WORLD GASTROENTEROLOGY NEWS World Digestive Health Day

Official e-newsletter of the World Gastroenterology Organisation www.worldgastroenterology.org

VOL. 15, ISSUE 4 DECEMBER 2010

In this issue Message from the WDHD Chair World Digestive Health Day (WDHD) 2011: Enteric Infections: prevention and management

2010 World Digestive Health Day Robert Steffen, MD, Hon. FFTM/ACTM Professor Daniel C. Baumgart WDHD 2011 Campaign Director University of Zurich, Switzerland Emeritus Professor of Travel Medicine University of Zurich - Epidemiology and Prevention of Communicable Diseases WHO Collaborating Centre for Travellers’ Health and Adjunct Professor, Epidemiology and Disease Prevention Division University of Texas School of Public Health Houston, TX, U.S.A.

IBD Research Review Prof. Jesús K. Yamamoto-Furusho M.D., Ph.D., “Nearly one in five child deaths – about a two week stay in a developing country.3 M.Sc. 1.5 million each year – are due to diar- Enteric infections associated with a rhea. Today, only 39 per cent of children variety of pathogens thus are a global with diarrhea in developing countries problem, no country being unaffected. As receive the recommended treatment, and gastroenterologists anywhere have to deal limited trend data suggest that there has with such diagnoses, the objective of the been little progress since 2000.”1 Enteric WDHD 2011 is to focus attention on the infections, however, occur not only in prevention and management of diarrheal developing countries. In the United States diseases. We will tend to improve child it is estimated that children less than survival in developing countries and also five years in age will have 2.2 episodes of to reduce morbidity and mortality in the Rome Foundation-WGO Joint industrialized world. Special attention will Symposium diarrhea per year; in those above the age of 16 years this rate is still 1.7. German be given to at risk travelers. Obviously the Ami D. Sperber, MD, MSPH sources describe that one third of the strategies will vary in different parts of the total population will have diarrhea at least world. once annually. There were some 16,000 For instance clean water, clean food and deaths from diarrhea recorded in Europe clean environment initiatives will play a in 2002.2 Lastly, travelers originating in greater role in less developed, low resource industrialized countries must expect an countries. Improvement of the infra- incidence rate of travelers’ diarrhea in the structure will reduce the risk of children order of magnitude of 20 to 30% during continued on page 3 2 WORLD GASTROENTEROLOGY NEWS DECEMBER 2010

Contents

Editorials World Digestive Health Day 2010 News

World Digestive Health Day 01 WDHD 2010: The Year of IBD 09 (WDHD) 2011: Enteric Infections: A Recap of the 2010 IBD Symposium prevention and management Charles N. Bernstein, MD Robert Steffen, MD, Hon

WGO & WGOF News World Digestive Health Day 2010: Special Scientific Highlight Greece TTT Review 10

2010 World Digestive Health Day 04 Asian Pacific Digestive Week 2010 13 IBD Task Force Meeting Proceedings Professor Dr KL Goh Professor Daniel C. Baumgart Rome Foundation-WGO Joint 15 IBD Research Review 05 Symposium Ami D. Sperber, MD, MSPH

Scientific News Centre International De Formation 17 Post-Graduee En Hepato- Idiopathic Chronic Pancreatitis 06 Gastroenterologie in India and West: Differences Joint WGO-Turkey 2011 Meeeting 18 and Similarities Deepak Bhasin, MD, DM Announcement Surindar S. Rana, MD, DM

WGO Global Guidelines

Constipation Global Guideline 20 Updates

VOL. 15, ISSUE 4 e-WGN Editorial Board Editor: Henry J. Binder, Greger Lindberg • Todd Baron, USA • Klaus Mergener, USA Managing editor: Leah Kopp • Jason Conway, USA • Douglas Rex, USA Art Production: Laura Ludwig • Rodolfo Corti, Argentina • Max Schmulson, Mexico Editorial Office:WGO Executive Secretariat, 555 East Wells • Paul Goldberg, South Africa • Nicholas Shaheen, USA Street, Suite 1100, Milwaukee, WI 53202 USA • Abdel-Meguid Kassem, Egypt • Parul Shukla, India Email: [email protected] • Rene Lambert, France • Martin Smith, South Africa • Joseph Lau, China, Hong Kong • Wendy Spearman, South Africa • Pier-Alberto Testoni, Italy • Nick Talley, USA • Bader Fayaz Zuberi, Pakistan • Mamoru Watanabe, Japan • Chun-Yen Lin, Taiwan

©2010 World Gastroenterology Organisation. No part of this publication may be reproduced. stored in a retrieval system or transmitted in any form without the prior permission of the copyright owner. 3 WORLD GASTROENTEROLOGY NEWS DECEMBER 2010

à Message from the WDHD Chair Continued from page 1

developing the disease in the first place. The World Gastroenterology Organisation selection of the topic for the WDHD is timely: On July 28, 2010 the United Nations General As- sembly declared access to clean water and sanitation a human right. Also vaccines will increasingly play a role in prevention. Still, reducing deaths “depends largely on delivering life-sav- ing treatment of low-osmolarity oral rehydration salts and zinc tablets.”1 While sanitation is not perfect ev- erywhere in industrialized countries, even greater emphasis will be given here on the option of diarrheal prevention by vaccines, e.g. the recently Water well in Lamu, Kenya – how safe? introduced one against rotavirus, sometimes also by medication. Thera- peutic guidelines will be propagated, and appropriate travel kits will be rec- REFERENCES: ommended to those planning to visit high-risk countries. A broad range of 1. UNICEF/WHO. Diarrhoea: why children agents including anti-motility agents, are still dying and what can be done. New systemic and non-absorbed antibiot- York/Geneva, 2009 ics, probiotics, absorbents, antisecre- tory agents, etc. need to be discussed 2. WHO. The World Health Report: along the principles of evidence based Changing History. Geneva, 2004 medicine. Thus, gastroenterologists world- 3. Pitzurra R et al. BMC Infect Dis 2010;10:231 wide as ‘Global Guardians of Diges- tive Health’ are expected to greatly contribute to the global fight against enteric infections on May 29, 2011 and throughout next year. 4 WORLD GASTROENTEROLOGY NEWS DECEMBER 2010

