Digestive system diseases

A national education program would facilitate achieving the full potential of highly effective curative therapies

Paul J Clark

To the Editor: I read with interest the consensus statement on hepatocellular carcinoma (HCC)1 and wonder why it overlooked that smoking is a major cause. Smoking is an independent and dose‐related contributing factor for HCC (relative risk, 1.51; 95% CI, 1.37–1.67) around the world.2,3 In a large European cohort, the population‐attributable fraction — the proportional reduction in population disease or mortality that would occur if exposure to a risk factor were reduced to an alternative ideal exposure scenario — for tobacco use in HCC was 48 %, more than twice the population‐attributable fraction of the second most common risk factor: hepatitis C (21%).4 In France, where smoking prevalence is high and roughly twice that in Australia, tobacco, viral hepatitis and alcohol contribute to 33%, 31% and 26% respectively of HCC cases.5 The issue is not only about prevention but also about care, as smoking cessation is an important factor in cancer outcomes (ie, treatment effectiveness, overall survival, risk of second primary malignancies, and quality of life). Lastly, only nine out of 31 recommendations in the consensus statement are graded “A1” and none are among the four related to surveillance.

Alain Braillon

Rectal bleeding is common in pregnancy, with a reported prevalence of 10–43%

Ralley Prentice · Aysha Al‐Ani · Tiffany Cherry · Julia Dixon‐Douglas · Jade Eccles‐Smith · Julia Matheson · Jeanne Tie · Iniyaval Thevathasan · Jacob J McCormick · Britt Christensen

About one in five “exception” colonoscopies detect and excise advanced pre-cancerous polyps

Michelle Lee See · Antonio Lee · Roderick Roberts · Richard A Friedman · David G Hewett · Daniel L Worthley

A longer surveillance interval may entail an unacceptably increased level of risk of advanced neoplasia

Zaki Hamarneh · Charles Cock · Graeme P Young · Peter A Bampton · Robert Fraser · Fang LI Ang · Feruza Kholmurodova · Erin L Symonds

GPs are gaining confidence in prescribing DAA therapy, an important foundation for further enhancing access to treatment

Fergus Stafford · Gregory J Dore · Shawn Clackett · Marianne Martinello · Gail V Matthews · Jason Grebely · Anne C Balcomb · Behzad Hajarizadeh

To the Editor: The incidence of syphilis is dramatically rising in Australia. As such, previously rare sequelae like syphilitic hepatitis are occurring more frequently, supported by a growing number of case reports in the literature.1 We present a typical case of syphilitic hepatitis and review the evolving at‐risk populations, to raise awareness of this potentially fatal yet highly treatable disease. A 34‐year‐old Caucasian man presented with a maculopapular rash over the trunk and limbs associated with abdominal discomfort, anorexia and fatigue. He had been treated for early syphilis 2 years previously, with serological evidence of response. He had no history of human immunodeficiency virus infection. He was married with children and denied other sexual relationships. Aside from the aforementioned rash, his examination was unremarkable. His alkaline phosphatase level was 684 U/L (reference interval [RI], 50–130 U/L), γ‐glutamyl transpeptidase was 942 U/L (RI, < 55 U/L), alanine aminotransferase was 429 U/L (RI, < 45 U/L), and aspartate aminotransferase was 181 U/L (RI, 5–35 U/L); bilirubin was 18 μmol/L (RI, < 20 μmol/L) and C‐reactive protein (CRP) was 55 mg/L (RI, < 5 mg/L). Abdominal ultrasound and extensive liver screen results were normal. Treponema pallidum particle agglutination assay and rapid plasma reagin test results were reactive at a 1:32 titre, prompting a diagnosis of syphilitic hepatitis. He was administered 2.4 million units of benzathine benzylpenicillin intramuscularly once‐weekly for 3 weeks. His rash, symptoms and liver function tests resolved within 6 weeks. The Australian notification rate of syphilis increased from 5.0 to 18.3 per 100 000 population between 2010 and 2017. Women aged 15–19 years experienced a tenfold increase in incidence over this period. In 2017, women from remote areas were 27.3 times more likely to contract syphilis than those from major cities, while Aboriginal and Torres Strait Islander people were 6.6 times more likely to contract syphilis than non‐Indigenous Australians.2 Despite this disproportionate rise in vulnerable populations, rates remain highest among men who have sex with men and those with human immunodeficiency virus infection.3,4 Re‐infection is common, as was found in our patient. Described as the “great imitator”, secondary syphilis can be difficult to diagnose; consequently, the true incidence of syphilitic hepatitis is not known. While our case illustrates a typical presentation, cases of fulminant liver failure have been described.5 Rash (78%), anorexia (57%) and fatigue (57%) are the most common presenting symptoms.1 Marked elevation of alkaline phosphatase and γ‐glutamyl transpeptidase, coupled with milder elevation of alanine aminotransferase and aspartate aminotransferase are the most common laboratory findings, with hyperbilirubinaemia present only in severe cases. A liver biopsy is not essential for diagnosis, but may reveal inflammatory infiltration of the bile duct, hepatic granulomas or, less commonly, intrahepatic spirochetes via immunohistochemical staining.1 It is imperative that clinicians consider ordering treponemal serology in high risk patients fitting this presentation, as prompt treatment with penicillin leads to rapid disease resolution and aversion of tertiary complications, including death.

