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 15 I NO. 1 I APRIL 2017
The changing epidemiology of colorectal cancer The advent of economic development and industrialization was accompanied by a dramatic increase in the incidence of CRC after 1900.1 Currently it is the third most frequently occurring cancer worldwide and a leading cause of cancer death. It is difficult to separate the epidemiologic data of rectal cancer from that of colon cancer because epidemiologic studies often consider the two diseases together. Effective screening programmes introduced in developed countries allow for the prevention of CRC by the detection of precursor lesions and identification of early cancers so that cure is still possible. These effected a gradual decline in the incidence and mortality of CRC in adults older than 50 years since the mid-1980s.
C van Rensburg
The human gut microbiome can be considered a ‘new’ internal organ, with a metabolic capacity exceeding that of the liver, or our primary connection to the environment, linking us to the world’s ecology. The density of microbes within the colon is one of the highest in nature, and it is estimated that the number of microbes within our gut match or exceed that of our host human cell count, whilst their genetic machinery outnumbers our own by 100:1. This helps explain the remarkable new findings that show our microbiome not only affects the health and function of our intestines, but also has a strong influence on general body health through its close interaction with the gut immune system and through its production of bioactive metabolites that are absorbed and affect distant organ function. A state of dysbiosis can occur when its food source, fiberrich foods, becomes depleted and when oral antibiotics are used. Dysbiosis has been linked to an increasing list of human diseases, and in particular to ‘westernized’ diseases, such as colon cancer, allergy, diabetes, obesity, inflammatory bowel disease, and atherosclerosis, which pose the major threat to healthcare in the USA today.
S O’Keefe and the Stellenbosch University Working Group for the Microbiome
It seems not too long ago that colon and rectal cancer was called a ‘rare’ disease in rural Africa, however over the last 30 years in West Africa, published evidence has shown decade by decade increases in the incidence of Colorectal cancer (CRC). Therefore CRC should now be accepted as a recognized disease in native Africans; nevertheless we must acknowledge that the incidence is a fraction of what obtains in the developed countries of Europe and America. This presentation will attempt to examine the emergence of CRC within the West African axis over the last 4 decades.
Most published information about this topic will stress that all prebiotics are fibers, but not all fibers are prebiotics. In the past, we sort of thought that there were only two kinds of fiber – soluble and insoluble – and that they improved bowel movements and (later) one’s general health. Recently we came to understand that we have this invisible extra organ with a metabolic capacity of the liver and the weight of our brains – the microbiome, and that the fiber in our food is their ‘fertilizer’. Changes in our diet can lead to changes in the
microbial diversity and their fermented end products in as little as 24 hours. Unindustrialized rural communities have much more fiber in their diet that their Westernised counterparts, and therefore they seem to be less prone to develop non-communicable diseases such as obesity, type II diabetes, cardiovascular diseases, colon cancer and inflammatory bowel diseases.
The term microbiota is defined as an “ecological community of microorganisms” which reside in all multicellular organisms i.e plants and animals. These microorganisms include bacteria, archaea, protists, fungi and viruses. The microbiome on the other hand is a term that describes either the collective genomes of these microorganisms or the microorganisms themselves. Within the tissues, the interaction between the host tissues and microorganisms can influence wellness or disease of the human body. In the right balance, this host-microbiome interaction can be beneficial to the host and result in optimal functional activity such as enhanced immunity and metabolism. Conversely an unbalanced microbial profile, or dysbiosis, has been associated with disease process such as cancer. There are various methods of microbial detection in
host tissue, DNA sequencing allows the identification and characterization of whole microbial communities (commensal and pathogenic), while tissue culture has the limitation of identifying individual microbes only.
Delayed presentation of oesophageal injury is a well-known difficult problem to manage. We reported a case of missed oesophageal injury, which was managed by insertion of a Fully Covered Self Expandable Metal Stent. Certain missed oesophageal injuries with “benign” presentation, insertion of a fully covered self-expandable metal stent could be beneficial to the patient.