2010 World Digestive Health Day IBD Task Force Meeting Proceedings

along with other South Asians who Professor Daniel C. Baumgart live in Europe tend to be more likely Charité Medical Center - Virchow Hospital, Medical School of the to develop IBD than those living in Humboldt-University, Department of Medicine, Division of Gastro- their home countries. He discussed enterology & Hepatology, D-13344 Berlin / Germany there being a resemblance in various E Mail: [email protected] aspects of UC in Pakistan as there is in Western IBD and a noticeable male dominance. It was also mentioned Throughout 2010 e-WGN has CD and low frequency of NOD2 that patients in Pakistan that are brought various articles and scientific polymorphisms in Northern Europe. insured receive access to a majority of information on Inflammatory Bowel approved Western drugs. Disease from around the world to its JAPAN readers. In this issue we look at the Dr. Toshifumi Hibi of Japan spoke PHILIPPINES IBD task force meeting that occurred second and noted that according A challenge in the Philippines, as during Digestive Disease Week 2010 to the Japanese Ministry of Health, Dr. Jose Sollano reported during his in New Orleans, Louisiana, USA, Labor and Welfare the total num- presentation is the limited amount of where leading international research- ber of people affected with IBD is access to specialized care. An interest- ers and specialists gathered to share thought to be more than 100,000. ing fact he brought up is that a major- their view on the disease. The meeting He emphasized that there is almost ity of those with IBD have traveled was also used to plan an IBD Sym- no association between Korean and abroad, whereas those that haven’t posium which was held October Japanese IBD populations in regard tend to be healthy. This leads to the to most identified genes. This leads to 24, 2010 at the United European idea that a non-Philipino style of life the fact that the genetic risk of IBD Gastroenterology Week in Barcelona, or perhaps other infections could be varies greatly between Japanese and Spain (please see the recap on page possible factors. 9). A total of six experts from various Western IBD populations. Dr. Hibi countries gave presentations with ended by giving an overview of the CLOSING REMARKS Dr. Charles Bernstein, Chair of the Japanese management guidelines for The Task Force meeting ended WGO IBD Task Force moderating UC and CD. with a final panel discussion which and several other experts from Austria, LATIN AMERICA included an overall conclusion that Brazil, Canada, France, Germany, Ire- IBD is in fact an issue globally, train- Presenting on the epidemiology of land, Israel, Japan, Malaysia, Mexico, ing and education should continually IBD in Latin America was Dr. Flavio Norway, Pakistan, Philippines and the be supported and national registries Steinwurz of Brazil. He noted that USA engaged in a lively discussion. promoted. Events around the world the areas limited applicability to A brief summary of points from each have continued throughout 2010 the populations within respective presentation follows. which promote IBD education and countries is a major problem when awareness to both physicians as well as discussing epidemiological data and NORWAY to the general public. The WGO con- Latin America. Two more key points The presentation began with Dr. tinues to support this by frequently brought up by Dr. Steinwurz was that Morton H. Vatn of Norway. He sum- seeking updated information to the UC associated cancer is not seen in marized major epidemiological reports IBD Guideline via Graded Evidence Brazil at all, and those that are insured from both North American and Euro- and offering information on its2010 have access to almost all diagnostic pean groups, discussing incidence rates World Digestive Health Day page. and their increase in Western societies modalities and drugs. The full report appeared in: Inflamm since the mid-1970s as well as peak PAKISTAN Bowel Dis. 2010 Aug 19. [Epub ahead incidence in the third decade. Dr. Vatn of print] http://dx.doi.org/10.1002/ Dr. Zaighaim Abbas of Pakistan stated also emphasized the inverse relation- ibd.21409 ship between the high incidence of in his presentation that Pakistanis 5 WORLD GASTROENTEROLOGY NEWS DECEMBER 2010

IBD Research Review

As part of the WGO’s campaign to raise awareness about inflammatory bowel disease (IBD) throughout 2010, an IBD expert will be recommending and highlighting a “gold standard” article on IBD, with a direct link to the original source, in each issue of e-WGN this year.

ARTICLE Teruel C, López-San Román A, et al. IBD EXPERT: PROF. JESÚS K. YAMAMOTO- Outcomes of pregnancies fathered by FURUSHO M.D., PH.D., M.SC. inflammatory bowel disease patients Head of IBD Clinic, Department of Gastroenterology, Instituto exposed to thiopurines. Am�� J Gas- Nacional de Ciencias Medicas y Nutricion, Vasco de Quiroga 15, troenterol 2010 Sep;105(9):2003-8 Colonia sección XVI, Tlapan, C.P. 14000, Mexico City, MEXICO E-mail: [email protected] (PMID: 20700117)

Professor Yamamoto-Furusho’s comment Introduction to Professor Yamamoto- on the article: This paper provides Furusho: Professor Yamamoto heads novel and important information the IBD Clinic in Mexico City – the about the safety of thiopurines at the only IBD Clinic in Latin America time of conception in male patients with a sizeable publications pro- with IBD suggesting that it is not gramme in the IBD area. recommendable to interrupt this Click here to view his extensive kind of treatment when they want to output in IBD research. conceive. 6 WORLD GASTROENTEROLOGY NEWS DECEMBER 2010