Matthew Smale · William R Connell · Julien D Schulberg

▪ Obesity is reaching pandemic proportions globally, with overweight or obesity affecting at least two‐thirds of Australian adults. ▪ Bariatric surgery is an effective weight loss strategy but is constrained by high resource requirements and low patient acceptance. ▪ Multiple endoscopic bariatric therapies have matured, with well established and favourable safety and efficacy profiles in multiple randomised controlled trials (RCTs), and are best used within a multidisciplinary setting as an adjuvant to lifestyle intervention. ▪ Three types of intragastric balloon are currently in use in Australia offering average total weight loss ranging from 10% to 18%, with others available internationally. ▪ Endoscopic sleeve gastroplasty produces average total weight loss of 15–20% with low rates of severe complications, with RCT data anticipated in December 2021. ▪ Bariatric and metabolic endoscopy is rapidly evolving, with many novel, promising therapies currently under investigation.

Dominic A Staudenmann · Zhixian Sui · Payal Saxena · Arthur J Kaffes · George Marinos · Vivek Kumbhari · Patrick Aepli · Adrian Sartoretto

To the Editor: A 35‐year‐old man born in Dire Dawa, Ethiopia, with childhood exposure to swimming in rivers, migrated to Australia 18 years ago. He presented with recurrent gastrointestinal bleeding. His index gastroscopy revealed portal hypertensive gastropathy and large oesophageal varices with high risk stigmata of recent bleeding requiring banding. Abdominal ultrasonography and transient elastography excluded liver cirrhosis. Six weeks later, he re‐presented with recurrent severe haematemesis associated with dark maroon rectal bleeding. Repeat urgent gastroscopy and flexi‐sigmoidoscopy revealed oesophageal varices without active bleeding. On sigmoidoscopy, a large amount of dark blood was seen, presumed to be related to rapid transit from recent oesophageal variceal bleeding. In the next 48 hours, a repeat colonoscopy was performed. Colonoscopy identified yellowish nodules throughout the colon with diffuse telangiectasia (Box, A and B). Mucosa was oedematous and friable. Aphthous ulcers were seen in the transverse colon and biopsies were obtained. No polyps or focal source of colonic bleeding were evident. Histopathology confirmed the presence of cystic ova resembling Schistosoma in the lamina propria immediately adjacent to crypts. Although classical granuloma formation was absent, aggregation of eosinophils was seen around a ruptured ovum (Box, C and D). Indirect assay via serology testing was positive for Schistosoma mansoni antibody (titre of 1:640). His eosinophil count was normal and stool microscopy was negative. He was treated with praziquantel. Four months later, a follow‐up gastroscopy revealed stable appearance of grade 1 oesophageal varices without high risk features. Routine variceal surveillance had been organised but not further colonoscopies. Schistosomiasis affects over 200 million people worldwide but is not acquired in Australia. In a national survey in Ethiopia, 37.3 million individuals were living in endemic areas.1 Schistosoma mansoni is the commonest species to cause intestinal and hepatic schistosomiasis. In the 2016 national census, there were 11 795 people in Australia who were born in Ethiopia, 64.3% (7584) of whom were Australian citizens.2 Most screening data for schistosomiasis in Australia are based on African refugees, with 37% in Newcastle, 38% in Hobart and 12% in Melbourne.3 Despite anecdotal knowledge, there are no published cases of non‐cirrhotic portal hypertension related to schistosomiasis in Australia. As a multiracial country with high immigration and tourism, increased recognition in Australia is paramount. Box – Colonoscopy showing widespread yellowish nodules (arrows) with oedematous and friable mucosa (A) and diffuse telangiectasia (B); and histopathology showing aggregation of eosinophils surrounding a Schistosoma ovum(C) and a cross‐sectional image of a Schistosoma ovum (D)

