The SOUTH AFRICAN GASTROENTEROLOGY REVIEW is written by specialists in the field. Its aim is to publish articles pertinent to the practicing Gastroenterologist in South Africa. The South African Gastroenterology Review is distributed to a broad spectrum of clinicians who have an interest in clinical gastroenterolgy and hepatology. The views expressed in individual articles are the personal views of the Authors and are not necessarily shared by the Editors, the Advertisers or the Publisher. No articles may be reproduced in any way without the written consent of the Publisher.
VOLUME 14 I NO. 3 I NOVEMBER 2016
The changing economic climate locally and internationally will impact on our ability to deliver effective and affordable care to the citizens of South Africa. Challenges will also be felt in the public sector as a result of the ‘fees must fall’ campaign with already intern posts being unfunded. Dr Stephen Grobler’s article about the state of private practice and the constant challenges from the medical aids should make us more vigilant about the rules and regulations in order to offer our patients a fair deal.
A bruit that is heard over the liver most commonly originates from hepatocellular carcinoma (HCC). With the exception of HCC, other conditions may very rarely generate a bruit (Table 1).
P Premsagar, R Padayachee, Agata Czajkowski, Carolina Nel
With the advent of video capsule endoscopy, small bowel ulcerations have become a more common clinical finding. These lesions have a wide differential diagnosis and should be interpreted in the clinical context of the patient presentation, and alongside other appropriate investigations. Here we highlight a case of multiple isolated jejunal ulcerations.
K Naidoo, VG Naidoo
A 70-year-old man was admitted with massive haematochezia. It was the first episode, and had not been associated with haematemesis, melaena or abdominal pain. He was diabetic and hypertensive, but well controlled on insulin injections and enalapril. He was alert, but pale. The blood pressure was 90/60 mmHg, the pulse was 100/min, and there was fresh blood on rectal examination. The haemoglobin value was 4.7g/dl. Resuscitation was started, and blood transfusion initiated. Gastroscopy revealed a small mucosal defect in the pylorus, with clot on the base, suggestive of Dieulafoy lesion. The lesion was injected with dilute adrenaline(1:10,000). After transfusion of six units of blood, the haemoglobin rose to 12g/dl. However the haematochezia continued, and haemoglobin had fallen to 8g/dl by the next morning. Colonoscopy was performed after rapid bowel preparation. A single Dieulafoy lesion was found in the caecum. The lesion was injected with dilute adrenaline(1:10,000), and then coagulated with the diathermy forceps. The haematochezia stopped, and the haemoglobin rose to 10g/dl after two further units of blood. There was no further evidence of haemorrhage during the seven days of hospitalization, nor up to four weeks after discharge.
M Tun, R Barrow, GJ Oettlé
Economic theory dictates that who controls the purse strings, controls everything; this notion is borne out by our current practical experience in healthcare. Medical schemes, their powerful administrators and the dominant hospital groups have “captured” the provision of healthcare in South Africa to such an extent that they are telling doctors how to practice medicine.
This year the Gastroenterology Foundation of South Africa celebrates its 10th anniversary. It is an appropriate time, therefore, to reflect on the achievements the Foundation has made over the past 10 years. It is an exciting time to be in South Africa and indeed in the whole of sub-Saharan Africa. Looming over the horizon and well within our reach lies the birth of the Gastroenterology and Hepatology Association of Sub-Saharan Africa (GHASSA). To begin with, the focus of the Foundation was on the continuing medical education of the practising gastroenterologist. It soon became apparent that this was not where our attention should be. Our fellows in training was where our attention shifted.
Chris Kassianides, Chairman of the Gastroenterology Foundation of South Africa, welcomed everyone and expressed thanks, on behalf of all the Trustees, to Professor Michael Kew, his wife Daphne and his son Garth who accompanied him from Cape Town. He introduced the Foundation by describing its origins as a Liver interest group over 20 years ago that he and Professor Pauline Hall, a hepatic pathologist at the University of Cape Town, had established. He paid tribute to Professor Mike Kew’s contributions to Hepatology in South Africa and to the Foundation and, although the Foundation had its origins as a liver group, it has grown and developed over the last 10 years incorporating all aspects of Gastroenterology and Hepatology. Recognition and thanks was given to Jay Hoofnagle, Director of the Liver Disease Research Branch in the Division of Digestive Diseases and Nutrition at the NIH in Bethesda, MD, who hosted three of Mike Kew’s fellows in his unit over a period of 20 years – Geoff Dusheiko, Adrian Di Bisceglie and Chris Kassianides.
