10 Key Primary Care Takeaways: Digestive Disease Week (DDW) 2017

David A. Johnson, MD


June 14, 2017

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

I'm Dr David Johnson. I look forward to seeing you next time. Thanks again for listening.


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