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thedigest Primary Care Society for GastroenterologySample Article Cancer focus: Screening acceptability: more than the public can swallow?Pancreatic cancer: tracking a silent killer Beyond our scope:Endoscopy special Functional illness training - Treating constipation Patients deserve more In my early years in practice I looked after a young woman with primary liver cancer. Her family were Irish and in her last weeks of life, a seemingly endless stream of relatives moved in and shared the nursing care. She died late one night and the family called me. When I got to the house the priest was already there. I suspected that they called him first.
FOBt: what's not to like? The next day I returned to complete the death certificate. There was a Quite a lot, argues Richard Stevens stream of visitors at the front door where murmured condolences were said. They then went upstairs to see the body. She was still in her bed and her Cancer and screening: eight-year-old sister was brushing her hair. A moment's silence with heads Identify IBD clearly
Primary care makes the difference 8-9 bowed; then down to the kitchen where a party, led by the priest, seemed in full swing.
Oesophageal cancer: less invasive and Death rituals can be deeply ingrained. And if behaviour around death costly screening is on the way Inflammatory bowel disease (IBD) or irritable bowel syndrome (IBS)? Differentiate between can be culturally specific, perhaps other behaviour can be, too; something demonstrated in this issue of The Digest, which focuses on gastrointestinal Pancreatic cancer: IBD/IBS quickly and clearly with EliA Calprotectin – the first fully automated calprotectin stool cancer and screening. silent killer or hiding behind the white Though perhaps less ritualistic, there may nevertheless be deep-rooted test. High sensitivity, high specificity, and excellent predictive values deliver reliable results attitudes around accepting advice and health messages especially: taking up screening, presenting a worrying symptom to a doctor, complying with and provide early diagnostic guidance. Go one step beyond in autoimmune diagnostics: treatment and approaching the last stages of life. All the stages that can affect cancer outcomes, in fact.
How a budding GP endoscopist Culture can be defined as ‘the way we do things around here' and can be fought for her training at a family and social grouping level, as well as a racial and national one. As doctors, we need to be aware of the unwritten, and usually unconscious, rules that our patients live their lives by, and tailor our messages accordingly.
creating a high quality, In this issue we have major articles on gastrointestinal cancer topics sustainable service by leading figures. The national bowel cancer screening programme has the opportunity to significantly reduce mortality from colorectal cancer. Community endoscopy in Bristol However, it is not without contentious areas: consent, especially for those with limited capacity, being one of them. How can the benefits and risks Do all heartburn patients need an OGD? 21 (physical and psychological) of entering a screening programme be ethically • For further information please contact [email protected] Hepatitis C in context communicated? And is the fact that the take-up of screening is only a • Tel : +49 761 47805-0 • www.thermoscientific.com/phadia little over 50 per cent down to people voting with their feet, or a lack of Endoscopy conference knowledge and awareness? These and other issues are discussed.
Other topics covered touch on the role and provision of endoscopy, Functional disease education: especially in community settings. Sophie Summers' account of training as a too important to be ignored GP endoscopist (almost an endangered species) relates the story of how hard it is to swim against the tide in the current training set-up. Fast facts: Obesity Attitudes to functional disorders may be ingrained early, and this is examined in medical student Lydia Yarlott's challenging account. It is worth Bowel screening and learning disabilities: remembering that, taken literally, functional means ‘working and in order, i.e. it Good practice isn't yet the norm Profile: Professor John Ashton As always, comments, criticism, compliments and contributions are most welcome. The Digest editorial team is always happy to receive, discuss and Why it's well worth signing up to CPRD 33 help with ideas for articles and contributions. Whether you have a special interest in the area or not, a major part of your work will be dealing with gastrointestinal problems. Our aim is therefore to produce a lively and readable journal that is stimulating to all GPs. Taking the tedium out of constipation 2012 Thermo Fisher Scientific Inc. All rights reserved. All trademarks are the property of Thermo Fisher Scientific Inc. and its subsidiaries. Legal Manufacturer: Phadia AB, Uppsala, Sweden Hepatitis C in context: A rapid guide for GPs The global problem useful for patients who have injected intravenously in the With 3 per cent of the world's population living with past and in whom venepuncture is difficult or impossible. Editor-in-Chief, the disease, Hep C – a major cause of cirrhosis and liver Confirmatory PCR testing of the serum for HCV RNA The Digest cancer – is a significant global problem. Infection rates vary may be followed by a liver biopsy. significantly from country to country. Hep C affects 2 per Selecting patients for treatment cent of the USA population, 3 per cent in China and 5 per Fewer than 3 per cent of known Hep C patients are treated. cent in Pakistan. In Egypt, the figure rises to 22 per cent Practical difficulties arise as they need to be stable enough of the population (probably as a result of a schistosomiasis to attend for testing, discussion of the results, OPD, further vaccination programme with contaminated instruments). investigations such as ultrasound and liver biopsy. They In the UK, the numbers of those infected is believed to must also commit to treatment which can last for between be 200,000–400,000. London accounts for 26 per cent of 6 and 12 months, with side effects. all hepatitis C diagnoses, according to a report published by Public Health England, while Scotland has an estimated There are 11 major genotypes, numerous sub-types 37,500 carriers (about 0.8 per cent of the population). (designated by numbers and letters respectively) and an The vast majority of those with hepatitis C, however, are estimated 100 or so strains, and considerable geographic unaware that they are infected.