Julia Lim · Shweta Sharma · Damian Dowling

Objective: To compare the characteristics and outcomes of drug‐induced liver injury (DILI) caused by paracetamol and non‐paracetamol medications, particularly herbal and dietary supplements. Design: Retrospective electronic medical record data analysis. Setting, participants: Adults admitted with DILI to the Gastroenterology and Liver Centre at the Royal Prince Alfred Hospital, Sydney (a quaternary referral liver transplantation centre), 2009–2020. Main outcome measures: 90‐day transplant‐free survival; drugs implicated as causal agents in DILI. Results: A total of 115 patients with paracetamol‐related DILI and 69 with non‐paracetamol DILI were admitted to our centre. The most frequently implicated non‐paracetamol medications were antibiotics (19, 28%), herbal and dietary supplements (15, 22%), anti‐tuberculosis medications (six, 9%), and anti‐cancer medications (five, 7%). The number of non‐paracetamol DILI admissions was similar across the study period, but the proportion linked with herbal and dietary supplements increased from 2 of 13 (15%) during 2009–11 to 9 of 19 (47%) during 2018–20 (linear trend: P = 0.011). Despite higher median baseline model for end‐stage liver disease (MELD) scores, 90‐day transplant‐free survival for patients with paracetamol‐related DILI was higher than for patients with non‐paracetamol DILI (86%; 95% CI, 79–93% v 71%; 95% CI, 60–82%) and herbal and dietary supplement‐related cases (59%; 95% CI, 34–85%). MELD score was an independent predictor of poorer 90‐day transplant‐free survival in both paracetamol‐related (per point increase: adjusted hazard ratio [aHR], 1.19; 95% CI, 1.09–3.74) and non‐paracetamol DILI (aHR, 1.24; 95% CI, 1.14–1.36). Conclusion: In our single centre study, the proportion of cases of people hospitalised with DILI linked with herbal and dietary supplements has increased since 2009. Ninety‐day transplant‐free survival for patients with non‐paracetamol DILI, especially those with supplement‐related DILI, is poorer than for those with paracetamol‐related DILI.

Emily Nash · Abdul‐Hamid Sabih · John Chetwood · Georgette Wood · Keval Pandya · Terry Yip · Avik Majumdar · Geoffrey W McCaughan · Simone I Strasser · Ken Liu

In Australia, there is a paucity of coordinated strategies for preventing, detecting, and managing NAFLD

Lucy Gracen · Elizabeth E Powell

Objectives: To investigate the prevalence of non‐alcoholic fatty liver disease (NAFLD) and its risk factors in regional Victoria. Design: Prospective cross‐sectional observational study (sub‐study to CrossRoads II health study in Shepparton and Mooroopna). Setting: Four towns (populations, 6300‒49 800) in the Goulburn Valley of Victoria. Participants: Randomly selected from households selected from residential address lists provided by local government organisations for participation in the CrossRoads II study. Main outcome measures: Age‐ and sex‐adjusted estimates of NAFLD prevalence, defined by a fatty liver index score of 60 or more in people without excessive alcohol intake or viral hepatitis. Results: A total of 705 invited adults completed all required clinical, laboratory and questionnaire evaluations of alcohol use (participation rate, 37%); 392 were women (56%), and their mean age was 59.1 years (SD, 16.1 years). Of the 705 participants, 274 met the fatty liver index criterion for NAFLD (crude prevalence, 38.9%; age‐ and sex‐standardised prevalence, 35.7%). The mean age of participants with NAFLD (61 years; SD, 15 years) was higher than for those without NAFLD (58 years; SD, 16 years); a larger proportion of people with NAFLD were men (50% v 41%). Metabolic risk factors more frequent among participants with NAFLD included obesity (69% v 15%), hypertension (66% v 48%), diabetes (19% v 8%), and dyslipidaemia (63% v 33%). Mean serum alanine aminotransferase levels were higher (29 U/L; SD, 17 U/L v 24 U/L; SD, 14 U/L) and mean median liver stiffness greater (6.5 kPa; SD, 5.6 kPa v 5.3kPa; SD, 2.0 kPa) in participants with NAFLD. Conclusion: The prevalence of NAFLD among adults in regional Victoria is high. Metabolic risk factors are more common among people with NAFLD, as are elevated markers of liver injury.

Stuart K Roberts · Ammar Majeed · Kristen Glenister · Dianna Magliano · John S Lubel · Lisa Bourke · David Simmons · William W Kemp

