INTRODUCTION TO GASTROINTESTINAL

							      INTRODUCTION TO
     GASTROINTESTINAL
             AKA

GASTROINTESTINAL: NOW THAT TAKES
              GUTS
1.   October 11, 2005 Asked by Helga Sicker/Bob Sangster to give a 20
     minute talk titled “Intro to Gastrointestinal” and an abstract
     requested.

2.   Replied with no abstract but indicated; “Doctor Goldenberg will
     present data from his office practice to indicate the most frequent
     referrals from family practitioners to gastrointestinal office for
     consultation and briefly reviewing each of these with a take home
     message with practical application”

3.   Reply and thanks from Helga Sickert:

     “We are hoping to empower our membership with information on
      the management of gastrointestinal issues so that family
      practitioners can help unload the system”



                                                             cont‟d
4. Received the syllabus.
Note the change in title “Access Issues”
   and description of the talk:

   “Dr. David Goldenberg will introduce
   which cases can be managed in a
   primary care setting and which
   symptoms signify urgent referral to a
   gastroenterologist. In addition he will
   outline which gastroenterologists
   have a specific area of expertise.”!!
          “INTRODUCTION TO
         GASTROINTESTINAL”

1.   GERD
2.   Screening for Colon Cancer
3.   Constipation
4.   (IBS)
5.   (Celiac Disease)
6.   (IBD)
                       GERD
FP Consult #1: JW is a 56 year old male
with occasional heartburn over the years.
Recently it has become much worse and no
longer Responds to OTC antacids, H2RAs
and attention to diet. Barium swallow was
normal. Does he need to be scoped? He
is H.pylori +.

Issues:

          1.   Diagnosis
          2.   Endoscopy
          3.   H.pylori
          4.   Recommendation
                 GERD

FP Consult #2:I had planned to treat
him with esomeprazole (Nexium) but he
couldn’t afford it because it was not
covered by Pharmacare. I was going to
prescribe pantoprazole (Pantoloc) but
the new Pharmacare regulations will only
cover omeprazole or rabeprazole (Pariet)
as first line PPIs. What should I do?

Issues:
     1.   PPIs
                  GERD
FP Consult #3:If I do that, will he have to
be on medication for the rest of his life?
Is that safe?

Issues:

       1. Length of treatment
       2. Long-term safety of PPIs
       3. Reduced-dose PPIs
       4. Domperidone
                      GERD
FP Consult #4: I also look after his brother. He has
a similar history but he’s had his symptoms now
for 15 years. He’s well controlled on PPIs and in
fact did ok on H2RAs years back. Do you need to
see him?
ISSUES:

1.   Esophageal cancer
2.   Barrett‟s esophagus
3.   Relation to reflux
4.   Efficacy of screening
5.   Recommendation
                      GERD
FP Consult #5:LR is a 28 year old
healthy male with episodes of short
lasting meal related obstructions dating
back several years. Please scope.

Issues:

1.   Dysphagia as “red flag”
2.   Heartburn equivalent
3.   Schatzki‟s ring
4.   Recommendation
5.   Exceptions
                 GERD
FP Consult #6: He’s only 28 years old.
What about surgery for this individual?


Issues:
  1.      Ideal patient
  2.      Efficacy
  3.      Alternative approach
              CONSTIPATION
FP Consult #1: Mrs. X is a 64 year old female
with a history of constipation for 4 years.
Colonoscopy was normal. She was warned
against using laxatives but continues to do so,
perhaps because she can’t have a bowel
movement without one. Any suggestions?

Issues:
1.         Laxative dependency
2.         Fibre
3.         Wheat bran
4.         Recommendation
            CONSTIPATION
FP Consult #2: This patient drinks only 3
cups of tea daily. How much water is
needed in the average diet to ensure a
regular B.M.? Should I ensure she has
the necessary 8 cups of water?

Issues:
1. 2L H2O
2. Recommendation
            CONSTIPATION
FP Consult #3: For this same patient,
now with adequate fibre and fluid in her
diet, which laxative would you
recommend?

Issues:

1. Laxative choices
2. Recommendation
           CONSTIPATION
FP Consult #4: This lady had a
colonoscopy 2 years ago. What causes
do we need to rule out when evaluating
constipation? Is a colonoscopy always
required?

Issues:
1. Causes (table)
2. Investigation
3. Recommendation
            CONSTIPATION
FP Consult #5: For reference, is there an
algorithm to use in this and similar
patients for investigation and treatment?