Idiopathic Chronic Pancreatitis in India and West: Differences and Similarities

centre.2 Of 155 patients with chronic Deepak K Bhasin, MD, DM pancreatitis (CP), ICP was the most Professor, Department of Gastroenterology, Post Graduate common form of CP (41.3%) (Fig Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh – 160012, India 1). When we compared the clinical Past President, India Society of Gastroenterology profile of our patients of ICP with the Past President, Society of Gastrointestinal Endoscopy of India profile of classical tropical pancreatitis Email: [email protected] or [email protected] (as revealed by published reports in 1990s from various centers in South India), various interesting differences Surinder S Rana, MD, DM were noted. In contrast to ‘classical’ Assistant Professor, Department of Gastroenterology, Post tropical pancreatitis, where most of Graduate Institute of Medical Education and Research (PGIMER), Sector 12, Chandigarh – 160012, India the patients were between 10 to 30 years of age at the time of diagnosis, the mean age at presentation in our series of idiopathic pancreatitis was 33 Chronic pancreatitis is characterized Such patients often developed an ac- years. Patients with ‘classical’ tropical by irreversible damage to the pancreas celerated course of the disease leading pancreatitis were usually malnour- that eventually leads to pain and/or to diabetes and/or steatorrhea, and ished and emaciated and abdominal exocrine and endocrine insufficiency. a higher susceptibility to pancreatic pain was seen in 30 to 90% of the In spite of large number of reports cancer. Physicians attempted to find patients. Majority of our patients with on chronic pancreatitis, it remains a the underlying cause of such intrigu- ICP had normal mean body mass fascinating disease of uncertain patho- ing presentations, which tended to be index and 96.9% of the patients had genesis, unpredictable clinical course more common in a specific geo- abdominal pain as one of the present- and unclear treatment. While alcohol graphical area of India (south India).1 ing clinical feature. More than 90% is an important and major cause of Various hypotheses like malnutrition, of the patients of tropical pancreati- chronic pancreatitis worldwide, the oxidant stress hypothesis, trace ele- tis had pancreatic calcification and cause remains unidentified in a large ments deficiency or cassava ingestion diabetes whereas in our study, the number of patients. Chronic pancre- (Tapioca, Manihot esculenta) were frequency of pancreatic calcification atitis of unknown etiology has been proposed as etiopathogenesis, but and diabetes was 46.9% and 23.4% labeled as idiopathic chronic pancre- have not been proven.1 respectively. Majority of patients with atitis (ICP) which includes a number Limited studies have looked into tropical pancreatitis frequently had of disease entities like early and late the profile of ICP in North India and large intra-ductal calculi whereas cal- onset idiopathic chronic pancreatitis, most suggested that ICP of North culi were noted in only 9/64 (14%) of minimal change chronic pancreatitis, India is similar to tropical pancreatitis our patient population. Also, none of small duct chronic pancreatitis and of South India. However, recent anec- our patients had history of ingestion tropical pancreatitis. dotal observations suggested that ICP of cassava. In contrast to high risk Ever since its first description in the of North India is probably different. of pancreatic malignancy in tropical 1950s, tropical pancreatitis has con- In our daily clinical practice over the pancreatitis, none of our patients with tinued to fascinate and challenge the last decade, at a major tertiary health ICP had pancreatic cancer. pancreatologists in India and world, care center in North India, we have Another study from North India alike. A case of classical tropical pan- encountered patients with classical on idiopathic chronic pancreatitis creatitis was a young patient who had tropical pancreatitis only infrequently. reported that classical tropical pan- pot belly, clinical signs of malnutri- With a goal to dissect the differ- creatitis was uncommonly seen with tion and deficiency. Plain radiograph ences between ICP within India, only 5.8% of the patients fitting into of abdomen revealed the pancreas we undertook a study on clinical the standard criteria for diagnosis of studded with large intraductal calculi. profile of patients with ICP at our tropical pancreatitis.3 The patients 7 WORLD GASTROENTEROLOGY NEWS DECEMBER 2010

Figure 1: EUS images of patients with idiopathic chronic pancreatitis 1a: Dilated pancreatic duct (between the marks +) with small ductal calculi (arrow); 1b: Large ductal calculi in body of pancreas (arrow); 1c: Dilated pancreatic duct with large ductal calculi in head of pancreas (arrow); 1d: Parenchymal calcification (white arrows) with stent in the pancreatic duct (black arrow). SV: splenic vein, PD: pancreatic duct with ICP presented at a later age than people with the mean age at onset of patients had a significant higher male the classical tropical pancreatitis, were disease being 30.6 years in contrast to preponderance and lower frequency not malnourished and diabetes was 20.7 years in the 1984 cohort. The of exocrine insufficiency. Also, our also uncommon at presentation, seen frequency of pain was higher and that patients with late-onset idiopathic in only one third of the patients with of diabetes was lower in the recent chronic pancreatitis all had pain that ICP. Midha et al also reported better cohort (95.9% vs. 81% and 59.7% vs. was absent in a significant number survival for patients with ICP with a 77%, respectively). Only 10%-15% of cases from the West. Exocrine 35 year probability of survival being of patients presented with the classical insufficiency was seen in significantly 85%. This is in contrast to earlier features of tropical pancreatitis. A greater number of patients with late studies on ‘classical’ tropical pancre- recent prospective multicenter study onset ICP of West in comparison to atitis which had shown it to be an from India involving 1086 subjects late onset ICP at our centre. Thus, the aggressive disease with many patients from all parts of India including ICP of our population has started to dying early in the course of disease. South India also reported that only resemble ICP of West, but there are These observations from two large ter- 3.8% of the patients with chronic still persistent pertinent differences in tiary care centres in North India make pancreatitis were diagnosed as having the clinical profile of the two. us wonder whether the ICP of North classical tropical pancreatitis.5 We The cited studies above suggest that India is different from the classical then looked at patients with early classical tropical pancreatitis is now tropical pancreatitis described earlier, onset ICP in our study to see if there seen uncommonly both in North or is this indeed the same disease that were any cases that resembled classi- and in South India. It also appears has changed its’ phenotypic expression cal tropical pancreatitis. Even cases that over a period of time the profile over a period of time? To get closer to that appeared to be classical tropical of tropical pancreatitis/ICP in India the answer of this intriguing ques- pancreatitis had a lower incidence of has changed. So what has happened tion, let us see what has happened to diabetes, ductal calculi and less dense over the last two decades that has tropical pancreatitis in South India, calcifications. changed the profile of tropical pan- the part of India from where a large Let us have a look at the profile of creatitis? ICP is a complex polygenic number of studies on tropical pancre- ICP in the West. Layer et al6 reported disorder with interaction of genes atitis have emanated. two distinct forms of ICP in the with environment determining the Balakrishnan et al4 in 2006 com- West: early and late onset ICP. Early phenotypic expression of the disease. pared a cohort of 220 patients with onset idiopathic chronic pancreatitis It is unlikely that the genetic profile of ICP studied in 1984 with another was characterized by a long course of the population is going to change in cohort of 244 patients seen in 2004. severe abdominal pain with calcifica- few decades. It seems that this change These authors from Kerala in South tions. The exocrine and endocrine in- in profile of ICP may be due to the India reported that the clinical profile sufficiency also developed more slowly changes in the environment, diet, and and presentation of the disease has than in late onset idiopathic chronic nutritional status brought about by changed over a period of time. They pancreatitis. When compared with the economic progress of India in the reported that ICP in the recent group early onset idiopathic chronic pancre- past two decades. (2004) of patients occurred in older atitis of the West, our North Indian Genetic studies have been con- 8 WORLD GASTROENTEROLOGY NEWS DECEMBER 2010