M Tun, TP Thulo, E Degiannis
The 7th liver interest group meeting, organised by the Gastroenterology Foundation of South Africa, was held at the lovely Vineyard Hotel in Cape Town on 6 December 2016. The theme for the meeting was “liver unusual”. The meeting explored atypical aspects of liver disease and less common liver problems and it most certainly lived up to that title of “liver unsual”. The meeting was attended by those with an interest in liver disease including hepatologists, gastroenterologists, fellows in training , pathologists and paediatric hepatologists to name a few. Among the guests was Professor Michael Kew who, as we all know, did extensive research in the field of hepatology and has vast experience in managing many liver diseases.
The eighth annual Gastroenterology Foundation Fellows Weekend was held at the beautiful Spier Wine Farm during the weekend of 27th-29th January. The Fellows Weekend is a meeting dedicated to promoting the development of future specialists within gastroenterology. As a result of the formation of the Gastroenterology and Hepatology Association of sub- Saharan Africa (GHASSA), fellows from Ghana, Rwanda, Tanzania, Ethiopia, Cameroon, Mozambique, Kenya and Nigeria joined their South African counterparts for the meeting.
The 8th Gastro Foundation weekend for fellows from the 27 – 31 January 2017, has come and gone but the impact lingers. I arrived in Cape Town early with a Rwandan fellow, thanks to the ever efficient Karin and Bini et al and we explored the beautiful Spier Hotel grounds. That evening we were treated to an exotic dinner with the guest speaker, Prof Rogler from Switzerland. The academic programme got underway the next day, with a welcome address by Dr Chris Kassianides and immediately got more intense with talks on Faecal transplantation for C. difficile colitis, new horizons in imaging and diagnostic and therapeutic techniques in surveillance of dysplasia all taken by the international guest speaker, Prof Gerhard Rogler. Prof Sandie Thomson, Prof Eduard Jonas, Prof Jose Ramos, Dr Dion Levin, Prof Mark Sonderup and Dr Adam Boutall did justice to the other “Top Tip” topics.
The Gastro Foundation hosted the second Gauteng IBD interest group breakfast at the Inanda Club in Johannesburg on Saturday 25 March 2017. After the success of the first meeting in 2016, it is obvious that there is a lot of interest in this topic. Dr Chris Kassianides opened the proceedings with an introduction to the 10 year anniversary of the Gastro Foundation. This included the exciting foray that this Foundation has taken into Africa with a liver interest group that will, hopefully, shortly be followed by an IBD interest group.
Having qualified in May 2016 in South Africa as gastroenterologist and hepatologist my desire was to also gain international exposure. My lifelong dream was realized when I was awarded, a generous educational travel grant by the Gastroenterology Foundation of South Africa and Medtronic. I had an opportunity to learn skills in interventional endoscopy for three months from October to December 2016 in Amsterdam, Netherlands. This attachment to Netherlands is one of the greatest milestones for me in my career path and I will always value it. Going to Amsterdam was the correct decision for me to pass through what I would say the central city or “Mecca” or epicenter of gastroenterology and hepatology especially for a young gastroenterologist. I could be biased as a result of having spent all my days around giants in gastroenterology and hepatology there. It did not take long before I adjusted to the Dutch way of life i.e. having brood and melk (bread and milk) as well as going to work riding the fiets (bicycle).
Inflammatory bowel disease (IBD) is a group of idiopathic chronic inflammatory intestinal conditions. The two main disease categories are Crohn’s Disease (CD) and ulcerative colitis (UC), which have both overlapping and distinct clinical and pathological features. The pathogenesis of IBD is incompletely understood. Genetic and environmental factors such as altered luminal bacteria and enhanced intestinal permeability play a role in the dysregulation of intestinal immunity, leading to gastrointestinal injury. In the absence of knowing definite causes of IBD there are currently several therapies that dampen the aberrant immune response. Some therapies in development are aimed at the gut microbiome. These therapies can range from diet supplements to fecal transplantation. As IBD is increasingly a worldwide disease one challenge will be to determine if therapies proven to be effective in one population will be comparably effective in another. Another challenge will be to facilitate access to novel expensive therapies in lesser privileged countries.
- 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