The efficacy of a low-fat diet to manage the symptoms of bile acid malabsorption - outcomes in patients previously treated for cancer.

Dietary fat ingestion triggers bile secretion into the gastrointestinal tract. Bile acid malabsorption affects >1% of the population, causing loose stool and other gastrointestinal symptoms. The diagnosis is frequently missed. Treatments are often considered ineffective. We evaluated low-fat diets for managing gastrointestinal symptoms in these patients. All patients reporting type 6 or 7 stool were offered a selenium-75 homocholic acid taurine (SeHCAT) scan. Prospective data in patients with 7-day scan retention <20% were analysed. -Patients requiring a bile acid sequestrant were given this before receiving dietary advice. Patients completed a 7-day food diary before dietetic consultations. Personalised dietary interventions, providing 20% of daily energy from fat, were prescribed. Symptoms were assessed using a modified gastrointestinal symptom rating scale questionnaire before and 4-12 weeks after dietary intervention. A total of 114 patients (49 male, median age 64 years, median body mass index 27 kg/m2) were evaluated. 44% of these patients were taking colesevelam. After dietary intervention, there was statistically significant improvement in abdominal pain and nocturnal defecation (0.2% alpha, p=0.001). Improvement in bowel frequency, urgency, flatulence, belching, borborygmi and stool consistency were seen, but did not reach statistical significance (p≤0.004-0.031). Dietary intervention is an effective treatment option for patients with symptomatic bile acid malabsorption and should be routinely considered.

Guide to managing persistent upper gastrointestinal symptoms during and after treatment for cancer.

BACKGROUND: Guidance: the practical management of the gastrointestinal symptoms of pelvic radiation disease was published in 2014 for a multidisciplinary audience. Following this, a companion guide to managing upper gastrointestinal (GI) consequences was developed. AIMS: The development and peer review of an algorithm which could be accessible to all types of clinicians working with patients experiencing upper GI symptoms following cancer treatment. METHODS: Experts who manage patients with upper GI symptoms were asked to review the guide, rating each section for agreement with the recommended measures and suggesting amendments if necessary. Specific comments were discussed and incorporated as appropriate, and this process was repeated for a second round of review. RESULTS: 21 gastroenterologists, 11 upper GI surgeons, 9 specialist dietitians, 8 clinical nurse specialists, 5 clinical oncologists, 3 medical oncologists and 4 others participated in the review. Consensus (defined prospectively as 60% or more panellists selecting 'strongly agree' or 'agree') was reached for all of the original 31 sections in the guide, with a median of 90%. 85% of panellists agreed that the guide was acceptable for publication or acceptable with minor revisions. 56 of the original 61 panellists participated in round 2. 93% agreed it was acceptable for publication after the first revision. Further minor amendments were made in response to round 2. CONCLUSIONS: Feedback from the panel of experts developed the guide with improvement of occasional algorithmic steps, a more user-friendly layout, clearer time frames for referral to other teams and addition of procedures to the appendix.

The holistic management of consequences of cancer treatment by a gastrointestinal and nutrition team: a financially viable approach to an enormous problem?

There is no national NHS tariff to fund services for patients experiencing long-term bowel and nutritional problems after cancer treatment. In this paper, we report the clinical characteristics and outcomes of patients referred to our service and the estimated cost of a completed episode of care. Patient characteristics, symptom severity, investigations, diagnoses, number of clinic visits and referrals elsewhere were recorded in a prospective cohort study. During 2013-14, 325 patients completed assessment and treatment. The majority of original cancer diagnoses were urological (43%) and gynaecological (21%). A median of six investigations were requested. 62% were found to have three or more new diagnoses including small intestinal bacterial overgrowth (46%), vitamin D deficiency (38%), bile acid malabsorption (28%), gastritis (22%), radiation-induced bleeding (20%), vitamin B12 deficiency (17%), pelvic floor weakness (17%), colorectal polyps (13%) and pancreatic insufficiency (5%). A median of three visits were required and all commonly reported gastrointestinal symptoms improved by discharge. The mean episode of care per patient was costed at £1,563. Effective amelioration of chronic gastrointestinal toxicity after cancer treatment costs substantially less than treating the cancer in the first place and requires an NHS tariff.