ducted to unravel the mystery of this ferent diseases altogether. Until such 8. Whitcomb DC, Gorry MC, Preston RA, intriguing disease. Gain-of-function time we will continue to designate Furey W, Sossenheimer MJ, Ulrich CD, Mar- mutations of the cationic trypsinogen these mysterious and challenging tin SP, Gates LK Jr, Amann ST, Toskes PP, (PRSS1) gene are associated with he- diseases by latitudes, longitudes and/ Liddle R, McGrath K, Uomo G, Post JC, Eh- reditary chronic pancreatitis and idio- or geographical boundaries. rlich GD. Hereditary pancreatitis is caused 7,8 by a mutation in the cationic trypsinogen pathic chronic pancreatitis of West. gene. Nat Genet 1996; 14: 141-145 However, studies from India have not found its association with tropical 9. Hassan Z, Mohan V, McDermott MF, Ali pancreatitis.9,10 Instead, SPINK 1 L, Ogunkolade WB, Aganna E, Cassell PG, mutation is reported to be more com- REFERENCES: Deepa R, Khan AK, Hitman GA. Pancreatitis monly associated with tropical pan- in fibrocalculous pancreatic diabetes mellitus is not associated with common muta- creatitis.3,9-11 There have been attempts 1. Barman KK, Premalatha G, Mohan V. Tropical chronic pancreatitis. Postgrad Med tions in the trypsinogen gene. Diabetes to identify other genetic mutations J 2003; 79: 606–615. Metab Res Rev 2000; 16: 454-457 that can explain the pathogenesis of tropical pancreatitis or idiopathic 2. Bhasin DK, Singh G, Rana SS, Chowdry 10. Chandak GR, Idris MM, Reddy DN, pancreatitis of India. Cystic fibrosis S, Shafiq N, Malhotra S, Sinha SK, Nagi B. Bhaskar S, Sriram PV, Singh L. Mutations in the pancreatic secretory trypsin inhibitor transmembrane regulator (CFTR) Clinical profile of idiopathic chronic pancreatitis in North India. Clin Gastroenterol and gene (PSTI/SPINK1) rather than the cationic mutations and polymorphisms in Hepatol 2009; 7: 594-99 trypsinogen gene (PRSS1) are significantly cathepsin B (CTSB, OMIM 116810) associated with tropical calcific pancreatitis. J Med Genet 2002; 39: 347-351 have also been shown to be associ- 3. Midha S, Khajuria R, Shastri S, et al. ated with tropical pancreatitis. Recent Idiopathic chronic pancreatitis in India: studies have identified chymotrypsin phenotypic characterization and strong 11. Bhatia E, Choudhuri G, Sikora SS, Landt O, Kage A, Becker M, Witt H. Tropical C (CTRC, OMIM 601405) as a new genetic susceptibility due to SPINK1 and CFTR gene mutations. Gut 2010; 59: 800-7. calcific pancreatitis: strong association pancreatitis-associated gene. This mu- with SPINK1 trypsin inhibitor mutations. tation has been reported in Idiopathic Gastroenterology 2002; 123:1020-1025 4. Balakrishnan V, Nair P, Radhakrishnan chronic pancreatitis of both West and L, Narayanan VA. Tropical pancreatitis - a India.12,13 distinct entity, or merely a type of chronic 12. Rosendahl J, Witt H, Szmola R, et al. In conclusion the several studies pancreatitis? Indian J Gastroenterol. 2006 Chymotrypsin C (CTRC) alterations that ;25:74-81. diminish activity or secretion are associ- discussed in this summary indicate: 1) ated with chronic pancreatitis. Nat Genet Classical tropical pancreatitis is being 2008;40:78-82. 5. Balakrishnan V, Unnikrishnan AG, seen less and less, even in India; 2) Thomas V, et al. Chronic�� pancreatitis. A pro- ICP of North India differs from classi- spective nationwide study of 1,086 subjects 13. Derikx MH, Szmola R, Te Morsche RH, cal tropical pancreatitis with a higher from India. JOP. 2008 ;9:593-600. et al. Tropical calcific pancreatitis and its association with CTRC and SPINK1 (p.N34S) frequency of pain, lower frequency variants. Eur J Gastroenterol Hepatol of: diabetes, pancreatic calcification 6. Layer P, Yamamoto H, Kalthoff L. Clain 2009;21:889-94. and intra-ductal calculi.2,3,14 This JE, Bakken LJ, DiMagno EP. The different courses of early and late onset idiopathic disease has better prognosis compared and alcoholic chronic pancreatitis. Gastro- 14. Bhasin DK, Rana SS, Chandail VS, to classical tropical pancreatitis with enterology 1994; 107: 1481-7. Singh G, Gupta R, Kang M, Sinha SK, Singh improved survival rates; and 3) ICP K. Clinical Profile of Calcific and Noncalcific Chronic Pancreatitis in North India. J Clin of our population in North India has 7. Teich N, Rosendahl J, Tóth M, Mössner Gastroenterol. 2010 Oct 19. [Epub ahead of started to resemble ICP of the West J, Sahin-Tóth M. Mutations of human print] but there still exist differences in the cationic trypsinogen (PRSS1) and chronic pancreatitis. Hum Mutat 2006; 27: 721-730 clinical profile of ICP of North India compared to that of the West. We expectantly look forward to genetic and other studies that hopefully will unravel the mystery that idiopathic pancreatitis of North and South India and that of the West are either 1) the same disease with different presentations and manifestations; or 2) dif- 9 WORLD GASTROENTEROLOGY NEWS DECEMBER 2010

