Read Like Gastroenterologists

What Did Gastroenterologists Learn in the Past 12 Months That PCPs Should Know?

Lauri R. Graham; Laurie Scudder, DNP, NP; Joanna M. Pangilinan, PharmD


June 04, 2018

Should We Change the Way We Screen for Colorectal Cancer?

Colorectal cancer rates have been on the rise in adults younger than age 50 years.[2] This has led to concerns that the screening recommendations may be outdated. An evaluation of results from approximately 6000 consecutive colonoscopies performed at a French referral center found that, even when higher-risk patients with a personal or family history of polyps or cancer were excluded from the analysis, detection rates for adenomas and neoplasias rose substantially in patients older than 45 years. Based on these results, the investigators recommend that screening begin at age 45 years rather than the current recommended age of 50 years.

While the reasons for this rise in colorectal adenoma in younger adults are unclear, there is increasing evidence that the use of antibiotics, which alter gut microbiota, may be a factor in its later development. An analysis of data from the Nurses' Health Study found that exposure to antibiotics earlier in life (age range, 20-59 years) was significantly associated with an increased risk for colorectal adenoma after age 60 years. Of note, recent exposure to antibiotics (within 4 years of their colonoscopy) was not associated with an increased risk for colorectal adenoma.

This is yet one more reason to be cautious in the use of antibiotics.

Expanding Data on Fecal Transplantation

Fecal microbiota transplantation (FMT) has entered the public consciousness in the last decade with a wealth of information, often suspect, and available to the public providing do-it-yourself instructions. Interest in the professional community is also sharply on the rise. FMT has primarily been studied for the treatment of recurrent Clostridium difficile infection, but it is also under investigation to treat several other chronic conditions.

A comprehensive systematic review of the methodologic details of all 85 investigations published prior to January 31, 2017, assessing FMT determined that the methodologic rigor varied widely. While the overwhelming majority—85%—of published reports examined the use of FMT to treat C difficile, a large majority of the trials were nonrandomized and generally small.

This review concluded that the research methodology used to examine FMT needs to be more standardized. Research has been limited owing to the difficulty of classifying FMT as a drug or tissue for evaluation by the US Food and Drug Administration (FDA).

Despite these hurdles, new guidelines from the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America support the use of FMT for patients with two or more episodes of C difficile infection and who have not responded to antibiotics. And, while the FDA issued a guidance document for FMT in 2013, it has not tested this therapy in a standard clinical trial.

So, while patients may ask about this therapy—and possibly turn to YouTube to find out how to do it themselves—healthcare professionals should be aware of the existing evidence and be cautious in their treatment approach.

PPIs Still Warrant Discussion

This past year brought several new articles about the use of proton pump inhibitors (PPIs). There is still reason to be cautious about their use—a longitudinal observational cohort analysis of over 6 million patients enrolled in the US Veterans Affairs system found that compared with H2-blocker use, PPI use was associated with a 25% increased risk for death from all causes. The risk increased the longer the PPI was taken.

So, if you are now thinking that you might want to discontinue PPI use in some of your patients, a new practice guideline developed by the Deprescribing Guidelines for the Elderly project was issued in the summer of 2017 to help clinicians make decisions about when and how to safely deprescribe PPIs.

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