Professor Ingvar Bjarnason

The Cliinc provides investigation and treatment of all Gastroenterological complaints by recognised experts

The lead for this service is Prof Ingvar Bjarnason Professor of Digestive Diseases at Guy s, King s, St Thomas Medical School, London and Consultant Physician and Gastroenterologist at King s College Hospital. He has a distinguished clinical and academic career having published 700 scientific papers.

A valued principal of our service is that we aim to minimise and avoid as much as possible the use of expensive, time consuming and uncomfortable invasive tests (such as endo-, entero- and colonoscopy) without compromising diagnostic accuracy. We achieve this by carrying out appropriate, well validated and highly sensitive non-invasive screening tests prior to or after the first consultation. This may involve testing for intestinal permeability, intestinal disaccharidase deficiecy, intestinal inflammation (faecal calprotectin), intestinal transit, screening tests for Coeliac disease and Helicobacter pylori, etc. All of these tests have been published in high impact, peer reviewed, scientific journals, but many are not at present available in routine clinical laboratories. The efficacy of this approach can be demonstrated in the investigation of three common diseases, namely the irritable bowel syndrome, colorectal cancer and inflammatory bowel disease.

The Irritable bowel syndrome
The irritable bowel syndrome accounts for over 40% of all Gastroenterological consultations and has a prevalence in the community of at lease 20%. It is a diagnosis made by the exclusion of "organic" intestinal disease and therefore calls on a number of investigations in usual Gastroenterology practice (various combinations of flexible endoscopic and radiological procedures) in the vast majority of patients. However a combination of a "positive" symptom based questionnaire, normal intestinal permeability and faecal calprotectin virtually excludes any other diagnosis and reduces the need for invasive investigation in 85% of patients. This effectively reduces the need for invasive investigation (such as colonoscopy which usually demands setting a day aside prior to the investigation while taking purgatives and the day of examination due to administration of sedative and analgesic drugs during the procedure) in all patients to 3 in 20.

Colorectal cancer
Colorectal cancer is the 2nd and 3rd most common cancer in men and women, respectively and is a common cause of cancer related mortality. The prognosis of colorectal cancer has not changed appreciably in the last few decades. The best hope for reducing mortality and improving prognosis is to diagnose the cancer at an early asymptomatic stage (when surgery is associated with a 85% 5 year survival, as opposed to less than 20% for more advanced lesions) or to detect precancerous lesions such as large colonic polyps that can be removed during colonoscopy. Similar to the situation in the irritable bowel syndrome the vast majority of patients at risk of the disease or those concerned that they may be at risk (with symptoms compatible with colorectal cancer or those with a family history of the disease) do not have the disease when investigated by colonoscopy. In order to minimise the need for colonoscopy we screen patients with the faecal calprotectin test. In patients with established colorectal cancer the test has a sensitivity in excess of 90% for detecting any stage of the disease (early or advanced disease). The test also detects most of the larger (more than 1 cm) colorectal polyps (that confer the greatest risk of cancer transformation). A normal faecal calprotectin test result in subjects with average risk of the disease provides good to excellent assurance that a colonoscopy is not indicated. The test can be repeated at 6 to 12 month intervals for reassurance. A positive test of course is an indication for colonoscopy in most subjects.

Inflammatory bowel disease
The use of intestinal permeability tests and the faecal calprotectin method has altered our management to the treatment of patients with Crohn s disease and ulcerative colitis as these tests provide functional information which is not obtainable with conventional imaging (radiology or endo-, colono-scopy). Firstly in patients with suspected inflammatory bowel disease a normal test result is most suggestive of the irritable bowel syndrome (and invasive investigations can be avoided). In patients with raised intestinal permeability and/or faecal calprotectin we can target the investigations to the appropriate organ (small or large bowel) for diagnosis and thereby avoid studying both which is often done by those not using this approach. We treat patients with active Crohn s disease and ulcerative colitis by established treatments (such as 5-aminosalicylic acid, prednisolone, azathioprine, elemental diets (and other dietary regimes), antibiotics, cyclosporine, surgery, etc. as appropriate for the severity of the disease). We also offer new treatments that have shown great promise and efficacy such as anti-cytokine treatment (TNF-antibiodies) and white cell adsorption (apheresis) with Adacolumn which is a particularly safe and effective treatment for disease resistant to corticosteroids which involves removal of a proportion of circulating white blood cells. The most valuable information that the intestinal permeability and faecal calprotectin results show in patients with inflammatory bowel disease is that they identify patients in full clinical remission that are at significant risk of clinical relapse of the disease. In these cases we can start treatment (at an asymptomatic stage) to prevent the relapse of disease that is not associated with the high prevalence of severe side effects of treatment required when treating the clinical relapse of the disease.

A holistic approach to treatment
We aim to provide first class treatment for all Gastroenterological disease. As a general rule we treat all diseases by conventional means as dictated by evidence based medicine. For instance in the irritable bowel syndrome we would always implement appropriate dietary treatment for constipation-diarrhoea, consider the use of anti-spasmodics, anti-diarrhoeal agents, questran, low dose antidepressants, etc. However these treatments are famed for their lack of efficacy. In these circumstances we advocate a holistic approach as well as a biomedical one. This may involve cognitive treatment and/or hypnotherapy (both are of proven efficacy in sub-types of the irritable bowel syndrome) or in more resistant cases eradication regimes for intestinal Candida albicance and/or a major dietary intervention treatment such as an elemental diet (for up to 6 weeks followed by serial re-introduction of food in order to detect food intolerances) or gluten, yeast and/or starch free diets and food exclusion regimens in close collaboration with dieticians to ensure nutritional adequacy during the treatment. This treatment is not only helpful in some patients with problematic irritable bowel syndrome but efficacy is also suggested in patients with rheumatic diseases including fibromyalgia, post-viral fatigue syndrome, various immune deficiency syndromes and of course food allergy and intolerance.

Links
www.acg.gi.org
www.gastrojournal.org

Contact us
Professor I Bjarnason
10 Harley Street
London W1G 9PF

T 020 7346 3417
F 020 7346 6474
E lgc@myswift.co.uk