INTRODUCTION TO GASTROINTESTINAL

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INTRODUCTION TO GASTROINTESTINAL

• AKA
• GASTROINTESTINAL NOW THAT TAKES GUTS

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• October 11, 2005 Asked by Helga Sicker/Bob
  Sangster to give a 20 minute talk titled Intro
  to Gastrointestinal and an abstract requested.
• 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
• 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
• 
  
  contd

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• 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.!!

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INTRODUCTION TO GASTROINTESTINAL

• GERD
• Screening for Colon Cancer
• Constipation
• (IBS)
• (Celiac Disease)
• (IBD)

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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
• Diagnosis
• Endoscopy
• H.pylori
• Recommendation

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GERD

• FP Consult 2I had planned to treat
• him with esomeprazole (Nexium) but he
• couldnt 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

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GERD

• FP Consult 3If I do that, will he have to
• be on medication for the rest of his life?
• Is that safe?
• Issues
• Length of treatment
• Long-term safety of PPIs
• Reduced-dose PPIs
• Domperidone

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GERD

• FP Consult 4 I also look after his brother. He
  has
• a similar history but hes had his symptoms now
• for 15 years. Hes well controlled on PPIs and in
• fact did ok on H2RAs years back. Do you need to
• see him?
• ISSUES
• Esophageal cancer
• Barretts esophagus
• Relation to reflux
• Efficacy of screening
• Recommendation

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GERD

• FP Consult 5LR is a 28 year old
• healthy male with episodes of short
• lasting meal related obstructions dating
• back several years. Please scope.
• Issues
• Dysphagia as red flag
• Heartburn equivalent
• Schatzkis ring
• Recommendation
• Exceptions

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GERD

• FP Consult 6 Hes only 28 years old.
• What about surgery for this individual?
• Issues
• Ideal patient
• Efficacy
• Alternative approach

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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 cant have a bowel
• movement without one. Any suggestions?
• Issues
• Laxative dependency
• Fibre
• Wheat bran
• Recommendation

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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
• 2L H2O
• Recommendation

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CONSTIPATION

• FP Consult 3 For this same patient,
• now with adequate fibre and fluid in her
• diet, which laxative would you
• recommend?
• Issues
• Laxative choices
• Recommendation

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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
• Causes (table)
• Investigation
• Recommendation

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(No Transcript)
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CONSTIPATION

• FP Consult 5 For reference, is there an
• algorithm to use in this and similar
• patients for investigation and treatment?
• Algorithm
• History, physical, blood work
• Fibre
• Psyllium
• Milk of magnesia, cascara, senna
• Lactulose
• GoLytely
• GI consult

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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
• wont pay for it unless he has symptoms.
• Hes asymptomatic and his physical
• exam is normal. He has no family history
• of colon cancer. Please colonoscope.

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SCREENING FOR COLON CANCER

• FP Consult 1 (contd)
• Issues
• Manitoba Health policy
• Epidemiology
• Screening Programs
• FOB
• Flexible Sigmoidoscopy vs colonoscopy
• Guidelines for usual risk CPSM
• 
  CTFPHE,USPSTF
• 
  CAG, AGA/ACS
  Bottom
  line

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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?

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SCREENING FOR COLON CANCER

• FP Consult 2 (contd)
• Issues
• Risk with family history
• Guidelines for family history
• CPSM
• CTFPHE, USTFPHS
• CAG, AGA/ACS
• Bottom line

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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?

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COLON CANCER SCREENING

• FP Consult 3
• Issues
• Polyps vs. cancer
• Recommendation
• Guidelines for family history of polyps
• CPSM
• CTFPHE, USPSTF
• CAG, AGA/ACS
• Bottom line

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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
• Recommendation
• ACBE vs colonoscopy

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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
• True virtual (CT) colonography vs virtual (CT)
  colonography
• Recommendation

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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
• contd

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CANADIAN GUIDELINES

• Family History
• CAG
• 1st degree relative with colon cancer or adenoma
  lt60
• Colonoscopy every 5 years starting at age 40 or
  at least 10 years earlier than the relatives age
  at diagnosis.
• 1st degree relative with colon cancer or adenoma
  gt60
• Average risk screening but begin at age 40

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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

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CPSM

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

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CPSM

• Family History
• 1st degree with colon CANCER lt 55
• Colonoscopy q5 years starting age 40 or 10 years
  before diagnosis
• 1st degree with colon CANCER gt 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.

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• 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