Risk‐based testing is failing a third of people living with chronic hepatitis B in Australia The United States Preventive Services Task Force recently issued new guidance that all adults aged 18–79 years should be offered screening for hepatitis C virus infection,1 expanding on prior risk‐ and age‐based recommendations. The rationale is that hepatitis C virus infection is a common condition (estimated 1% prevalence) that is leading to an increasing burden of disease from cirrhosis and liver cancer, it is easy to test for, there are well tolerated and highly effective treatments available, and treatment costs have dropped substantially in the past 5 years. The guidance acknowledges that risk‐based screening has been insufficient in increasing the number of people diagnosed and able to access treatment, and further change is needed to address the ongoing burden of adverse outcomes. In Australia, an estimated 80% of people living with hepatitis C have been diagnosed,2 and treatment uptake is among the highest in the world; however, progress in diagnosing people living with chronic hepatitis B is much less impressive. We argue that Australian guidelines for hepatitis B screening should be similarly changed and expand from a risk‐based approach to a more universal one. Hepatitis B is a condition that affects more than 225 000 Australians,3 and when untreated, it leads to serious adverse outcomes such as liver cirrhosis and cancer in up to one‐quarter of people affected despite being generally asymptomatic.4 Infant vaccination in Australia since 2000 has reduced local transmission,3 but hepatitis B is most commonly acquired at birth or in early childhood when there has been inadequate access to vaccination, and it disproportionately affects Australians born overseas.2 While a cure is not yet available, highly effective antiviral treatments can be accessed through Medicare which have been shown to reduce liver cancer risk by up to 70% within 5 years.5 Based on this evidence, treatment for hepatitis B is recommended in national and international guidelines when there is either cirrhosis or ongoing liver inflammation to reduce morbidity and mortality associated with hepatitis B virus infection. Australia’s National Strategy for Hepatitis B sets the target of 80% of people diagnosed by 2022, but this proportion has barely improved in recent years, from 63% in 2011 to 69% in 2018.3 Although about 6000 people6 are newly diagnosed with hepatitis B each year, the number of people living with hepatitis B in Australia has continued to increase due to the addition of people who acquired the disease in their country of birth (Box).7 This leaves an estimated 71 000 Australians (plausible range, 32 000–93 000) undiagnosed and at risk of significant adverse outcomes. As this estimate is reliant on underlying model estimates — incorporating data on migration, natural history, immunisation and transmission7 — these data are subject to uncertainty. However, even accounting for this uncertainty, it is estimated that there is only a 4.6% chance that Australia will reach the 2022 target of 80% of cases diagnosed.3 The late diagnosis of hepatitis B in an individual is a missed opportunity for that person to receive appropriate care, including antiviral treatment to prevent liver cancer and cirrhosis.5 In New South Wales in 2011–2012, 29% of people diagnosed with hepatitis B‐related liver cancer were diagnosed late (< 2 years before their cancer diagnosis).8 Failure to diagnose not only affects the individual but is a missed opportunity for family members to be appropriately screened and receive vaccination to prevent transmission of hepatitis B within households. Data indicate only a third of people requiring antivirals to prevent liver cancer or cirrhosis are currently receiving them in Australia.7 Increasing the percentage of people receiving treatment to 20%, as per the National Strategy target, would prevent an estimated 1700 deaths by 2030.7 Improving diagnosis is key to meeting these treatment targets. For over 25 years, the diagnosis of most people affected by hepatitis B in Australia has relied on risk group‐based screening. The National Hepatitis B Testing Policy lists 16 indications and 13 risk groups that should be considered for testing. Universal screening is only recommended during antenatal care, and a substantial proportion of women are first diagnosed with hepatitis B at this time. For clinicians, conducting a guideline‐based ascertainment of risk is complex, requiring knowledge of country of birth; Indigenous status; history of travel, vaccination, incarceration, and medical procedures; occupation; sexual activity; family history; and previous or current injecting drug use. There is limited evidence regarding the acceptability and uptake of these recommendations, but research assessing general practitioner attitudes to hepatitis B has identified discomfort with profiling patients based on cultural background.9 A study of GPs identified that 33% were not aware people from these communities are the main at‐risk population for hepatitis B, and 67% agreed that assistance with identifying patients who should be tested was needed.10 This targeted approach to testing can also contribute to the experience of stigma and discrimination among people affected by or at risk of hepatitis B, particularly given the structural and health care inequalities experienced by many members of these groups. Chronic hepatitis B meets all the World Health Organization criteria for disease screening:11 it is an important health problem for the person and the community; highly accurate diagnostic tests are available; there is typically a long asymptomatic period of infection; treatments are available and they are more effective when started earlier in the course of the disease; and based on cost‐effectiveness studies, the cost of diagnosis and treatment is economically balanced in relation to health care costs as a whole. A further advantage with hepatitis B is that, given the availability of a highly effective vaccine and the generally lifelong nature of infection, screening will usually only need to be done once. Subsequently, one‐time screening will simplify patient engagement in regular follow‐up and monitoring, with most needing annual recall for reimbursed blood tests and liver ultrasounds (for Medicare‐eligible people, the majority of Australians living with hepatitis B). Community engagement strategies including community codesigned and place‐based outreach programs will also be essential. Although some hepatitis B community outreach occurs in Australia, it is profoundly underfunded compared with other community programs such as those for the human immunodeficiency virus (HIV), and increased investment will be central to supporting a more universal testing approach. The prevalence at which hepatitis B screening is cost‐effective has been estimated at 0.3%12 (United States) and 0.41%13 (the Netherlands), well below Australia’s estimated prevalence of 1%.7 Although further study is needed to assess local cost‐effectiveness of screening, the management and treatment of people diagnosed with hepatitis B has been found to be cost‐effective in Australia. A 2009 study found that appropriate treatment was not only cost‐effective but more so than many currently existing population‐based cancer prevention programs.14 More recent research has also suggested that improving the hepatitis B cascade of care in Australia is cost‐effective.15 The current risk‐based screening approach for hepatitis B in Australia has failed to meaningfully increase the proportion of people diagnosed with this disease in the past decade, and we argue that it is time for a radical rethinking of our approach to testing for hepatitis B. Although difficult to quantify due to crossover in populations, given the breadth of the existing screening criteria — including all women who have been pregnant in the screening era (3.5 million Australians), all migrants from countries with more than 2% prevalence (2.1 million), all Aboriginal or Torres Strait Islander people (850 000), all adults at higher risk of infection (1.4 million), and any person with existing liver disease (over 5 million) — it is likely that most of Australian adults meet least one screening criteria, and a universal approach would represent a relatively small expansion in the total number eligible. We believe that guidelines should now recommend that all Australians aged 20–79 years whose hepatitis B status has not been documented should be offered testing. This minimum age coincides with the enactment of universal hepatitis B vaccination in Australia, which led to a substantial reduction in prevalence. However, screening would still be required in cases where a child was born overseas or was born in Australia to a mother living with hepatitis B. The upper age limit for offering testing may not reach cost‐effectiveness thresholds; however, this has not been locally established and there is evidence that older Australians have a considerable burden of hepatitis B6 and liver disease.7 Offering testing should always be conducted within the context of informed consent,16 and given most tests currently take place in primary care settings, GPs should be supported to incorporate hepatitis B screening into standard preventive health care for all adults.2 In line with Australia’s historical approach to blood‐borne virus responses, involvement of community and professional organisations and people with lived experience should be central to implementation. There is a need to change the way we approach testing for hepatitis B in Australia as we fail to meet both interim and longer term targets.7 Innovation and simplification of our testing policy are necessary to reach people unaware of their risk, encourage clinicians to test, and reduce stigma and discrimination associated with questioning people about risk factors. This approach would help integrate routine hepatitis B screening and care into primary care. A fundamental change is needed if Australia is to meet our National Strategy targets for 2022 and the WHO elimination targets for 2030. Importantly, it would allow the more than 70 000 Australians with undiagnosed hepatitis B7 to be informed about their condition and to enable them to access care and potentially life‐saving treatment. To not do so will further entrench the status quo and the ongoing preventable morbidity and mortality associated with late diagnosis of hepatitis B.7,8 Box – Trends in chronic hepatitis B diagnosis in Australia during 2010–2019, incorporating modelled estimates of diagnosed and undiagnosed population (area) and annual surveillance notifications of newly diagnosed cases (line) Modelled data sourced from previously published work.7 Annual number of notified cases sourced from the Australian Government Department of Health National Notifiable Diseases Surveillance System.6

