequent duodenal biopsy and histological confirmation rates. METHODS: Details of patients in whom coeliac serology was requested from 1997 to 2006 were obtained from laboratory databases. The origins of request were categorized into gastroenterology, general practice, paediatrics and other specialities. Duplicate requests were excluded. RESULTS: A total of 9976 serological tests were requested. Testing increased from 302 in 1997, to 1826 in 2006. In all, 66% of requests were in females. Tests in children accounted for 14-25% of each year's total. General practitioner requests increased from 3.3% in 1997 to 52% in 2006. The proportion of positive serological results fell from 5.7% in 1997 to 2.6% in 2006. Duodenal biopsies were performed in approximately 85% of seropositive patients in earlier years and approximately 75% of seropositive patients in later years. Most nonbiopsied seropositive patients had serology requested by general practitioners. Biopsies confirmed coeliac disease in 91% of seropositive patients. CONCLUSION: Increasingly, coeliac serological testing is requested by general practitioners. Twice as many females are tested. Increasing test numbers but diminishing positivity rates suggest testing is requested at lower symptom thresholds. Positive serological results are often not confirmed histologically.

Escalating polypharmacy.

New drug treatments, new indications for older drug treatments, lower thresholds for treating risk factors in preventative medicine, and an ageing population acquiring multiple pathologies all contribute to the development of polypharmacy. Longitudinal studies document the rise in prescribed medications, particularly in the elderly. The potential dangers of adverse drug reactions and interactions, poor adherence and confusion associated with ever-increasing polypharmacy are likely to worsen. Strategies to reduce prescribing will obviously decrease the dangers of polypharmacy. These include more considered prescribing when contemplating additions to patients' already lengthy prescription lists, and external reviews of medicine lists by a doctor or pharmacist. Despite such strategies, polypharmacy seems inevitable and considerations must be given to simplifying patients' multiple drug administrations using single-daily-dose regimens, fixed-dose combination pills, calendar-blister packaging and pill organizers.

Abdominal malignancy masquerading as gastro-oesophageal reflux.

Gastro-oesophageal reflux disease is a common condition, and the typical symptoms of postprandial heartburn and upper abdominal pain usually respond well to acid-suppressive medication. Occasionally, the gastro-oesophageal reflux is secondary to gastric outlet obstruction, and rarely, it is due to more distal intestinal obstruction. Two patients are described who seemed to have a primary diagnosis of gastro-oesophageal reflux but who were subsequently found to have disseminated intra-abdominal malignancy. Further investigation beyond the endoscopic confirmation of oesophagitis should be considered in patients who have typical gastro-oesophageal reflux symptoms but who also have any associated worrying clinical features.

Oral methotrexate in ulcerative colitis.

BACKGROUND: We performed an audit of methotrexate for ulcerative colitis, because efficacy is unclear. Aim : To investigate the role of methotrexate in the management of ulcerative colitis. METHODS: Patients with ulcerative colitis treated with oral methotrexate at the inflammatory bowel disease clinics of Oxford and Wycombe General Hospital, UK, were evaluated. Efficacy was defined by remission (complete steroid withdrawal for >3 months) and response (good, partial or nil, proportionate reduction of steroids). RESULTS: There were 50 patients (42 ulcerative colitis alone; eight had rheumatoid arthritis associated with ulcerative colitis and were analysed separately). Indications for methotrexate in ulcerative colitis alone were azathioprine intolerance (31 of 42) and lack of benefit from azathioprine (11 of 42). The mean dose of methotrexate in ulcerative colitis alone was 19.9 mg/week for a median of 30 weeks (range: 7-395). Remission occurred in 42%. The response was good in 54% and partial in 18%. Side-effects occurred in 23%; 10% stopped treatment because of side-effects. Of those treated with methotrexate because of treatment failure with azathioprine, three of 11 achieved remission, but four came to colectomy within 90 days of starting methotrexate. The colitis remained in remission in seven of eight of those with RA treated with methotrexate and ulcerative colitis (mean dose 15.0 mg/week). CONCLUSION: Oral methotrexate (approximately 20 mg/week) is well-tolerated and moderately effective in steroid-dependent or steroid-refractory patients with ulcerative colitis.

Contrasting liver function test patterns in obstructive jaundice due to biliary strictures [corrected] and stones.

