Latest developments in gastroenterology discussed at ISG Summer Meeting

Niamh Cahill reports on some of the highlights at the recent Irish Society of Gastroenterology meeting in Cork

Around 200 delegates recently gathered for the Irish Society of Gastroenterology (ISG) Summer Meeting at the Radisson Blu Hotel, Little Island, Cork, on 23-24 May.

Attendees were warmly welcomed by proud Corkonian and ISG President, Prof Orla Crosbie, Consultant Hepatologist, Cork University Hospital.

In her opening address, Prof Crosbie commended the outstanding work contained in the 80 abstracts, case presentations, and electronic posters on display during the course of the two-day meeting. She paid special tribute to the speakers, and the diverse range of topics they discussed. These included: Patient safety and simulation training in endoscopy; cirrhosis; mucosal healing in inflammatory bowel disease (IBD); interleukin (IL)-23 antagonists in IBD; faecal microbiota transplantation (FMT); and alcohol misuse and health consequences.

Finally, Prof Crosbie remembered the late Prof Douglas Veale, a Consultant Rheumatologist at St Vincent’s University Hospital (SVUH), Dublin, who had sadly passed away the day before the meeting. She noted how Prof Veale had been given a lifetime achievement award last year by “our sister society the Irish Society for Rheumatology” in recognition of his significant contribution to his specialty.

First on the ISG agenda was a clinical and scientific abstract session consisting of seven short presentations. The subjects covered included the management of alcohol-associated hepatitis and the role of the microbiome gut-brain axis in resilience and vulnerability.

Endoscopy

The first keynote speaker, Dr Manmeet Matharoo, Consultant Gastroenterologist, St Mark’s Hospital and Academic Institute, London, UK, gave a presentation on ‘Patient safety in endoscopy’. Dr Matharoo began her talk with a personal story of her own healthcare experience.

She stressed how endoscopy is a “team sport” in terms of achieving safety, quality, and excellence. “This is a hard balancing act. We have increased pressures and reduced resources while trying to do safe, high-quality procedures.”

Dr Matharoo added that the changing nature of the endoscopy and patient landscape create a “perfect storm for errors”.

As part of her research, she recounted how she retrospectively examined 140 procedures, rating technical skills and non-technical skills, and collated a total of 140 errors.

While most were mild and moderate errors, some were serious, she noted.

The research showed that often small errors led to more significant errors. This finding highlighted the importance of focusing on the “near misses”, she said. 

Dr Matharoo defined endoscopic non-technical skills as the cognitive, interpersonal, and social skills that complement and enhance one’s technical skills to enhance performance and reduce error. She noted James Reasons’s ‘Swiss cheese model’ of accident causation – the many holes in the cheese represent system issues and areas where intervention could have occurred to prevent failure.

Dr Matharoo then outlined a list of areas along the patient pathway where improvements in patient safety in endoscopy can be achieved, beginning with patient selection and consent.

“Getting it right the first time to avoid multiple procedures… being smart with patient selection is key,” she said.

Dr Matharoo explained how team briefings or “team huddles” before procedures are important to plan through cases and help to reduce error. Briefings are about teamwork, but this can be “complex and complicated” due to human factors, such as fatigue, stress, and distraction. Input, process, and output are critical factors in teamwork, she added. Team training in teamwork is another vital element.

To this end, a team training module was developed for staff in Dr Matharoo’s workplace to help improve knowledge and skills, she said.

A specific, bespoke endoscopy checklist to improve patient safety was also developed and tested by Dr Matharoo. Patients are a central part of the checklist, she said. Checklists can also help to empower all team members to speak up if they notice an issue. Debriefing and dissecting errors when they occur are all part of the patient pathway in endoscopy, Dr Matharoo added. Learning when errors occur and recognising the impact errors have on staff is critical to help improve patient safety, she concluded.

Training

Prof Glen Doherty, Consultant Gastroenterologist, St Vincent’s University Hospital, Dublin, followed next with a presentation on simulation training for endoscopy in Ireland. As National Training Lead on the HSE National Endoscopy Programme, Prof Doherty outlined the traditional “see one, do one, teach one” model of training in endoscopy.