The Paediatric Interest Group Meeting of the Gastroenterology Foundation of South Africa was held at the Vineyard Hotel in Cape Town on 27 August this year. Topics addressed at the meeting included inflammatory bowel disease in children, transitioning care of adolescent patients, and emerging intestinal diseases (eosinophilic oesophagitis and congenital diarrhoea). Prof Sanja Kolacek was the international speaker while Prof Levin, Sr K Davidson and Dr’s Strobele and Nel were the local speakers. Professor Kolacek is head of Paediatrics at the Children’s Hospital Zagreb, Croatia and chief of the Referral Center for Paediatric Gastroenterology and Nutrition in the same hospital. She has published widely on paediatric IBD and nutrition and is a member of ESPGHAN working groups for IBD, Acute Diarrhoea and Probiotics. She also serves on the editorial boards of a number of journals including the Journal of Pediatric Gastroenterology, Hepatology and Nutrition, the Journal of Crohn’s and Colitis and Paediatria Croatica. She presented an overview of new developments in inflammatory bowel disease in children.
K Mentor, E Jonas, S Thomson
Ethiopia is developing exponentially in terms of infrastructure, airline, airport (although much too small now for the massive amount of transfers), hotels and their service industry. Albeit, the majority of Ethiopians are still poor and probably do not have the same access to healthcare, as we have (despite our problems in the public sector). Our South African group arrived on the Tuesday evening where we were joined for a late dinner by colleagues who had travelled from Nigeria, Kenya, DRC and Tanzania. In all, representatives from 14 sub Saharan countries were to join the meeting.
It was my great pleasure to participate in the Gastroenterology Association of South Africa and Gastroenterology Association of Ethiopia’s conference in Addis Ababa from 28 September to 1 October 2016. This conference was the first of its kind and comprised a post-graduate training for fellows, best of AGA and best of EASL sessions. A generous sponsorship from Medtronic made it possible for delegates across Africa to meet and discuss their perspectives on gastrointestinal disease in Sub-Saharan Africa. I was asked to present a half day introduction to the use of capsule endoscopy. Medtronic acquired Given Imaging, the originator of PillCam, and the leader in its field.
Chris Kassianides, Chairman of the Gastro Foundation of South Africa, in conjunction with EASL put together a whole day symposium of Liver talks at the Gastroenterology Association of Ethiopia meeting in Addis Ababa, Ethiopia. The Faculty included International speakers Professor Massimo Pinzani, Director of the UCL Institute for Liver and Digestive Health; Professor Franco Negro from University of Geneva, Switzerland (Departments of Specialty Medicine, Pathology and Immunology) and Educational Councilor of EASL; and Dr Funmi Lesi from the University of Lagos and Lagos University Teaching Hospital in Nigeria. Local Faculty speakers from Addis Ababa were Drs Abate Bane, Hailemichael Desalegn, Rezene Gebru and Yohannes Berhanu; and the South African speakers were Mark Sonderup and Wendy Spearman from Cape Town.
“Liver Unusual” • atypical aspects of liver disease • less common problems • case discussion • AASLD update
Gastro Foundation Scholarship: R50,000.00 Topic Title: Next Generation DNA Sequencing of Early-onset Colorectal Cancer in an African Population Name: Dr Leolin Katsidzira
Midst all the turmoil on UCT main campus with #feesmustfall, David Metz returned as the Solly Marks Visiting Professor having previously spent 4 months here on sabbatical in 2005. David graduated from Wits University and sojourned to the USA shortly afterwards. His gastroenterology pathway and some serendipity led to a research focus in Zollinger Ellison Syndrome which expanded into Gastrointestinal and Pancreatic Neuroendocrine tumours in general at the NIH and subsequently at the University of Pennsylvania Perelman Medical School. He now has a busy referral and routine gastroenterology practice with a foregut flavour.
The annual congress of the Hepato-Pancreato-Biliary Association was held in Stellenbosch from 21-23 October 2016. This was the first hosting of the multidisciplinary Society’s congress in Stellenbosch. The main congress was preceded by workshops on cholangioscopy and microwave liver tumour ablation at the Sunskill training laboratory at the Faculty of Medicine and Health Sciences of the University of Stellenbosch. The cholangioscopy workshop focused on stone management by lithotripsy and tissue biopsy, as well as demonstrations and lectures by Dr. Paul Edwards from Sydney. The microwave ablation workshop offered hands-on experience with ultrasound-guided ablation of liver tumours with microwave antennae on bovine and laparoscopic cadaver models.
2016 is the 22nd surveillance trip to the Northern Cape. Above (Picture 1) are 21 of the 32 team members. The additional 11 were part of the PinkDrive squad who followed us on the entire journey this year. Breast surveillance was additionally offered to Colo/Gynae in Upington, Alexander Bay, Garies and Vredendal. The PinkDrive retraced their steps and spent a second week visiting the Verdant mines in Aggenys, Pella and Pofadder. See the latest PinkDrive video on Youtube (google pinkdrive northern cape video) in which our international guest Prof Klaus Matzel, coloproctologist from University Erlangen, Germany, features.
Northern Cape Lynch Syndrome Surveillance trip ‘Splash of Red’
- Prof Reid Ally
- University of the Witwatersrand
- Prof Christo van Rensburg
- University of Stellenbosch
- Prof SR Thomson
- University of Cape Town
- Prof Paul Goldberg
- University of Cape Town
- Dr C Kassianides
- Private practice
- Prof Jake Krige
- University of Cape Town
- Dr Schalk van der Merwe
- Private practice & University of Pretoria