WDHD 2010: The year of IBD A Recap of the 2010 IBD Symposium

issues therapeutically. Dr. D’Haens re- Charles N. Bernstein, MD viewed diagnostic issues in IBD from Professor of Medicine, Head, Section of Gastroenterology, Direc- blood testing to endoscopy to imag- tor, IBD Clinical Research Centre, University of Manitoba, Canada ing. Dr. Dotan reviewed the complex Email: [email protected] issues of deciding on surgery versus advanced immunomodulatory therapy in patients with complicated disease. During the panel discussion audi- This past year the WGO has devoted United European Gastroenterology ence participants raised such issues as much time and energy toward pro- Week, Barcelona in October, 2010. the emergence of IBD in developing moting knowledge about inflamma- The meeting was held on October 24 countries and distinguishing Crohn’s tory bowel diseases (IBD) for an in- and several hundred attendees were disease from tuberculosis. ternational audience. We have aimed treated to three superb presentations The WGO considers our “WDHD to reach both patients and health care by Ernest Seidman, MDCM, FR- 2010: year of IBD” a success in that providers with information about CPC, FACG, Professor of Medicine we were able to generate increased diagnostic and management issues. & Pediatrics, Canada Research Chair interest in IBD. For example, our “10 At the Digestive Diseases Week in in Immune Mediated Gastrointestinal tips for patients” was translated into New Orleans in May, 2010 we con- Disorders, Bruce Kaufman Endowed multiple languages and our “cascades” vened a meeting of IBD experts from Chair in IBD at McGill University guidelines for diagnosis and manage- around the world including Austria, Health Center, Montreal General ment in countries of different resource Brazil, Canada, France, Germany, Ire- Hospital, Canada; Geert D’Haens, capabilities was published in the land, Israel, Japan, Malaysia, Mexico, MD, PhD, Professor of Medicine, journal Inflammatory Bowel Diseases. Norway, Pakistan, Philippines and Academic Medical Centre, Section of However, the real measure of success the USA to discuss issues germane to Gastroenterology, Amsterdam, The will come if in fact practitioners and managing IBD in different cultures, Netherlands, Director, Imelda GI patients alike in developing coun- different economies, different coun- Clinical Research Centre, Bonheiden, tries feel that there is greater clarity ties. Proceedings of this meeting are Belgium; and Iris Dotan, MD, Head in approaching the management of published in the journal Inflammatory of IBD Service, Department of Gas- IBD and if we have raised awareness Bowel Diseases as well as on page 4. troenterology and Liver Diseases, Tel- so that their local health care provid- Another goal of this meeting was Aviv Sourasky Medical Centre, Israel. ers, governments, and pharmaceutical to lay the groundwork for the kind of Dr. Seidman reviewed nutritional industries will have recognized the issues we wanted discussed at an inter- issues as they may pertain to disease importance of IBD as an emerging national symposium to be held at the etiology as well as key nutritional and costly clinical problem. To view the full scope of the 2010 WDHD Campaign and to access IBD resources and information regarding the broad range of events held globally, please visit http://www.worldgastroenterology.org/wdhd-2010.html. The Inflammatory bowel disease: a global perspective guideline can be downloaded for free here: http://www. worldgastroenterology.org/inflammatory-bowel-disease.html. (from left to right) Charles N. Bernstein, MD, Iris Dotan, MD, Geert D’Haens, MD, PhD and Ernest G. Seidman, MDCM, FRCPC, FACG were the panel of experts during the IBD Task Force Symposium, Barcelona, Spain 10 WORLD GASTROENTEROLOGY NEWS DECEMBER 2010

WGO Train the Trainers: Trial Design Workshop Athens 2010

Author: Jim Toouli, MBBS, PhD, FRACS Department of Surgery, Flinders University Bedford Park, Adelaide, Australia Email: [email protected]

In collaboration with the Hellenic Syria, Colombia, China, Brazil and Society of Gastroenterology (HSG), Cameroon. WGO is proud to have successfully One of the highlights throughout completed its 2nd annual Train the this workshop were the breakout Trainers: Trial Design Workshop, sessions, which allowed for partici- which took place on November 11th pants to work with local facilitators and 12th 2010 in Athens, Greece. in developing small group presenta-

Like the standard TTT this work- tions on topics discussed during the WGO Faculty front row, left to right: Nicoletta shop, developed by WGO, exposes lectures. Based on the feedback from Mathou, Greece; Adam Adamopoulos, Greece; clinical investigators in gastroenterol- Dubrovnik in 2009, faculty decided John Karagiannis, Greece. Back row: Eamonn Quigley, Ireland; Spyros Michopoulos, Greece; ogy and GI surgery to current trial that it was important to incorporate Jim Toouli, Australia; David Bjorkman, USA. design techniques and philosophies. additional time for participant en- It brings together faculty and par- gagement. With this in mind, a new ticipants from across the globe in an element to this course was introduced Dilation vs. Mechanical Lithotripsy intensive and interactive workshop. which provided participants with the for the Treatment of Difficult Com- The workshop is characterized by opportunity of developing a clinical mon Bile Duct Stones; Inflammatory hands-on sessions and ample oppor- study relevant to their region’s needs Bowel Diseases, Trends and Pattern of tunity for discussion and interchange. prior to the commencement of the Admission in Major Referral Hos- The workshop syllabus includes: types workshop. pital, Dammam Medical Complex, of clinical trials, data analysis and Topics which were tendered for dis- in Eastern Province in Kingdom of statistics, grant writing, data interpre- cussion included: Study of Anti-HIV Saudi Arabia; Antimicrobial resistance tation and ethical considerations. seroprevalence in Deirezor Province, incidence among adult patients with On behalf of WGO, our most Syria; Comparing conventional light dyspepsia Helicobacter pylori-infected: sincere appreciation goes to the host endoscopy (CLE) versus FICE for di- A prospective and multicenter, coordinator, Dr. John Karagiannis of agnosis of esophageal minimal lesions Colombian trial; and EUS-guided the HSG, as well as all of the local in patients with gastroesophageal non- Ablation of Mucus Cystic Neoplasms facilitators and international faculty erosive reflux disease; The Prevalence of Pancreas using P131 Brachytherapy who contributed to the successful of Pancreatic Intraductal Papillary in Liquid formulation. outcome of the program. Mucinous Neoplasm (IPMN) by The sessions provided participants The Trial Design Workshop consist- EUS evaluation in Greek popula- with the research tools and references ed of 19 participants and seven faculty tion concerning ages between 25 and needed in conducting these diverse members representing countries from 60 years old; Defining Criteria For studies. In addition the workshop all over the world, including Greece, Upper Gastrointestinal Endoscopy discussed ways of publishing the data Australia, Ireland, USA, Nigeria, In Nigerians; Large Balloon Papillary and discussed mechanisms for obtain- 11 WORLD GASTROENTEROLOGY NEWS DECEMBER 2010