However, over time it became clear there was a need to improve the structure of endoscopy training, he said.

In the past there was too much focus on the “magic number” of how many endoscopies trainees had performed in order to be considered competent.

UK research shows that most trainees in colonoscopy will become competent after they have performed 200 or 250 procedures – but others may need to perform 400-to-500 to reach a similar level, he said.

The shift towards a competency-based model of training is something Prof Doherty said he has been working on in recent years to ensure all staff performing gastrointestinal (GI) endoscopies are trained to the same standard. He also pointed out that the role of simulation does not end once competency has been achieved, but can continue during many phases of training. 

The HSE competency model in GI endoscopy in Ireland, developed in 2021, is a tool to provide hospitals with structure and oversight of training.

Prof Doherty spoke about the STEPS [Skills Training for Endoscopy Procedures] programme, which aims to standardise content and learning objectives for all GI endoscopy training courses in Ireland. Simulation is an important part of STEPS and has a key role to play in teaching technical skills and endoscopic non-technical skills, he added. Simulation has received more attention within healthcare in recent years, and a new strategy and dedicated simulation office is being established within the HSE, said Prof Doherty.

But while simulation has a lot to offer trainees about learning how to work in teams and the development of non-technical skills, a sizeable knowledge gap remains around the impact of simulation, Prof Doherty said. He noted there was a need for additional research into the impact simulation techniques can have on healthcare. He also highlighted a number of different types of simulator devices currently in use.

Scenario simulation exercises are being performed by trainees in the Irish health service to develop non-technical skills, he added. Overall, Prof Doherty concluded that there is evidence that simulation training is useful in endoscopy training, not just at the foundation stage, but throughout training.

Antimicrobial resistance

Dr Vishal Patel, Consultant Hepatologist, King’s College Hospital, London, UK, spoke on ‘The role of the “oral-gut-liver axis” in cirrhosis: Challenges of antimicrobial resistance (AMR) and opportunities for novel therapeutics’.

Dr Patel’s work involves translational research on the oral-gut-liver axis in cirrhosis. The global threat of AMR in cirrhosis is a key part of his work as well as therapeutics and diagnostic opportunities. He stressed the importance of research around liver disease due to a large rise in mortality from the condition in recent decades.

The complications of cirrhosis are often infection and inflammation-driven, therefore most of the guidelines stress the need to give antimicrobial therapies, said Dr Patel.

He added that antibiotic therapy can have a huge impact on patient outcomes as the early detection and prevention of infection in cirrhosis is essential. However, Dr Patel said infection diagnostic processes are not fit for purpose and more work is required in preventing infections. The microbiome is an important driver for many chronic diseases, he outlined.

Cirrhosis has been associated with a higher incidence of AMR. Cirrhosis patients are more at risk of AMR infections due to repeated hospitalisations and the need for invasive procedures, according to the presentation.

New techniques to target this problem are required, Dr Patel argued, as studies have shown the microbiome is becoming more dysfunctional.

He then discussed new therapeutic interventions, opportunities, and ongoing studies in this area to reduce the use of antimicrobials, including a gut-liver axis study in liver failure syndromes.

After Dr Patel there were themed oral presentations on endoscopy and IBD ahead of the Society’s AGM and awards ceremony.

It was announced that Dr Manus Moloney, Consultant Gastroenterologist and Group Endoscopy Lead, University of Limerick Hospital Group, will be the next President of the ISG. His term commences in the summer of 2025.

FMT

Prof Jens Walter, Professor of Ecology, Food and the Microbiome, School of Microbiology, University College Cork (UCC) and APC Microbiome Ireland, spoke next on ‘FMT in different clinical conditions: Ecological and mechanistic consideration’. Prof Walter’s talk highlighted how the microbiome has evolved and the influence of this on the gut. He outlined the history of FMT, which dates back hundreds of years, and is currently being explored in the treatment of many clinical conditions. Challenges and opportunities exist in the field, according to Prof Walter, with one of the challenges being the difficulty publishing negative studies in the area.

