Transcript Updates in Gastroenterology

Updates in Gastroenterology
Kally Alexandropoulou MBBChir MA MRCP
Consultant Gastroenterologist
Topics to cover
• GORD and oesophageal physiology - NICE guidelines 2014
HRM/ pH impedance
• Barrett’s - BSG guidelines 2012, 2013
• Eosinophilic oesophagitis - ACG guidelines 2013
• Coeliac disease – BSG guidelines 2014
• IBD - BSG guidelines 2010, 2011, 2012
• IDA - BSG guidelines 2011
• Bowel preparation - BSG guidelines 2012
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Hepatology: Early access programme for directly acting antiviral drugs (DAAs) protease inhibitors ; nucleotide polymerase inhibitors
Dyspepsia
Switch from PUD to GORD
• PUD – gastric and duodenal ulceration
• Still high risk mortality in elderly
• Falling rates due to reduction in prevalence of helicobacter pylori
• HP prevalence reduction due to
- improving socio-economic conditions
- exposure to antibiotics and PPIs
- Eradication policies via dyspepsia guidelines with ‘test and treat’.
GORD
• Increasing prevalence, affecting up to 25% in USA and Europe
El-Serag, GUT 2014
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Increased BMI
Increasing prevalence of hiatus hernia
H pylori eradication
Older population: polypharmacy (IHD/COPD)
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Reflected increases in BO and oesophageal adenocarcinoma
OAC has overtaken squamous oesophageal cancer in incidence
OAC is the 9th commonest malignancy in UK, and has poor prognosis
UK has the highest incidence of OAC in Europe
OAC is rapidly increasing in incidence, with rates increased from 7.6 to
12.8 /100 000 men between 1971 and 1999 in England and Wales
Alim Pharm Ther.2003; 17(5):655-64
Symptoms
Heartburn
Epigastric pain/atypical chest pain
Nausea and vomiting
Dysphagia
Laryngo-pharyngeal reflux
Sore throat, post nasal drip, early morning nausea, breathlessness/ ‘asthma’
10-15% patients with PPI refractory symptoms
Severity of symptoms do not necessarily correlate with endoscopic findings;
endoscopy and pH manometry studies help distinguish between
• Erosive reflux
• Non erosive reflux
• Weakly acidic and non acid reflux – impedance testing
• Hypersensitive oesophagus/ Functional heartburn
Endoscopic findings
• Erosive reflux
LA classification
• Ulceration
• Strictures
• Barrett’s
• Malignancy
• Normal
?Non erosive reflux
?Eosinophilic oesophagitis
Oesophageal physiology
Oesophageal manometry and 24 hour pH impedance study
• Oesophageal manometry: initially pull through water perfused
8 sensor catheters with 4 longitudinal sensors, 5 cm apart, assessing body
activity and 4 radial sensors assessing lower oesophageal body activity;
• Cumbersome and limited information
Now:
• High Resolution Manometry (HRM) catheters with digital 36 point
pressure sensors, 1 cm apart
• Enables simultaneous monitoring of motility from the pharynx to the
stomach
• Can be combined with impedance to assess function by observing bolus
clearance: evolution in oesophageal function assessment
High resolution manometry
• High-resolution manometry
(HRM):pressure sensors spaced at
1cm intervals, so simultaneous
monitoring of motility from the
pharynx to the stomach
• Indications:
-evaluate peristalsis and LOS
for GORD severity and prior to
fundoplication
- dysphagia: achalasia, spastic
disorders
-non cardiac chest pain
24 hour pH study
Trans-nasally inserted pH catheter with 2 sensors at distal end of the catheter,
15cm apart:
lower sensor at the tip of the catheter measures gastric pH while upper sensor is
positioned 5 cm above the proximal edge of the LOS and measures oesophageal
acid exposure.
Impedance testing
• Impedance measures resistance to current flow
• Impedance changes across the oesophagus during passage of
air, liquid, food and refluxate
• It identifies direction of bolus movement and clearance in the
oesophagus
• Combined with HRM to assess bolus clearance and
• 24 hour pH testing to identify acid and non acid reflux events
more insight into ‘PPI refractory reflux’ aetiology
HRM - impedance
HRM – with impedance
HRM – weak oesophageal dysmotility
Combined pH and Impedance
‘Mass’ symptoms with partial response to PPIs; OGD: large hiatus hernia;
assessment for fundoplication
Impedance testing
• Comparing recordings of the same individuals with PPI refractory GORD on
and off PPIs, there is a striking decrease in acid reflux events, but a
corresponding increase in weakly acidic reflux events and heartburn was
replaced by regurgitation as the dominant symptom.