BACKGROUND: Obstructive jaundice is believed to be characterized by abnormalities of alkaline phosphatase (ALP), rather than aspartate transaminase (AST). AIM: To compare liver function tests (LFTs) in obstructive jaundice due to malignant strictures with those of jaundice due to gallstones. METHODS: LFTs were measured immediately before endoscopic retrograde cholangio-pancreatography (ERCP) in 207 jaundiced patients. Group 1 (n = 69) had malignant strictures, group 2 (n = 97) had common bile duct stone(s), and group 3 (n = 41) appeared to have recently passed a stone. LFTs in groups 2 and 3 were also analysed at maximal liver enzyme derangement, maximum hyperbilirubinaemia and during acute pain episodes. RESULTS: Group 1 had higher median bilirubin, AST and ALP levels than groups 2 or 3 (p < 0.001). In group 1, median rise in ALP exceeded that in AST (4.3 x normal upper limit (NUL) vs. 2.6 x NUL, p < 0.01), but in groups 2 and 3, AST and ALP were similarly elevated (both approximately 2 x NUL). At the time of maximum enzyme derangement in groups 2 and 3, median AST elevation (4.4 x NUL, 185 IU/l) exceeded that for ALP (2.4 x NUL, 276 U/l), (p < 0.001), and this was also true at peak hyperbilirubinaemia in these groups (AST 3.6 x NUL, ALP 2.4 x NUL, p < 0.01. Similarly, severe pain episodes in groups 2 and 3 were accompanied by greater elevations in bilirubin and AST, but not ALP, compared with levels at ERCP. DISCUSSION: The conventional wisdom that ALP rises more than AST in obstructive jaundice holds true where the jaundice is due to strictures, but in obstructive stone disease, the rise in AST may equal that in ALP, or even exceed it during maximum jaundice and during painful episodes. Clinicians should consider the possibility of extrahepatic biliary obstruction, even when AST is the predominantly elevated enzyme.

Are patients' sedation preferences at gastroscopy influenced by preceding patients' decisions?

BACKGROUND: When patients choose sedation or no sedation for gastroscopy, it is unknown whether the decision and experience of preceding patients on the same endoscopy list influence such decisions. AIM: To address this question in an endoscopy unit, where pre- and postprocedure patients are free to communicate. METHODS: The order and sedation decisions of 503 out-patients attending diagnostic gastroscopy lists were analysed. One hundred patients completed a preprocedural questionnaire about sedation preferences. RESULTS: Three hundred and fifteen (63%) patients chose no sedation. Men were more likely to be unsedated, 170 (72%), than women 158 (59%) (chi(2) = 9.1, P < 0.01). Age did not influence decisions. If the first patient on an endoscopy list requested sedation, 36% of subsequent patients were also sedated. This was similar to 38% of subsequently sedated patients on lists where the first patient was unsedated. Similar proportions of subsequent patients requested sedation when comparing lists where the first two patients were both sedated or both unsedated and when comparing lists where the first three patients were all sedated or all unsedated. Ninety per cent of the patients completing preprocedural questionnaires had made sedation choices before arrival; the remaining undecided patients had unsedated endoscopies. CONCLUSIONS: Patients' sedation decisions are not influenced by preceding patients' decisions. Most patients attending for out-patient gastroscopy have already decided about sedation.

Completion rate to caecum as a quality measure of colonoscopy in a district general hospital.

OBJECTIVE: Published colonoscopy completion rates vary substantially and audits suggest they often fall short of the 85% completion rate to caecum considered acceptable by some authorities. We audited colonoscopy completion rates in our unit and aimed to investigate reasons for failure. METHODS: We analysed all colonoscopies, including those by trainees, performed in a district general hospital over a 16-month period. Reasons for failure to complete were investigated and alterations to working practices made where necessary. RESULTS: The unit had an 89.1% completion rate overall (95% CI 87-92%) with rates varying from 75% to 97% for individuals. Colorectal carcinomas were detected in 3.9% of all colonoscopies of which 17% occurred proximal to the caecum and 16% in the ascending colon. Working practices in those endoscopists felt not to be meeting targets were altered and a re-audit confirmed a trend towards improvement in those individuals. Using these data we also identified a definite learning curve in trainees, with at least 40 procedures required to meet the target of 85% completion rate to caecum. CONCLUSION: In a District General Hospital high standards of colonoscopy can be achieved. Reasons for failure to complete colonoscopy to the caecum are many and often they are beyond the control of the colonoscopist (e.g. poor preparation, obstructing lesion). Colonoscopy to the caecum is not always necessary and is not a good measure of the quantity of colonic mucosa visualized. We have reservations with regard to using this target alone as a measure of quality.