FMT is an established treatment for Clostridium difficile (C. difficile) infection, but evidence on the safety of FMT for other conditions remains unclear, and safety concerns have been expressed about its use, said Prof Walter.

He stated that FMT is not a safe and efficient treatment option for gut dysbiosis in immune-mediated diseases. “In contrast to C. difficile infections it is unclear if and when microbiome dysbioses make a causal contribution to chronic disease,” said Prof Walter. “Even if it is causal to disease, it is unclear to what degree dysbiosis can be corrected. It may be detrimental to expose patients that display pathologic immune responses to thousands of foreign microbial strains,” he warned.

Prof Walter added that “there are safety concerns regarding the exposure to infections and the predisposition to chronic diseases”, but that nevertheless FMT will remain an important research tool for noncommunicable diseases. Prof Walter’s take-home message to delegates was that clinical use of FMT should focus on clinical conditions for which causal contributions of the gut microbiome are clearly established.

The final presentation of the day was made by Prof Subrata Ghosh, Chair and Head of the Department of Medicine, UCC, on the topic of ‘Evolving concepts of mucosal healing as a target in IBD’. Prof Ghosh outlined how targets for mucosal healing are evolving in ulcerative colitis (UC) and Crohn’s disease and presented the latest data around mucosal healing in IBD.

Treatment goals in UC are evolving from symptom management towards disease modification, said Prof Ghosh. “Histologic activity may be present despite clinical remission or endoscopic healing for patients with UC,” he said, adding that histology may be a more specific marker of disease activity than endoscopic remission. He further noted that histologic healing is associated with favourable clinical outcomes, such as reduced risk of relapse, hospitalisation, and colorectal cancer.

Prof Ghosh also spoke on the emerging and future role of artificial intelligence, and using histology and endoscopy together, as well as the patients’ long-term benefits in achieving endoscopic and histologic remission. He emphasised the importance of “treating to target” as a disease management strategy.

Day 2

On the second day of the conference delegates gathered to hear a virtual presentation on IL-23 antagonists in IBD by Prof Laurent Peyrin-Biroulet, Consultant Gastroenterologist, Lorraine University, France. He discussed the role of IL-23 antagonists in patient care, presenting data on their effectiveness in treatment. Prof Peyrin-Biroulet then presented research on the use of risankizumab in patients with Crohn’s disease and noted high mucosal healing rates relative to placebo in both bio-naive and bio-failure patients.

Alcohol

Later in the day, there were two sessions on alcohol misuse and health consequences. Dr Audrey Dillon, Consultant Hepatologist, SVUH, Dublin, opened the first session with a presentation on ‘Liver transplant for alcohol-related liver disease (ARLD) in Ireland: What’s new in 2024’.

The former Medical Council Vice-President began by outlining current practices at SVUH, including the “six-month rule” on alcohol abstinence for liver transplant candidates. She noted, however, that evidence to support the rule, which is validated with a negative Peth test, is poor. In reality, she said, longer abstinence periods occur as referrals are often only received after six months. Research presented on the rule highlighted that it is “questionable and not evidence-based” and illustrates that liver transplant candidates should not be selected solely on a fixed abstinence interval.

Dr Dillon then presented data showing self-reported alcohol relapse rates of between 30 and 40 per cent at five years post-transplant for patients in this category. She explained that the risk of “severe relapse” is higher among younger people and those with shorter abstinence periods. In order to prevent relapses post-transplant, she said that greater social supports, an acknowledgement of addiction, and awareness of the negative consequences of relapse are important considerations.

Dr Dillon noted the use of psychosocial assessments for candidates and how efforts are underway at SVUH to perform such assessments more frequently. Early referral to a dietician is significant, along with the use of risk scores for relapse. It is helpful, she advised, to refer patients to some form of alcohol service for relapse prevention. Furthermore, she added, it is important to request as much information as possible on a patient’s history from their GP during the assessment process for transplant.

Dr Dillon noted that alcohol support services and resources are available in Ireland – but could be much better. Nevertheless, doctors should always encourage patients to seek counselling, she said.