Nicole L Allard · Jennifer H MacLachlan · Lien Tran · Nafisa Yussf · Benjamin C Cowie

Until we reach “prevalence equilibrium”, even small increases in incidence eventually result in higher prevalence When I attended medical school in the 1980s, we were taught that ulcerative colitis and Crohn disease were conditions seen in white people in highly developed regions such as northern Europe, the United Kingdom and some Commonwealth nations, and North America. Over the past four decades, the incidence of inflammatory bowel disease (IBD) across geographic regions and ethnic groups has risen sharply.1 The global burden of IBD, which can substantially reduce quality of life, is clearly increasing.2 Patients with IBD often require expensive medications or procedures,3 have higher rates of anxiety and depression,4 and are more likely to have disabilities.5 The prevalence of a chronic disease (number of new and old cases per number of persons) roughly corresponds to the incidence (number of new cases per person‐years) multiplied by the mean duration of the condition.6 For IBD, for which the median age at diagnosis is 30–35 years7 and life expectancy is normal or near normal,8 the prevalence will ultimately be 30 to 50 times the incidence rate. Consequently, even small increases in incidence will eventually result in higher prevalence, especially when the incidence rate is higher than the mortality rate. This concept of “compounding prevalence” has only recently been applied to IBD,9 but it is an extremely accurate description. We are now seeing these effects in several areas of the world. In Canada, the prevalence of IBD may be as high as 700 cases per 100 000 population;10 the prevalence may be even higher in the Lothian region of Scotland, where it is estimated to exceed 800 cases per 100 000 population and is projected to rise over the next eight years to more than 1200 per 100 000.11 To put this into context, the global age‐standardised prevalence of IBD in 2017 was estimated to be 84.3 cases per 100 000 population.2 The high prevalence of IBD in the City of Canada Bay in metropolitan Sydney described in this issue of the MJA by Pudipeddi and colleagues12 fits this pattern. The reported overall age‐standardised prevalence of about 350 cases per 100 000 population means that 1 in 280 people in this region has ulcerative colitis or Crohn disease, and prevalence rises with age, to roughly 1 in 160 people aged 65 years or more. On the basis of their findings, the authors estimate that more than 81 000 Australians have IBD. Most patients with IBD are diagnosed before the age of 40 years. Higher prevalence in older people may be partly explained by the inverse epidemiological association between cigarette smoking and ulcerative colitis, one of the few conditions against which cigarette smoking is seemingly protective;13 most patients with ulcerative colitis are never or former smokers. In Olmsted County, Minnesota, for example, mortality among patients with ulcerative colitis is actually lower than for the general population, as any increase in deaths related to gastrointestinal causes or cancers is more than offset by lower cardiovascular mortality.8 This consideration would, however, not apply to Crohn disease. We must also remember that the typical patient with IBD is diagnosed in their 20s or 30s, but more than one‐third of people with Crohn disease and 40% of those with ulcerative colitis are diagnosed after the age of 40 years.7 In fact, the age at diagnosis in Olmsted County and some other regions has a bimodal distribution, with a second peak in incidence later in life,8 although some diagnostic confusion — older people with diverticulitis or ischaemic colitis being diagnosed with IBD — is possible.14 Another explanation for increasing prevalence with age in the study by Pudipeddi and colleagues may be the ethnic makeup of suburban Sydney, in which more than 15% of residents are Asian.12 Studies in Asian countries have reported higher median ages at IBD diagnosis.15,16 Why is the higher prevalence of IBD among older people important? Although some studies have suggested a milder disease course for those diagnosed with IBD later in life,17 they comprise only a minority of older people with IBD; in the Canada Bay study, only 25% of patients with IBD had been diagnosed after the age of 48 years.12 Older patients with IBD can be more difficult to manage, as they are two to three times as likely to have serious infections after treatment with biologics,18 and post‐operative morbidity and mortality are significantly more likely than for younger or middle‐aged adults.19 Older patients are also more likely to meet the definition of “frailty”, itself associated with higher rates of serious adverse events during immunosuppressive therapy,20 and mortality and re‐admission rates for hospitalised patients with IBD are higher.21 I agree with the recommendation by Pudipeddi and his colleagues to consider non‐systemic immunosuppressive therapies when possible. Until we reach “prevalence equilibrium”22 — that is, when prevalence stabilises because the overall mortality rate is equal to the incidence rate — physicians and health authorities need to continue adjusting to the increasing burden of IBD.