ing funding which allows the conduct of the studies. Following the workshop, participants were encouraged to provide feedback both openly and using an evaluation form. One participant wrote that, “You gave us good examples …., very good.” Many felt that the “faculty provided exceptional presentations,” and that the “report- back session was very interesting and useful.” Furthermore, participants expressed their interest in participat- ing in future TTTs and requested that additional days be added to the Trial WGO Train the Trainers: Trial Design Workshop. The photo was taken at Eleftherias Park in Vasil- Design Workshop. lisis Sofias Avenue. With one workshop ending successfully, we begin the process of preparing for the upcoming Train the Trainers workshop. 2011 will mark the 11th year anniversary of Train the Trainers! This TTT, in collaboration with the Indian Society of Gastroen- terology, will take place in Chennai, India, from April 11-14, 2011. A recap of the TTT will be reported in the June issue of e-WGN following the Chennai workshop. For more information on WGO’s Train the Trainer Workshops visit http://www. worldgastroenterology.org/train-the- trainers.html 12 WORLD GASTROENTEROLOGY NEWS DECEMBER 2010

Asian Pacific Digestive Week 2010 “Gastroenterology in the Asia-Pacific- Excellence in the New Decade”

Professor Dr KL Goh President, APDW 2010 Gastroenterology in Asia-Excellence in the New Decade E-mail: [email protected]

The APDW 2010 was successfully graduate course, two special OMED organized from 19th-22nd September endoscopy course/courses and 12 2010 in Kuala Lumpur, Malaysia. focused research meetings were suc- It was the first time that this pre- cessfully held at APDW 2010. Thirty- mier event was held in Malaysia and eight biomedical companies, utilizing it was indeed heartening to receive 102 unit booths participated in a truly a record crowd of 2,661 registered beautiful trade exhibition and we also delegates coming from 59 countries, held nine pharmaceutical sponsored including 31 Asian countries and 28 satellite symposiums. A record 583 outside Asia including from Africa, original scientific submissions for oral the USA, Slovakia, Russia and Swe- and free paper presentations were re- den. We had a formidable line-up of ceived, as well as two Young Investiga- 143 internationally renowned speak- tor Awards sessions. The record does Professor Neville Yeomans delivering the Mar- ers and 83 moderators. Ten special speak for itself. shall and Warren lecture at APDW 2010 lectures, 33 symposiums, two days of Apart from the four host societies: live endoscopy workshop, a post- Asian Pacific Association of Gastro- enterology, Asian Pacific Society of Digestive Endoscopy, Asian Pacific Association of Study of Liver Dis- ease and the International Society of Digestive Surgery, we had participa- tion from eight sister GI organizations: World Endoscopy Organization (OMED), International Organization of Inflammatory Bowel Disease (IOI- BD), European Association of Gas- troenterology (EAGE), International Digestive Cancer Alliance (IDCA), The International Working Group for the Classification of Esophagitis (IWGCO), Asian Neurogastroenterol- ogy Motility Association (ANMA), Japan Society of Gastroenterological Endoscopy, and the American Society Professor Fock opening the APDW 2010 of GI Endoscopy (ASGE). 14 WORLD GASTROENTEROLOGY NEWS DECEMBER 2010

The APDW 2010 was truly a top- class event which the Malaysian Soci- ety of Gastroenterology and Hepatol- ogy was proud to host and organize. It was landmark event for us and we are grateful for its huge success. I wish to thank everyone who had participated in the meeting and hope that you have benefited scientifically, profes- sionally and socially from it and have brought back home fond memories of the APDW 2010.

Professors Ken McColl and Mrs. McColl. Pali Hungin and Peter Malfertheiner 15 WORLD GASTROENTEROLOGY NEWS DECEMBER 2010

The Rome Foundation and WGO Announce Joint Symposium IBS – The Global Perspective Prevalence, Pathophysiology, Presentation and Management

Ami D. Sperber, MD, MSPH Emeritus Professor of Medicine Faculty of Health Sciences, Ben-Gurion University of the Negev Email. [email protected]

The Rome Foundation along with the Culture, Health and FGIDs World Gastroenterology Organisa- • Culture and Health tion will be holding a symposium • Explanatory Models of Health titled IBS – The Global Perspective. and Illness, Impact of Culture on The meeting, co-directed by Dr. Ami Physicians’ and Patients’ Explana- Sperber (Rome) and Dr. Eamonn tory Models Quigley (Ireland, WGO) will be held Mechanisms and Pathophysiology Conducting Multinational Drug for one-and-a-half days on April 6-7, • A Global Perspective on the Trials 2011 in Milwaukee, Wisconsin, USA. Effect of Genetics and Ethnicity • Unique Problems in Multi- The symposium will be held just prior on Pathophysiology and Manage- th National Studies: Organizational to the 9 International Symposium ment and Regulatory Issues on Functional GI Disorders (April • GI Microbiology: Pathogens, • Unique Problems in Multi-Na- 8-10, 2011). Exposure Patterns and Immune tional Studies: Ethical Issues and This will be an exciting and stimulat- Responses Recruitment Problems ing meeting, which will provide a new • Geographical and Cultural Food- • Unique Problems in Multi-Na- perspective on IBS and other func- Related Symptoms, Food Avoid- tional Studies: Regional Per- tional GI disorders that is relevant to ance and Elimination spectives on Inclusion Criteria, clinicians and academicians alike. • Worldwide Differences in Psy- Endpoints and Outcomes The faculty will include a stel- chopathology and the Interpreta- lar group of speakers from the areas tion and Effects of Stress WORKSHOPS INCLUDE: of functional GI disorders, medical Patient Care in Different Geo- Clinical Competence Workshop anthropology, health and culture, and graphical Areas and Cultural • Working in a Multiethnic Clinic psychopathology, as well as represen- Settings • Role Play with Professional Ac- tatives of regulatory agents from the tors - Clinical Encounters with US, Europe and Japan. • Practicing in a Multicultural Milieu: Physician Competence Cross-Cultural Issues THE PROGRAM WILL INCLUDE • Practicing in a Multicultural Research Competence Workshop THE FOLLOWING SESSIONS: Milieu: Patient Health Literacy • Cross-Cultural, Multinational • Folk Remedies, Self-Medicating, Epidemiology and Socio-Cultural Research and CAM Around the World Issues • Examples of Cross-Cultural Stud- • Impact of Local Regulations • Culture and Symptom Reporting ies and Healthcare Organization on • Translation and Validation of • Interpretation and Reporting of Management Options GI Symptoms, Differential Di- Instruments for Cross-Cultural • Effect of Religious and Cultural Studies agnosis and Diagnostic Work-up Beliefs on Healthcare Around the Around the World World 16 WORLD GASTROENTEROLOGY NEWS DECEMBER 2010

