Prof Anupam Sibal, Group Medical Director, Apollo Hospitals Group, New Delhi, in conversation with ENN, talks about the advancements in paediatric gastroenterology and hepatology at Apollo Centre of Advanced Paediatrics
You have dedicated much of your career to the study and treatment of pediatric GI disorders. Please elaborate on the history of the field of functional GI and its transition over the years.
In the early part of life of an individual, genetic and environmental factors (family attitudes toward bowel training or illness in general, major loss or abuse history or exposure to infection) may affect ones psychosocial development (susceptibility to life stress, psychological state, coping skills, social support) or the development of gut dysfunction (abnormal motility or visceral hypersensitivity).
In the later part of the life, the presence and nature of a functional GI disorder is determined by the interaction of psychosocial factors and altered physiology via the braingut axis. In other words, one individual afflicted with a bowel disorder but with no psychosocial disturbances, goodcoping skills and adequate social support may have less severe symptoms and not seek medical care.
Another having similar symptoms but with coexistent psychosocial disturbance, high life stress, or poor coping skills may frequent his physicians office and have generally poor outcome.
The expansion and refinement of investigative methods have helped in understanding the pathophysiology of functional GI disorders in terms of biological, cultural, and psychosocial (i.e. brain) spheres. These developments include the improvement of motility assessment, the standardisation of the barostat to measure visceral sensitivity, the enhancement of psychometric instruments to determine psychosocial influences, the introduction of brain imaging (PET, fMRI) to determine CNS contribution to symptoms, and the molecular investigation of brain-gut peptides, which provide insight into how these symptoms become manifest.
The Rome Criteria is an international effort to characterise and classify the functional GI disorders using a symptom-based classification system. The rationale for such a system is based on the premise that patients with functional GI complaints consistently report symptoms that breed true in their clinical features, yet cannot be classified by any existing structural, physiological or biochemical substrate. The Rome Criteria was built upon the Manning Criteria, which was developed from discriminate function analysis of GI patients.
The decision to develop diagnostic criteria by international consensus was introduced as part of a larger effort to address issues within gastroenterology that are not easily resolved by usual scientific inquiry or literary review. By 1992, several committees had met to discuss the criteria, which ultimately resulted in the publishing of many articles in Gastroenterology International and a book detailing the criteria titled The Functional Gastrointestinal Disorders. The criteria have been revised subsequently and currently Rome III criteria are being followed which were last revised in 2006.
What is the progress specifically in the area of pediatric liver transplant and surgical gastroenterology?
Pediatric liver transplant is an area which has progressed leaps and bounds in the last three decades. Especially in India, we have come a long way from the first pediatric liver transplant at our centre in 1998. With better training and skill refinement our surgeons are at par with the best in the world. Better intensive care, anesthetic care and potent immune suppressants have contributed in no small measure to the success of pediatric liver transplantation in India. The numbers have grown exponentially and we would have performed close to 150 pediatric transplants by the end of 2014.
Surgical gastroenterology, similar to transplant surgery, has benefitted from advent of new technology.
Your overview of liver failure issues among children in India?
The commonest cause of pediatricacute liver failure in the country unfortunately continues to be infectious causes like viral hepatitis which can be easily prevented by proper sanitation and hand hygiene. As regards chronic liver failure, biliary atresia continues to be the leading cause in India as elsewhere in the world.
The ability to identify patients who should be referred to a tertiary centre for further management of the disease state is limited. Facilities for intensive care monitoring of children with acute liver failure are scarce in the country. Financial issues and gender bias are other issues which affect ultimate outcomes in children with liver failure.
“Patients with more painful and severe symptoms may prove to have abnormal perception of normal gut function rather than abnormal function”
Please tell us about the advancements in paediatric gastroenterology and hepatology at ACAP (Apollo Centre of Advanced Pediatrics)?
ACAP has a state of the art facility for the advancement of Pediatric gastroenterology and Hepatology services in the country and subcontinent. All diagnostic and therapeutic modalities related to endoscopy, colonoscopy and ERCP are available. There is also provision for capsule endoscopy, endoscopic ultrasound and fibroscan. Simulators for UGI endoscopy, colonoscopy and enteroscopy are available for teaching our fellows the nuances of such techniques. They have also been used in international endoscopy and colonoscopy courses to teach delegates.
ACAP has conducted the Kunwar Virendra Oswal International course on Pediatric gastroenterology Hepatology and Nutrition for the past two years where international facultyand delegates have participated extensively to further the cause of the subject. For the first time a hands-on training endoscopy workshop was conducted in the country on porcine models by national and international faculty, where delegates mastered both diagnostic and therapeutic skills.
In addition, a gastroenterology CME is conducted annually in December wherein general pediatricians are encouraged to participate and bring forth their problems in pediatric gastroenterologies which are addressed by the experts.
What do you see as you look to the future of functional GI disorder treatment?
Future studies will identify pathophysiological subgroups each having their own determinants and treatments. Some patients will develop their disorders or exacerbate symptoms via sensitisation of afferent transmission from infection, enhanced motility, or trauma to the gut. They may respond to the newly-developing neurotransmitter blocking agents.
Patients with more painful and severe symptoms may prove to have abnormal perception of normal gut function rather than abnormal function. This dysfunction in the central regulation of incoming visceral signs may be remedied with a psychopharmacological treatment approach. The symptoms of some patients could be attributed to genetic factors, which result in abnormalities in central reactivity to stress, in which case genetic manipulation strategies would prove beneficial.
Early learning within the familial structure and socio-cultural influences has been demonstrated to affect symptom perception and illness behavior. Future studies are also likely to identify psychological and behavioral interventions that are targeted for this subgroup.