Edward V Loftus

Liver disease and liver cancer incidence and mortality are unacceptably high among Indigenous Australians

Jessica Howell · James S Ward · Jane Davies · Paul J Clark · Joshua S Davis

A 46-year-old man with a history of chronic hepatitis B and alcohol misuse presented with acute abdominal pain

Yoen Young Chuah · Yeong Yeh Lee

Choice of therapy will be determined by the compromises and uncertainties most acceptable for the patient and their clinician

Ian JS Cook

Objective: To describe the clinical and procedural outcomes of per‐oral endoscopic myotomy (POEM) for achalasia in Australia. Design, setting: Prospective observational study in three Australian tertiary referral centres, 5 May 2014 – 27 October 2019 (66 months). Participants: Patients who had undergone POEM for achalasia. Major outcome measures: Eckardt scores calculated prior to POEM and six months, one year, and two years after POEM. The primary outcome was clinical success, defined as an Eckardt score of 3 or less without a second intervention. Results: 142 patients underwent POEM for achalasia; their mean age was 52 years (SD, 18 years), 83 were men (58%), and the median length of hospital stay two days (IQR, 1–3 days). Their mean Eckardt score before POEM was 8.0 (SD, 2.4) and 1.1 (SD, 1.6) six months after POEM; it did not change significantly between six months and two years after POEM (mean monthly increase, 0.014 points; 95% CI, –0.001 to 0.029). A total of 127 patients (89%) improved clinically after POEM. Intra‐procedural capnoperitoneum was the only risk factor associated with treatment failure (adjusted hazard ratio, 2.85; 95% CI, 1.08–7.51). Previous treatments — botulinum toxin injection (25 patients, 18%), endoscopic balloon dilatation (69, 49%), and Heller myotomy (14, 10%) — did not affect POEM outcomes. Five patients (4%) experienced major adverse events, including pneumonia, oesophageal leak, empyema and melaena, that were managed during admission and without sequelae. Conclusions: POEM is an effective treatment for achalasia. Significant reductions in Eckardt scores achieved by six months are sustained at two years. POEM can be both a first line definitive therapy and a salvage therapy for patients not helped by other treatments.

Sunil Gupta · Mayenaaz Sidhu · Xuan Banh · Joseph Bradbear · Karen Byth · Luke F Hourigan · Spiro Raftopoulos · Michael J Bourke

While apparently non-inferior to originator biologics, other factors need to be considered before switching

Gregory T Moore · Charlotte Keung

To the Editor: In 1996, two articles showed that bowel cancer screening in subjects aged 45–741 and 45–752 years, recruited in the early 1980s, led to a significant reduction in mortality; since then, the age range in Australia’s screening program remains at 50–74 years. Between 1981 and 2015–2017, the mean life expectancy at birth for men and women in Australia rose by 9.3 and 6.3 years respectively.3 In 2016–2018, the mean life expectancy at 75 years was 12.3 and 14.3 years for men and women respectively, and even at 80 years, the mean life expectancy was 9.1 and 10.6 years respectively,3 suggesting a reduction in morbidity in the 75–79 years cohort over the 1981–2017 period. In 2015, the estimated bowel cancer incidence and mortality rates for Australians in the 75–79 years range were 28% and 82% higher than in the 70–74 years range.4 In the United States, in adults aged 65 years and older, the prevalence of screening was higher than 80% in nine states.5 In Australia, mean participation in the National Bowel Cancer Screening Program (NBCSP) increased with age cohort6 (Box). Although there is an increased risk of complications from colonoscopy with increasing age, a prospective observational study compared the risks in the 75–79 with the 70–74 years range and found no increase in perforation rates.7 A US study found that colorectal cancer screening was cost‐effective at ages 79 and 80 years even in persons with severe comorbid conditions.8 A recent Australian microsimulation study9 suggested that the cost‐effectiveness of screening the 50–79 and 50–74 year groups would be almost identical, although the advantage of a likely high participation in the 75–79 age range was not addressed. It found that the number of immunochemical faecal occult blood tests and colonoscopies would increase by 10–16% and 21–30% respectively if the screening cessation age were extended to 79 years, both of which should be welcomed. Facilities in Australia can cope with such an increase in colonoscopies. In view of the above, the NBCSP age range should be extended to 79 years. At a minimum, a pilot study of such an extension should be undertaken. Box – Australian National Bowel Cancer Screening Program participation Age (years) Participation rates (%) 2014–2015 2015–2016 2016–2017 2017–2018 Mean 50–54 28.5 28.1 29.8 31.9 29.6 55–59 36.8 35.5 35.5 37.3 36.3 60–64 43.2 42.7 43.1 43.7 43.2 65–69 43.5 44.2 47.5 49.6 46.2 70–74 52.5 52.5 52.6 53.1 52.7