WHO SHOULD PARTICIPATE: The scientific advisory and • Practicing gastroenterologists, organizing committee is primary care physicians, psychol- comprised of the following ogists, sociologists, and other members: Click Here health care providers interested Rome Foundation: Ami Sperber, in IBS and the functional GI Doug Drossman, Lin Chang, Max to Register disorders at a global level Schmulson • Scientists and academicians inter- WGO: Eamonn Quigley, Richard Now! ested in cross-cultural investiga- Hunt, Kok-Ann Gwee, Carolina tion of these conditions. Olano • Pharmaceutical company IFFGD:– Nancy Norton research, development and All meeting information and regis- marketing managers interested in tration is currently available at www. learning about cultural differenc- romecriteria.org/global_perspective. es in attitudes and beliefs toward medical treatments • Members of health policy and regulatory organizations 17 WORLD GASTROENTEROLOGY NEWS DECEMBER 2010

Centre International De Formation Post-Graduee En Hepato-Gastroenterologie Celebration of the 10th Annual Course of WGO-Rabat Training Centre

The WGO-Rabat Training is proud At the end of the Tenth Training to announce that in January of 2011, Course, the Third Symposium of the they will be celebrating the Tenth African Middle Eastern Digestive Gastroenterology and Hepatology Cancer Alliance, the regional arm of Training Course at their training the IDCA, will be held. This will be centre, Rabat, Morocco. The course, led by former WGO treasurer, Doug- which will be held January 27 through las LeBrecque. February 5, 2011, will include: BACKGROUND CONFERENCES: The Rabat Training Center was News Hepatology opened in January 2003. It is Viral hepatitis (news) situated in the Faculty of Medicine Cholestatic liver and Pharmacy of the Mohammed ACDI / Digestive Cancer V-Souissi University. It is open to all Chronic diarrhea French speaking gastroenterologists, NSAIDs and gut in particular from Africa, willing to Celiac disease improve their theoretical and practical Digestive Diseases and Nutrition, knowledge, in the fields of hepatology FI and gastroenterology. Since its open- Proctology practice ing, the Center has organised regular Non-HP gastritis training sessions ranging from 10 days Obesity to internships of 4 years. Attend- ees have come from all over French HELP WITH MEDICAL WRIT- speaking Africa and the Indian Ocean ING: ARTICLES AND CRITICAL Islands, and over 350 practitioners READING have already received training. For more information, please visit BIOETHICS www.centreomge-rabat.org. DISTANCE EDUCATION

PRACTICAL TRAINING: Endoscopy Workshop Ultrasound Workshop Animal Modles Simulator Video Corner Workshops Clinical Cases 18 WORLD GASTROENTEROLOGY NEWS DECEMBER 2010

GASTRO-ANTALYA 2011: Joint WGO-Turkish Society of Gastroenterology Meeting Announced WGO and the Turkish Society of Gastroenterology are pleased to announce and invite you to the upcoming joint meeting, Gastro-Antalya 2011, November 16 to 20. This clinically-oriented congress will feature a two- day case-based postgraduate course, numerous symposia on critical issues in Gastroenterology, Hepatology and Endoscopy and ample opportunities for the presentation of original work. While the main languages of the meeting will be English and Turkish, simultaneous translation into Russian will also be available. Continue watching future issues of e-WGN for the latest updates on registration, abstracts and general information, throughout 2011. You may contact the secretariats at [email protected] or [email protected], and visit www.wgo-turkey2011.org for more information. 19 WORLD GASTROENTEROLOGY NEWS DECEMBER 2010

DearDear Colleagues, Colleagues,

TheThe World World Gastroenterology Gastroenterology Organisation Organisation(WGO) and the International (WGO) and Digestive the InternationalCancer Alliance (IDCA), Digestive a division of theCancer WGO, have Alliance mutually (IDCA), agreed that a thedivision IDCA willof thebecome WGO, an independent have mutually organization. agreed Both thatWGO the and IDCA IDCA will continuewill become their interest an and independent activities in GI organization.oncology, with the Both special WGO focus of a thend WGO IDCA being will on continue those issues their that are pertinent on a global basis to its primary goals of education and training. interest and activities in GI oncology, with the special focus of the WGO being on Boththose organizations issues look that forward are pertinentto future collaborations on a global based basis on issues to of its mutual primary interest goals and for of the education benefit of our patientsand aroundtraining. the world.

WeBoth realize organizationsthat you may have lookquestions forward regarding to thisfuture decision collabora and invitetions you tobased contact on us atissues any time. of mutual interest and for the benefit of our patients around the world. Thank you for your continued support of both the WGO and the IDCA. We realize that you may have questions regarding this decision and invite you to Sincerely,contact us at any time.

Thank you for your continued support of both the WGO and the IDCA.

