We are
conversant with the glut of information that doctors and other health workers
face in today's practice - in so many ways a good thing!. But it has made it
impossible for any one practitioners to keep pace with developments in even the
smallest specialty.
We share
courtesy of Medscape a summary of latest evidence in 10 areas, especially for
Gastroenterologists:
READ
ON
' MEDSCAPE
COMMENTARY
10 Key
Primary Care Takeaways: Digestive Disease Week (DDW) 2017
David A.
Johnson,
MD
June 14, 2017
IN THIS
PRESENTATION
·
Proton Pump Inhibitors and Bone Mineral Metabolism
·
Diaphragmatic Breathing
·
Thiamine Deficiency After Bariatric Surgery
·
Nonalcoholic Liver Disease
·
Statins in Liver Disease
·
Hepatitis B Reactivation
·
Advance Fibrosis in NAFLD
·
Celiac Disease
·
Cardiovascular Disease in Inflammatory Bowel Disease
·
Fecal Immunochemical Test
Hello. I'm
Dr David Johnson, professor of medicine and chief of gastroenterology at
Eastern Virginia Medical School in Norfolk, Virginia.
Welcome back
to another Computer Consult.
I'm just
back from Digestive Disease Week (DDW) in Chicago. This is a consortium of the
gastrointestinal (GI) and surgical societies, and I've already discussed highlights
for the gastroenterology specialist.
Here is my
"top 10 list" (in no particular order) of highlights from this
meeting that primary care physicians can apply to their practice.
1 Proton
Pump Inhibitors and Bone Mineral Metabolism
What do
proton pump inhibitors (PPIs) do to bone mineral metabolism? We've all heard
lots of noise on this.
A
prospective study[1] looked at esomeprazole or dexlansoprazole versus
placebo after 26 weeks of exposure in postmenopausal women, with evaluation at
26 and 52 weeks. There was no difference between groups, and this is very much
consistent with what we've seen in prospective studies.
This bone
density thing needs to go away. Our patients should not be concerned about this
nor should we monitor people any differently. Reassure your patients. If they
need the medicine, they should take it. If they don't, they should not.
2
Diaphragmatic Breathing
A
prospective study[2] from Singapore looked at diaphragmatic breathing for
patients with refractory belching or hiccups singultus. I've discussed
this previously. Briefly, put one hand on your chest and one hand on the
abdomen. Now, when you breathe, try not to move the chest. It's belly
breathing—a form of yoga. It is extraordinarily helpful in patients with
rumination syndrome, belching, and refractory hiccups. Primary care providers
may find this useful.
3 Thiamine
Deficiency After Bariatric Surgery
Investigators
from Washington performed a retrospective analysis[3] on post–bariatric
surgery patients. They found that thiamine deficiency was evident in about
12%-15%. Very importantly, this study included gastric bypass and gastric
sleeve resection, which is the treatment for most bariatric surgeons.
For primary
care clinicians, this information is very important because some surgeons don't
programmatically follow up with these patients. Patients who come in to the
emergency room with nausea and vomiting need thiamine because thiamine
deficiency can precipitate something like Wernicke encephalopathy. Some
patients, around 12%, also have neurologic or cardiovascular symptoms. Think
about thiamine
deficiency in any evaluation from a neurologic, GI, or cardiovascular
standpoint, and order a whole blood thiamine level.
4
Nonalcoholic Fatty Liver Disease
Mild amounts
of alcohol in patients with nonalcoholic fatty liver disease (NAFLD) was shown
to be beneficial. Investigators[4] looked at the National Health and
Nutrition Examination Survey (NHANES) and found that patients did better with
one half to one drink of alcohol per day. More than that was not so good.
Be careful
how you counsel patients. Patients with NALFD should lose weight and have good
control of cholesterol and diabetes. Caffeine also
has been shown to be important. Again, a little bit of alcohol [is beneficial]
so don't take away their dinner wine if they like that.