Donald J Frommer

Objectives: To determine the age‐standardised prevalence of inflammatory bowel disease (IBD) in a metropolitan area of Sydney, with a focus on its prevalence among older people. Design, setting: Population‐based epidemiological study of people with IBD in the City of Canada Bay, a local government area in the inner west of Sydney, during 1 March 2016 – 10 November 2016. Participants: Patients diagnosed with confirmed IBD according to the Copenhagen or revised Porto criteria. Main outcome measures: Crude prevalence of IBD, including Crohn disease and ulcerative colitis; age‐standardised prevalence of IBD, based on the World Health Organization standard population; prevalence rates among people aged 65 years or more. Results: The median age of 364 people with IBD was 47 years (IQR, 34–62 years); 185 were women (50.8%). The crude IBD prevalence rate was 414 cases (95% CI, 371–456 cases) per 100 000 population; the age‐standardised rate was 348 cases (95% CI, 312–385 cases) per 100 000 population. The age‐standardised rate for Crohn disease was 166 cases (95% CI, 141–192 cases) per 100 000 population; for ulcerative colitis, 148 cases (95% CI, 124–171 cases) per 100 000 population. The IBD prevalence rate in people aged 65 years or more was 612 cases (95% CI, 564–660 cases) per 100 000, and for those aged 85 years or more, 891 cases (95% CI, 833–949 cases) per 100 000; for people under 65, the rate was 380 cases (95% CI, 342–418 cases) per 100 000. Conclusions: We found that the prevalence of confirmed IBD in a metropolitan sample was highest among older people. Challenges for managing older patients with IBD include higher rates of comorbid conditions, polypharmacy, and cognitive decline, and the immunosuppressive nature of standard therapies for IBD.

Aviv Pudipeddi · Jeffrey Liu · Viraj Kariyawasam · Thomas J Borody · James L Cowlishaw · Charles McDonald · Peter Katelaris · Grace Chapman · Crispin Corte · Daniel A Lemberg · Cheng H Lee · Anil Keshava · John Napoli · Robert Clancy · Webber Chan · Sudarshan Paramsothy · Rupert Leong

A 64-year-old man with underlying hypertension and hyperlipidaemia presented with abdominal distension, vomiting and no bowel movement for 2 days

Assyifaa Nik Mazian · Siti Soraya Ab Rahman

Introduction: Hepatocellular carcinoma (HCC) is a leading cause of cancer deaths both globally and in Australia. Surveillance for HCC in at‐risk populations allows diagnosis at an early stage, when potentially curable. However, most Australians diagnosed with HCC die of the cancer or of liver disease. In the changing landscape of HCC management, unique challenges may lead to clinical practice variation. As a result, there is a need to identify best practice management of HCC in an Australian context. This consensus statement has been developed for health professionals involved in the care of adult patients with HCC in Australia. It is applicable to specialists, general medical practitioners, nurses, health coordinators and hospital administrators. Methods and recommendations: This statement has been developed by specialists in hepatology, radiology, surgery, oncology, palliative care, and primary care, including medical practitioners and nurses. The statement addresses four main areas relevant to HCC management: epidemiology and incidence, diagnosis, treatment, and patient management. A modified Delphi process was used to reach consensus on 31 recommendations. Principal recommendations include the adoption of surveillance strategies, use of multidisciplinary meetings, diagnosis, treatment options and patient management. Changes in management as a result of this statement: This consensus statement will simplify HCC patient management and reduce clinical variation. Ultimately, this should result in better outcomes for patients with HCC.