Dr Dillon paid particular attention to the fact that smoking is an important and often unacknowledged factor in liver disease. Smokers, she said, have poorer survival rates post-transplant than non-smokers, which is why more emphasis should be placed on cessation.

She presented data showing the peak year for orthotopic liver transplantation in Ireland was in 2019, with 66 procedures occurring. Ireland continues to lag well behind other European countries in terms of liver transplants undertaken per million population and improved structures are needed in order to increase numbers.

At SVUH, more resources for a holistic psychosocial assessment are required. More ICU beds and more donor livers are also needed, Dr Dillon said. She concluded by saying that the period of alcohol abstinence is a starting point for assessment, but should not be the final point. Hopefully, she said, more transplant opportunities for sicker patients with ARLD can be offered before they become too sick for transplant. “Change is needed throughout the patient journey,” she said.

The second session on alcohol began with a presentation by Prof Alastair MacGilchrist, Chair, Scottish Health Action on Alcohol Problems, Royal College of Physicians of Edinburgh, Scotland, titled: ‘Why alcohol public health policy matters to gastroenterologists.’ Prof MacGilchrist, who has spent much of his life working as a liver transplant physician, told delegates how population measures to reduce alcohol consumption can have a huge impact on society. Clinicians, he argued, are currently “mopping the floor” with regard to alcohol use. He argued that there was the need to “turn off the tap”. He said that in Ireland and Scotland, alcohol-specific deaths are mostly due to liver disease, are twice as common in men as in women, occur mostly in middle-age, and are most common in areas of greatest deprivation.

Alcohol, he argued, is cheaper than it used to be and there is a close relationship between alcohol costs and consumption.

Measures to reduce harm include regulating alcohol distribution, restricting or banning alcohol advertising, and increasing prices. Greater education in schools and voluntary regulation by the alcohol industry are ineffective strategies in reducing harm, he said.

Prof MacGilchrist spoke about the introduction of minimum unit pricing in Scotland and its positive impact on reducing alcohol consumption and alcohol-specific deaths, particularly among deprived populations. But unfortunately, Covid-19 has been “very bad for alcohol deaths and harm” in the UK, data presented by Prof MacGilchrist showed, and has made the “problem worse”.

He underscored the importance of clinicians in helping to reduce alcohol harms. This is because clinicians, he argued, are trusted by politicians and the media as alcohol policy advocates. “Alcohol harm affects all areas of medicine, and all clinicians can help fight stigma and facilitate treatment,” he said. “Despite the power and influence of the alcohol industry trusted clinicians can advocate successfully for effective alcohol policies.”

The final speaker at the meeting ahead of the panel discussion on alcohol misuse and health consequences was Prof Michael Curry, Director of Hepatology, Beth Israel Deaconess Medical Centre, Boston, US.

His presentation, titled: ‘Dismantling the barriers to early transplantation for ARLD’ focused on the need to consider early liver transplantation (eLT) for patients with alcohol-associated liver disease. He described the “six-month rule”, outlined above, as a punitive measure designed to limit access to transplantation. The rule is not adhered to at his centre, he said, and no specific or defined period of sobriety is considered when selecting eLT candidates.

Relapse, contended Prof Curry, should not be classified as a failure and should be expected. Harm reduction and not abstinence should be the focus, he added. “The enemy of good should not be perfect.” The need for eLT among this cohort of patients has increased, as younger people are dying from ARLD and hospital admissions for alcohol-related hepatitis are increasing, he said.

Modelling scores can be utilised to identify the severity of alcohol-associated hepatitis among patients and identify suitable patients for eLT. Written protocols, defined goals, and institutional support and backing are among the requirements for successful eLT, he said.

Adequate resources and staffing for pre- and post-transplant behavioural health teams are needed along with appropriate referrals and regional agreements with other transplant centres.

During the panel discussion, some doctors questioned how the problematic culture around alcohol in Ireland could be changed. Prof MacGilchrist advised that it is a mistake to think there is “an inevitability around this”. He argued that effective advertising and marketing techniques reinforce the “normality” around having alcohol linked to social occasions, for example. “It’s seen as abnormal if we don’t do it. We need to reduce the expectation that this is normal,” he said.