• Impedance–pH monitoring studies in patients with PPI-refractory GORD
symptoms suggest that:
- acid reflux was associated with 7%–28% of persistent symptoms,
- weakly acidic reflux with 30%–40% of symptoms, and
- 30%–60% of symptoms were not preceded by any reflux – functional
heartburn
NB Hypersensitive oesophagus – reflux symptoms correlating with reflux
episodes in presence of non pathological acid reflux
Treatment
Importance of offering optimised PPI treatment:
• Full-dose PPI for 1 or 2 months.
- Extending treatment to 2 months increased healing of oesophagitis by a
further 14%.
- If patients have severe oesophagitis and remain symptomatic, doubledose PPI for a further month may increase the healing rate.
NB Surgical fundoplication
• Non erosive reflux disease still responds to PPIs – prn basis may be
sufficient
• Non acid reflux and functional reflux may still respond to PPI treatment;
trial of prokinetics and/or H2RA should also be considered
Barrett’s Oesophagus, BO
Prevalence rate for BO at 1.3% in the general population
There is 30 –fold increased risk of development of oesophageal
adenocarcinoma (OAC) in BO
Progression occurs through step wise change to low (LGD) and high grade
dysplasia (HGD)
Risk factors for development of Barrett’s:
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White males, >50yrs
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GORD >10yrs, Hiatus hernia, BMI >30
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Smoking
Risk factors for progression to OAC:
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Intestinal metaplasia, dysplasia: HGD vs LGD
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Length of BO >6cm, BO >10yrs
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Oesophagitis, GORD esp night-time
Barrett’s surveillance
Updated guidelines
• Reporting using the Prague
criteria: circumferential
extent (C), maximum extent
(M) of columnar epithelium
• Access to clinic to discuss
diagnosis and pros/cons of
surveillance
• Surveillance to take into
account risk factors, pt
fitness and pt preference
• IM and length of Barrett’s to
inform surveillance regimen
Consensus in Mx of HGD
GASTROENTEROLOGY 2012
GUT 2012
Endoscopic Mucosal Resection, EMR
• Inject saline to
raise lesion off
submucosa to
reduce risk of
transmural thermal
injury during
snaring
• Use polypectomy
snare to resect and
cauterise lesion
• Lesion retrieved for
histology
Endoscopic mucosal resection
Staging of invasive lesions
Curative resection of superficial lesions
Invasive, risk of strictures and perforation
Effective in expert hands, high volume centres
Combination with RFA for elimination of Barrett’s metaplasia in
patients with HGD/LGD
Radiofrequency ablation, RFA
Thermal ablation of
non-dysplastic and
dysplastic Barrett’s mucosa to
1mm depth with bursts of
heat via 360 degrees coil of
radiofrequency electrodes,
Fitted over a balloon and
applied circumferentially
or smaller 90 degrees catheter
Radiofrequency Ablation, RFA
Meta-analysis 24 studies, with >4000 pts with Barrett’s and
dysplasia (LGD or HGD)/IM treated with RFA
With follow up between 12 and 31 months, following 2-3
sessions of RFA:
91% complete tx of neoplasia
78% complete remission of IM
13% recurrence of IM
0.9% progressed to dysplasia and 0.7% to cancer after IM
remission, at 1.5yrs
5% developed strictures
Shaheen et al Clin Gastro Hep 2013; 11(10):p1245–1255
Eosinophilic Oesophagitis
Clinical and histologic information required for diagnosis:
• Symptoms related to oesophageal dysfunction: dysphagia, food bolus
obstruction, retrosternal pain/ heartburn
• ≥15 eos/hpf in at least 1 oesophageal biopsy specimen, with few
exceptions
• Eosinophilia limited to the oesophagus
• Other causes of esophageal eosinophilia need be excluded, particularly
GORD and PPI-related oesophageal eosinophilia (PPI-REE)
ACG guidelines 2013
• Affects children and adult (mainly) men aged 20-40 yrs with history of
atopy
• Responds to swallowed steroid inhalers: fluticasone; viscous budesonide.