5 Statins in
Liver Disease
The fifth
highlight is to alert you about the increasing use of statins in patients with
liver disease, particularly cirrhosis. Don't be alarmed when you see patients
coming back from the gastroenterologist [on statins], and don't be hesitant to
use statins in patients even with cirrhosis. We have good data showing that
statins decrease decompensation mortality. There is more evidence now for
hepatitis B, hepatitis C, and alcohol-related cirrhosis from a population-based
study[5] from Taiwan. It's always helpful to correspond with your
gastroenterologist, but there should not be any reticence to use statins in
this patient population.
6 Hepatitis
B Reactivation
Primary care
clinicians should be concerned about reactivation of previous hepatitis B[6] in
patients receiving chemotherapy or immunosuppressed from biologics or
steroids. Core antibody status needs to be monitored. You may be the
only person recognizing the need for such patients to be referred back to a
gastroenterologist for potential co-therapy during the oncologic or
immunosuppressive treatment. Be wary when you give steroids out; these patients
may reactivate.
7 Advanced
Fibrosis in NAFLD
There is a
high prevalence of advanced fibrosis in patients with NAFLD. Scarring and fatty
liver can result in an upregulation of cytokines and inflammatory mediators
leading to cirrhosis. In the next decade, this will be the leading cause for
liver transplantation in the United States because we have done so well
eradicating hepatitis C and controlling hepatitis B. The prevalence of advanced
fibrosis in NAFLD is greater than the prevalence of patients with hepatitis C
and hepatitis B combined.[7] Fatty liver needs to be looked for in
patients with metabolic syndrome. Think about obtaining a FibroScan® or a
fibrosis-4 score. Look hard for advanced fibrosis, and don't rely on liver
enzymes to guide whether these patients are in trouble or in impending trouble.
Primary care clinicians really need to take a lead on this.
8 Celiac
Disease
I realize
that most primary care providers do not provide the primary care for celiac
disease, but you may see these patients in follow-up.
We know that
patients with celiac disease are more predisposed to pneumococcus,
tuberculosis, and influenza. A study[8] from Columbia University in New
York showed an increased odds ratio of nearly fourfold for Clostridium
difficile infection within a year of celiac disease diagnosis. Have a low
threshold for screening of C difficile independent of antibiotic
exposures and other exposures in hospitalized patients. Remember, C
difficile may be increased in the celiac population.
9
Cardiovascular Disease in Inflammatory Bowel Disease
A very
interesting study from the Mayo Clinic[9] found that the risk for
myocardial infarction (MI) and congestive heart failure (CHF) was increased in
inflammatory bowel disease (IBD) patients. The odds ratio was about 1.9 times
greater and was co-adjusted for the standard risk associated with diabetes,
hypertension, dyslipidemia, family history, and body mass index. Independent of
anything else, IBD increased the risk for cardiovascular disease.
In the last
couple of years, there has been increased interest in C-reactive protein (CRP)
levels in cardiovascular patients as an indicator for advanced cardiovascular
disease. CRP levels are also increased in IBD patients; an upregulation of
these cytokines may be overlapping. Reassess these symptoms, even in younger
patients, and ask these patients about cardiovascular symptoms.
10 Fecal
Immunochemical Test
The last
highlight relates to the performance of the fecal immunochemical test (FIT) for
hemoglobin, which really should replace standard guaiac-based testing. It has
replaced fecal occult blood testing in guideline recommendations. A study[10] from
Belgium looked at the implications of using FIT in patients on antithrombotics
or anticoagulants. They found no difference in the positivity rate. Therefore,
you don't need to stop these agents in advance of FIT. You do need to respond
to those patients who are FIT-positive with a standard recommendation of
colonoscopy.
Hopefully
this "top 10" list for primary care will provide some guidance for
you and help you care for your patients with GI symptoms or GI diseases. I
wanted to share this information with you first because I thought it was really
hot stuff.’’
Joseph Ana.
Africa Center for Clin Gov Research &
Patient Safety
@ HRI West Africa Group - HRI WA
Consultants in
Clinical Governance Implementation
Publisher: Health and Medical Journals
8 Amaku Street Housing Estate, Calabar
Cross River State, Nigeria
Cross River State, Nigeria
Phone No. +234 (0) 8063600642
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