Types 1 to 3 have a worldwide distribution, with the The natural history is slowly progressive, with a median most common, 1a (predominant in northern Europe time to cirrhosis of 28–32 years. Risk factors for acquiring and America) and 1b (south and east Europe and Japan), the disease include blood-to-blood, IVDU, transfusion responsible for around 60 per cent of all infections. (pre-1992) haemodialysis, tattooing and body piercing, and The identification of the genotype will guide the medical (and dental) equipment as well as ‘not known'. It treatment regime as it provides a prediction of a patient's is estimated that 50 per cent of prisoners are exposed to likely response to antiviral treatment1. IVDU or tattooing.
Vaginal sexual contact in the absence of ulcers, broken Treatment consists of mono or combination therapy with skin or bleeding probably does not result in transmission. one or more interferon and/or ribavirin, lasting, usually, In the case of vertical transmission, the mother to child for between 24 and 48 weeks. Combining pegylated transmission rate is low (<10 per cent), although a long interferon-a with ribavirin results in a significant labour does increase the risk. Breast feeding is usually improvement for all genotypes. not contraindicated (in the absence of cracked nipples or Success rates can be high – over 75 per cent for similar problems) and there are high rates of up to 50 per patients with genotypes 2 and 3, and 40–50 per cent for cent of spontaneous clearing of the virus in babies. those with for genotype 1. Against this, however, other Acute infection is asymptomatic (85 per cent), or may patients, including those who have not responded with present as a mild illnesses characterised by nausea, myalgia, prior treatment, have severe liver fibrosis or cirrhosis, or fatigue and occasionally jaundice (which is associated with comorbidities – such as alcohol consumption, fatty liver or a better outcome).
insulin resistance, can be far harder to treat2. Between 15 and 20 per cent of adults and up to 50 per Side effects are common, most commonly fatigue, cent of children clear the virus. The remainder go on to together with flu-like symptoms and mild psychological be chronically infected. Of these, around half will go on reactions, while florid neuropsychiatric reactions can to develop fatty liver disease, a risk factor for progressing occasionally occur. Pre-treatment screening of mental to cirrhosis. Liver function tests are normal in about half illness risk is important.
Two recently published studies3 focusing on the difficult- Many of these will go on to develop fibrosis of the liver to-treat hepatitis C genotype 1 (the most common in with a median time of 30 years from infection. Concurrent Europe as well as in the USA, north Asia, Australia and Hep B, HIV and alcohol use are risk factors for progressive South America) suggest that two new oral antiviral drug treatments are shorter, more effective and have fewer side Cirrhosis can lead to portal hypertension and varices, liver failure, hepatic encephalopathy, and is a risk factor In the first study, 645 patients from 18 countries received for primary liver cancer (an annual ultrasound may a 6-month course of treatment with two oral DAAs, be recommended.) Liver transplantation is sometimes asunaprevir and daclatasvir, with a placebo control group performed. The re-infection rate after surgery, however, is consisting of 102 treatment-naïve patients. high (80 per cent).
Ninety per cent of patients who not previously been People who experience a needle stick injury from treated, and just over 80 per cent of patients where either someone with HCV have a 1.8 per cent chance of previous treatment had failed or were intolerant, were subsequently contracting the disease, greater if the needle is hollow and the puncture wound deep, though there is In the second study, 167 patients with HCV genotype only a small risk from mucosal exposure to blood and no risk from blood exposure to intact skin. "People who experience a needle stick injury from someone with Detection of HCV antibodies by enzyme-linked HCV have a 1.8 per cent chance immunosorbent assay (ELISA) is used for screening. There are some false positives, especially in low prevalence of subsequently contracting the populations. Dried blood testing is possible and is especially The Digest The Journal of the Primary Care Society for Gastroenterology 1a and 1b received either a 12 or 24-week course of once-daily sofosbuvir plus simeprevir with or without ribavirin. The cure rate, after just 12 weeks of treatment without ribavirin, was 93 per cent. Fewer than two per cent of patients reported any adverse effects. The GP's role GPs have five roles in Hepatitis C: • Screening and counselling. Hep C is a significant disease and informed consent and counselling are neededbefore testing.
• Case finding in at-risk groups. Members of at-risk populations should be sought out and counselled.
• Re-testing at intervals if indicated by ongoing high-risk behaviour (such as continued injecting of drugs) • Harm minimisation in those not ready for treatment. • Preparing and counselling patients, family and carers for treatment and supporting them throughout. Conclusion With HCV-related disease and morbidity rates predicted to rise and no vaccine as yet available, the short-term goal is to develop new treatments with fewer side effects, while GP education and knowledge of this complex disease also need to be improved. BRAY1411 RES(UK) Digest (143.5x210) AW.indd 1

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