Sincerely, Richard Kozarek, MD Sidney Winawer, MD President, WGO Chairman, IDCA

Richard Kozarek, MD Sidney Winawer, MD President, WGO Chairman, IDCA Eamonn Quigley, MD Meinhard Classen, MD Past President, WGO Past Chairman, IDCA

Eamonn Quigley, MD Meinhard Classen, MD Past President, WGO Past Chairman, IDCA

Henry Cohen, MD Guido Tytgat, MD Vice President, WGO Vice Chairman, IDCA Henry Cohen, MD Guido Tytgat, MD Vice President, WGO Vice Chairman, IDCA

Cihan Yurdaydin, MD Joseph Geenen, MD Secretary General, WGO Finance Officer, IDCA Cihan Yurdaydin, MD Joseph Geenen, MD Secretary General, WGO Finance Officer, IDCA 20 WORLD GASTROENTEROLOGY NEWS DECEMBER 2010

Constipation – WGO’s latest cascade-based global guideline featuring resource sensitive approaches to diagnosis and management This article is an abridged version of WGO’s new guideline on Constipation . It looks at its unique aspects – the Cascades for diagnosis and treatment developed by Professor Greger Lindberg and his Review Team

1. Introduction Table 1. Possible causes & constipation associated conditions

Constipation is a chronic problem in Mechanical obstruction Neurological disorder/neuropathy many patients all over the world. In Colorectal tumor Autonomic neuropathy some groups of patients such as the Diverticulosis Cerebrovascular disease elderly, constipation is a significant Strictures Cognitive impairment/dementia healthcare problem, but in the major- External compression from tumor/other Depression Large rectocele Multiple sclerosis ity of cases chronic constipation is an Megacolon Parkinson’s disease aggravating but not life-threatening Postsurgical abnormalities Spinal cord pathology or debilitating complaint that can be Anal fissure managed in primary care with a cost- Endocrine/metabolic condition GI disorders & local painful condition effective control of symptoms. Chronic kidney disease Irritable bowel syndrome Dehydration Abscess 2. Cascades– a resource-sensitive Diabetes mellitus Anal fissure Heavy metal poisoning Fistula approach Hypercalcaemia Haemorrhoids A gold standard approach is feasible Hypermagnesaemia Levator ani syndrome for regions and countries where the Hyperparathyroidism Megacolon Hypokalaemia Proctalgia fugax full scale of diagnostic tests and medi- Hypomagnesemia Rectal prolapse cal treatment options is available for Hypothyroidism Rectocoele the diagnosis and management of all Multiple endocrine neoplasia II Volvulus Porphyria constipation (sub)types. But what Uremia can be the approach in a resource Myopathy Dietary constrained setting? Enter WGO’s Amyloidosis Dieting unique ‘Cascade’ concept. Below we Dermatomyositis Fluid depletion reproduce three resource sensitive Scleroderma Low fiber approaches for the investigation and Systemic sclerosis Anorexia, dementia, depression management of constipation. Miscellaneous Cardiac disease CASCADE: A HIERARCHICAL Degenerative joint disease SET OF DIAGNOSTIC, THERA- Immobility PEUTIC AND MANAGEMENT OPTIONS TO DEAL WITH RISK Table 2. Medications associated with constipation

AND DISEASE - RANKED BY Prescription drugs Self-medication – over-the-counter drugs RESOURCES AVAILABLE. Antidepressants Antacids (containing aluminium, calcium) Antiepleptics Antidiarrheal agents 2.1 Cascade options for Antihistamines Calcium and iron supplements investigation of severe/therapy Antiparkinson drugs Nonsteroidal anti-inflammatory drugs Antipsychotics refractory constipation Antispasmodics Level 1 – limited resources Calcium channel blockers a. Medical history and general Diuretics Monoamine oxidase inhibitors physical examination Opiates b. Anorectal examination, 1-week Sympathomimetics bowel habit diary card Tricyclic antidepressants 21 WORLD GASTROENTEROLOGY NEWS DECEMBER 2010

c. Transit study using radio-opaque Level 1 – limited resources thin stools, feeling of blockage, or markers a. Dietary advice (fiber & fluid) failure of treatment for constipation d. Balloon expulsion test b. Fiber supplementation with hard stools. Level 2 – medium resources c. Milk of magnesia (Magnesium Level 1 – limited resources a. Medical history and general hydroxide in aqueous solution) a. Dietary and behavioural advice physical examination d. Stimulant laxatives (bisacodyl (fiber, fluid, timed bowel train- b. Anorectal examination, 1-week better than senna) for temporary ing) bowel habit diary card use b. Therapy for chronic constipation c. Transit study using radio-opaque Level 2 – medium resources Level 2 – medium resources markers a. Dietary advice (fiber & fluid) a. Dietary and behavioural advice d. Balloon expulsion test or defe- b. Fiber supplementation, psyllium (fiber, fluid, timed bowel train- cography c. Milk of magnesia, lactulose, ing) Level 3 – extensive resources macrogol b. Therapy for chronic constipation a. Medical history and general d. Stimulant laxatives for temporary c. Biofeedback therapy use physical examination Level 3 – extensive resources b. Anorectal examination, 1-week Level 3 – extensive resources a. Dietary and behavioural advice bowel habit diary card a. Dietary advice (fiber & fluid) (fiber, fluid, timed bowel train- c. Transit study using radio-opaque b. Psyllium or lactulose ing) markers c. Macrogol or lubiprostone b. Therapy for chronic constipation d. Defecography or magnetic reso- d. Prokinetics (prucalopride) c. Biofeedback therapy nance (MR) proctography e. Stimulant laxatives (bisacodyl or d. Surgical evaluation e. Anorectal manometry sodiumpicosulphate) f. Sphincter electromyography THE CONSTIPATION GUIDELINE (EMG) 2.3 Cascade options for treatment of evacuation disorders REVIEW TEAM 2.2 Cascade options for treatment This cascade is developed for patients Greger Lindberg (Chairman) of chronic constipation with chronic constipation without Saeed Hamid (Pakistan) The following cascade is intended for alarm symptoms but with suspicion Peter Malfertheiner (Germany) patients with chronic constipation of an evacuation disorder. The main Ole Thomsen (Denmark) without alarm symptoms and little symptoms would be prolonged strain- Luis Bustos Fernandez (Argentina) or no suspicion of an evacuation dis- ing, feeling of incomplete evacuation, James Garisch (South Africa) order. The main symptoms would be Alan Thomson (Canada) hard stools and/or infrequent bowel Khean-Lee Goh (Malaysia) motions. Rakesh Tandon (India) Suliman Fedail (Sudan) Benjamin Wong (China) Aamir Khan (Pakistan) Justus Krabshuis (France) Anton Le Mair (The Netherlands)