John S Lubel · Stuart K Roberts · Simone I Strasser · Alexander J Thompson · Jennifer Philip · Mark Goodwin · Stephen Clarke · Darrell HG Crawford · Miriam T Levy · Nick Shackel

The incidence of colorectal cancer in Australia is among the highest in the world.1 About 29% of Australians live in rural or remote areas. We have previously reported that colorectal cancer surgery in rural hospitals is safe and that short term outcomes are good.2 This report is based on prospectively collected data for 311 patients treated for stages 1 to 3 colorectal cancer by four surgeons in rural South Australia (Mount Gambier Hospital, with 110 beds and a six‐bed high dependency unit) during 1 February 2006 – 31 January 2020. The follow‐up parameters, intervals between follow‐up examinations, and data analysis tools have been reported previously.2 Briefly, data were analysed in SigmaStat 3.5 (Systat). Survival was analysed by single‐group and log‐rank testing; survival differences between groups were assessed by pairwise multiple comparison (Holm–Šídák). Group data were compared in t, rank sum, and χ2 tests; correlations of covariates and cancer‐specific survival were assessed by multiple logistic regression. The Central Adelaide Local Health Network Human Research Ethics Committee approved our study (reference, 12041). One hundred of 311 patients (32%) had Union for International Cancer Control (UICC) stage 1, 110 (35%) stage 2, and 101 (33%) stage 3 colorectal cancer. The median age of the patients was 71 years (interquartile range [IQR], 63–78 years); 172 (55%) were men. Of the 311 procedures, 277 were elective (89%); 113 were laparoscopic (36%) and 198 laparotomies (64%). Median hospital length of stay was 7 days (IQR, 4–10 days); 30‐day mortality was 1.3% (four deaths), 90‐day mortality 1.6% (five deaths). The proportion of deaths at 30 days after emergency colorectal cancer surgery (three of 34 patients, 9%) was significantly greater than following elective surgery (one of 277, 0.4%; P = 0.002). Leakage occurred in 13 of 259 procedures with anastomosis (5%). The median number of lymph nodes resected was 14 (IQR, 10–20). Overall 5‐year survival of patients (stages 1–3) was 79%, 10‐year survival was 45%. Cancer‐specific 5‐year survival was 86% and 10‐year survival 79% (Box). Multivariate analysis included patient sex, age, intra‐operative blood loss, laparoscopic surgery, American Society of Anesthesiologists (ASA) score, and UICC stage as covariates. More advanced tumour stage (stages 1/2 v stage 3: odds ratio [OR], 2.01; 95% confidence interval [CI], 1.39–2.90) and higher age (< 70 years v ≥ 70 years: OR, 2.28; 95% CI, 1.11–4.71) were significantly associated with lower overall survival. Cancer‐specific survival was significantly reduced by more advanced tumour stage stages 1/2 v stage 3: OR, 4.76; 95% CI, 2.53–8.94). Our follow‐up program included quarterly blood tests (carcino‐embryogenic antigen, carbohydrate antigen 19.9, full blood cell count) and clinical examination during the first two years, semi‐annual tests during the next three years, and annual blood tests and clinical examinations thereafter. Throughout follow‐up, annual computed tomography and colonoscopy were offered to all patients, and additional investigations initiated in response to changes in clinical or laboratory findings. This intense follow‐up program, based on that used at the University of Munich in Germany, was adopted when the current surgical unit was established in Mount Gambier. It is being reviewed and will be adjusted to current Australian recommendations. Recurrent disease was detected in a total of 52 patients (17%), and 13 patients (4%) underwent curative resection. The primary treatment for colorectal cancer is surgical removal. Surgical care should be provided in an adequately staffed and equipped hospital. We found that such surgery can be provided safely and with good long term oncological outcomes in a rural centre. Overall 5‐year survival in our study exceeded the most recent reported value for Australia (2011–2015: 69.9%),3 and contrasts with a Californian study which found that rural residence was associated with poorer cancer‐specific mortality.4 Published data on outcomes beyond 10 years after colorectal cancer surgery are limited. Our overall 10‐year survival rate of 45% is similar to that reported by an earlier study in Fremantle (44%).5 Our findings confirm that tumour stage and age at diagnosis are significant predictors of death following curative surgery for colorectal cancer. We found that colorectal cancer surgery in a non‐metropolitan surgical centre is safe and associated with low 30‐ and 90‐day mortality rates. Oncological results at 5 and 10 years compare well with the results of other groups. Surgery can be provided close to the patients’ homes and families in adequately staffed and equipped centres and can match outcomes in capital city hospitals. Box – Five‐ and 10‐year survival of patients undergoing curative resection for colorectal cancer at Mount Gambier Hospital, February 2006 – January 2020 5‐year survival 10‐year survival Overall Cancer‐specific Overall Cancer‐specific All 79% 86% 45% 79% Union for International Cancer Control (UICC) stage Stage 1 (pT1/pT2) 91% 99% 58% 99% Stage 2 (pT3/pT4) 82% 87% 51% 85% Stage 3 (any T, node positive) 55% 74% 39% 55% American Society of Anesthesiologists (ASA) physical status classification 1 100% — 100% — 2 84% — 58% — 3 70% — 32% — 4 62% — 0 — Age < 70 years 86% — 72% — 70–79 years 76% — 32% — ≥ 80 years 60% — 7% — pT = primary tumour staging. table#t1 tbody td:nth-child(n+2) P. Pleft { text-align: center; }

Matthias W Wichmann · Timothy K McCullough · Eben Beukes · Thomas Gunning · Guy J Maddern