• Elimination diets are effective in children, encouraging new data in adults
for dietary therapy
Diagnosis and
Management
algorithm for
EoE
Clin Gastro&Hep 2012
Coeliac disease
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Immune mediated small intestinal enteropathy
Triggered by dietary gluten (NB oats OK)
Prevalence 1%
Strong genetic component: HLA DQ2/8, 10% prevalence in 1st
degree relatives
Diagnosis by serology AND duodenal biopsy
6-22% seronegative CD
Follow up: better adherence to gluten free diet if in specialist clinic
97/5% vs 40.4%
Follow up D2 biopsies: at 1 yr if still symptomatic or positive
serology
Baseline Ca/vit D levels and supplementation if needed + DEXA scan
Pneumovaccine if hypospenism
Screen for CD in IDA/Down’s/DM type1/Osteoporosis/IBS
Refractory coeliac disease
Persistent or recurrent malabsorptive symptoms and/or villous
atrophy despite gluten free diet for >12 months (in absence of
other causes); Incidence ~1%
• RCD type I: may respond to oral steroids/ immunosuppresants
• RCD type II: monoclonal/ abberant T lymphocytes poor
prognosis: nutritional compromise and increased risk of
enteropathy associated T cell lymphoma (EATL)
EATL 5 year survival <20%
RCD type II tx limited, include cyclosporine and high dose
chemotherapy + autologous stem cell support
Inflammatory Bowel Disease
Induction of remission:
- Glucocorticoids: pred 40mg reduce by 5mg weekly (bone protection)
- Budesonide (9mg od) may be effective in ileal/ R colonic disease
- 5- ASA high dose, in moderate UC
- 5- ASA may have a role in colonic Crohn’s
- Cyclosporin vs Infliximab for acute colitis
Maintenance of remission:
- Steroids should not be offered routinely
- 5- ASA in UC, once daily dosing, reduce CRC risk (by as much as 75%)
- 5- ASA in Crohn’s colitis (?)
- Azathioprine/ 6 mercaptopurine – check TPMT; 6TGN/6MeMP
- Methotrexate
- Anti TNF: Infliximab/ Adalimumab (certolizumab, golimumab)
IBD – Quality Care Service standards
• Published in 2009; National IBD audits 2006, 2008, 2011, 2014
• Hospital IBD service aims to comply with set standards
- IBD team: IBD nurse, surgeons with IBD interest, dietetic input
- Local delivery of care: arrangements for shared care
- Patient centred care: patient choice, rapid access to care
- Patient education and support
- Audit and research: IBD patient databases
Latest Audit 2014:
• Variable care for UC patients across UK with >40% receiving substandard
or delayed initial standard treatment, not seeing pts with relapse in ≤7 d
• Need for accurate assessment of disease activity
• Nutritional assessment upon admission
• Anaemia to be actively investigated and treated
• Limited access to psychological support
Doing better in Bone protection
VTE prevention and screening for C diff infection
IBD
Faecal Calprotectin: screening and disease activity monitoring
ECCO guidelines 2009 against opportunistic infections
• Screen for HBV/VZV and vaccinate if negative
• HPV vaccination as per national guidelines
Locally
• IBD nurse specialist – telephone and email access
• IBD dietitian – ward based and parallel clinics with gastro
• Patient group
• Surrey IBD group
Iron deficiency anaemia
• Ferritin (check ESR/CRP) to confirm IDA
• Upper AND lower GI investigations (unless advanced gastric
neoplasia found) advised: dual pathology in up to 10% cases
• Coeliac screening in all
• Urine testing for blood mandatory in all
• FOBs of no benefit in IDA
• Iron deficiency with no anaemia, consider investigations in
post menopausal women and men >50yrs
GUT 2011
Bowel preparation for colonoscopy
• BSG guidance in response to National Patient
Safety Agency report in 2009 on the potential risks of bowel
cleansing agents (BSG guidance 2012)
• clinical assessment of each patient for contraindications and
risks required,
• the use and choice of a bowel-cleansing preparation is
authorised by a clinician, and
• an explanation on its use is provided to the patient
• Guidance is for clinicians prescribing these agents and for
those referring for procedures that require them
Cleansing agents
• Moviprep/kleanprep – iso- osmotic and non absorbable,
less fluid and electrolyte shifts
• Fleet, Citrafleet, picolax, citramag – hyper- osmotic: draw
large volume of water into colon SO considered 2nd line
agents in presence of comorbidities including CKD, CCF,
liver disease
• Complications include: hypovolaemia, hypokalaemia,
hyponatraemia, phosphate nephropathy
Prescribing bowel preparation
• Check U&Es, eGFR and co-morbidities to inform choice of
cleansing agent
• Diuretics, ACEi/ARA, NSAIDs to be omitted for 72 hrs
• Absorption of medication affected eg OCP
• In diabetics, insulin and oral anti-glycaemic medication
needs to be reduced
• Oral iron discontinued 5 days before
• Anticoagulants and clopidogrel may need to be
discontinued
Summary points
GORD
• Optimise PPI use in GORD (?EoE)
• HRM and Impedance testing for PPI refractory GORD
Barrett’s
• No surveillance for short segment BO with no intestinal metaplasia
• Endoscopic treatment advised for HGD/ in situ cancer in BO
IBD
• Once daily 5-ASA for UC
• Bone protection while on steroid treatment mandatory
• Screen and vaccinate for HBV/VZV prior to immunosuppressant Tx
• Risk stratification guiding surveillance colonoscopies
IDA
• Coeliac serology, urinalysis in all
• Iron deficiency with no anaemia investigations in >50yr men and post menopausal
women
Bowel cleansing agents
• Careful assessment of patients referred for colonoscopy needed