Adenomatous colonic polyps are rare in ulcerative colitis.

BACKGROUND: Uncertainty exists as to whether dysplastic polyps in ulcerative colitis should always be managed as dysplasia-associated lesions/masses requiring colectomy, or whether some can be managed by polypectomy. The prevalence of non-inflammatory polyps in ulcerative colitis is unknown. AIM: To compare dysplastic polyp occurrence in patients with ulcerative colitis and in patients without inflammatory bowel disease. METHODS: The clinical, endoscopic and histological records of 150 ulcerative colitis patients (median disease duration, 10 years; 57% with pancolitis) undergoing colonoscopy were scrutinized for any polyp history. Two hundred and five patients undergoing colonoscopy for altered bowel habit, but without features suggestive of polyp presence, were used as a control group. Immunohistochemical staining of flat and polypoid mucosa for p16, beta-catenin, p53 and cyclo-oxygenase-2 was compared in the two groups. RESULTS: Only six (4%) ulcerative colitis patients had ever had dysplastic polyps. Two had single adenomatous polyps proximal to the colitis segment. Of the four patients with dysplastic polyps within colitic mucosa, two were treated endoscopically, but in two the lesions were considered to be dysplasia-associated lesions/masses and colectomy was advised. In contrast, 24 controls had at least one adenomatous polyp (chi(2) = 6.7, P < 0.01). Ten (6.7%) ulcerative colitis patients and 24 (12%) control patients had metaplastic polyps (N.S.). Immunohistochemical staining was not discriminatory. CONCLUSION: Despite the increased cancer risk in long-standing ulcerative colitis, adenomatous polyps arise less frequently in ulcerative colitis patients than in patients without ulcerative colitis.

General practitioner and hospital specialist attitudes to functional gastrointestinal disorders.

BACKGROUND: Functional gastrointestinal symptoms generate a large workload in primary care. Research on functional gastrointestinal disorders is focused on hospital patients, but these patients may differ from those managed in primary care. AIM: To investigate any differences in attitudes of general practitioners and hospital specialists towards functional gastrointestinal illnesses. METHODS: A questionnaire was sent to 200 general practitioners and 200 British Society of Gastroenterology members. RESULTS: The response rate was 76%. Sixty-two general practitioners believed that functional gastrointestinal symptoms represented a 'real' currently unexplained gastrointestinal disorder, and 67 believed such symptoms probably represented somatization of a psychological illness. In contrast, most consultants (120) believed that functional gastrointestinal symptoms represented a 'real' gastrointestinal disorder, with only 36 perceiving them to have a psychological basis (chi2 = 26.7, P < 0.001). More consultants than general practitioners believed that the understanding of functional gastrointestinal disorders had improved in the last 20 years (chi2 = 4.31, P < 0.05). Most consultants and most general practitioners thought that treatment for these disorders had not improved over this period. Only 21% of general practitioners had heard of the Manning criteria for the diagnosis of irritable bowel syndrome, compared to 81% of consultants (chi2 = 107, P < 0.0001); 12% of general practitioners and 83% of consultants had heard of the Rome criteria for the diagnosis of functional gastrointestinal disorders (chi2 = 154, P < 0.0001); 37% of consultants used the Manning criteria and 40% used the Rome criteria; 11% of general practitioners used the Manning criteria and 3% used the Rome criteria. CONCLUSIONS: General practitioners and consultants have differing views on functional gastrointestinal disorders. In both primary and secondary care, most doctors do not use diagnostic criteria. Further research on the factors used to diagnose functional gastrointestinal disorders in primary care is warranted.

Proctitis with caecitis: an atypical presentation of ulcerative colitis.

Ulcerative colitis is characterized as an inflammatory process of the distal colonic mucosa, which may extend proximally. Its proximal extension is classically as a continuous lesion. We describe six patients presenting with typical ulcerative proctiits, who were also found to have an inflammatory area in the caecum, while the remaining colon was macroscopically and histologically normal. With no features to support a diagnosis of Crohn's disease, we believe these cases challenge the classic teaching that ulcerative colitis is a continuous disease. Performing total colonoscopy in patients who seem to have solely distal colitis will permit recognition of this distribution of inflammation.