Algorithm:
1. History, physical, blood work
2. Fibre
3. Psyllium
4. Milk of magnesia, cascara, senna
5. Lactulose
6. GoLytely
7. GI consult
 SCREENING FOR COLON CANCER
FP Consult #1: JR is a 50 year old
healthy male presenting to my office
requesting screening for colon cancer.
He understands that Manitoba Health
won’t pay for it unless he has symptoms.
He’s asymptomatic and his physical
exam is normal. He has no family history
of colon cancer. Please colonoscope.
  SCREENING FOR COLON CANCER
FP Consult #1 (cont‟d):

Issues:
  1.   Manitoba Health policy
  2.   Epidemiology
  3.   Screening Programs
  4.   FOB
  5.   Flexible Sigmoidoscopy vs colonoscopy
  6.   Guidelines for „usual risk” : CPSM
                                     CTFPHE,USPSTF
                                     CAG, AGA/ACS
                                     “Bottom line”
SCREENING FOR COLON CANCER

FP Consult #2: A 37 year old healthy
male is referred because of a family
history of colon cancer. His 47 year
old sister just had a right
hemicolectomy for ascending colon
cancer metastatic to the liver.
Should he be screened?
 SCREENING FOR COLON CANCER
FP Consult #2 (cont‟d)
Issues:
     1.   Risk with family history
     2.   Guidelines for family history
               CPSM
               CTFPHE, USTFPHS
               CAG, AGA/ACS
               “Bottom line”
 COLON CANCER SCREENING
FP Consult #3: 46 year old white female
is referred with no significant health
problems or GI symptoms. Her 55 year
old sister just had 4 polyps removed at
colonoscopy. None were malignant. Does
she need screening?
  COLON CANCER SCREENING
FP Consult #3:
Issues:
   1. Polyps vs. cancer
   2. Recommendation
   3. Guidelines for family history of polyps:
          CPSM
          CTFPHE, USPSTF
           CAG, AGA/ACS
          “Bottom line”
SCREENING FOR COLON CANCER

FP Consult #4: JO is a 52 year old female
   who had an ACBE 2 years ago for
   colon cancer screening. Now her 59
   year old brother has been diagnosed
   with colon cancer. Does she need a
   colonoscopy?

Issues:
   1.   Recommendation
   2.   ACBE vs colonoscopy
      SCREENIN FOR COLON CANCER
FP Consult #5: RL is a 62 year old male
   asymptomatic executive who has followed all
   screening guidelines to date. His last 2
   experiences with colonoscopy were
   “intolerable”. I tried to get a virtual (CT)
   colonography done here but failed. Should I
   send any asymptomatic patients who can afford
   it to Calgary?

ISSUES:
1.   True virtual (CT) colonography vs virtual (CT)
     colonography
2.   Recommendation
      CANADIAN GUIDELINES
Average Screening:
CAG:
Start at age 50
FOB every 2nd year (this is a main difference
  from other guidelines)
Flexible sigmoidoscopy every 5 years
Above combined
ACBE q5years
Colonoscopy every 10 years
                                       cont‟d
           CANADIAN GUIDELINES
Family History:
CAG:

1st degree relative with colon cancer or adenoma
  <60:
Colonoscopy every 5 years starting at age 40 or at least
  10 years earlier than the relative’s age at diagnosis.

1st degree relative with colon cancer or adenoma
  >60:
Average risk screening but begin at age 40
       CANADIAN GUIDELINES
Family History (cont):

2 1st degree relatives with colon cancer or
  adenomas at any age:
Colonoscopy q5 years starting age 40 or 10 years
  before relative

2 2nd degree relatives with colon cancer or
  adenomas:
Average screening beginning at age 40
               CPSM
Average Screening:

Start at age 50
FOB yearly or q1-2years and/or
Flexible sigmoidoscopy q5 years
(Colonoscopy with informed consent)

                              cont‟d
                         CPSM
Family History:

1st degree with colon CANCER < 55:
Colonoscopy q5 years starting age 40 or 10 years before
  diagnosis

1st degree with colon CANCER > 55:
Average risk screening

2 1st degree relatives with colon cancer at any
  age:
Colonoscopy q5 years starting age 40 or 10 years before
  diagnosis.
CTFPHC 2001:
Average Risk:
FOB q1-2 years starting age 50 (grade A)
Flexible sigmoidoscopy (grade B)

1st degree relatives:
No recommendation (grade C)


USPSTF 2002:
Same as CTFPHC