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Guiding clinicians through GI diagnoses

From the September ACP Internist, copyright 2009 by the American College of Physicians

By Paula S. Katz

CHICAGO—Digestive Disease Week offered attendees insight into dyspepsia, weight loss and incontinence, as well as the latest about the risks of proton-pump inhibitors and antithrombotics.

Differential on dyspepsia

While it’s not always easy to diagnose patients with functional dyspepsia, a methodic approach considering all the possibilities and the latest research can help physicians and lead to the best treatment plan.

Attendees at Digestive Disease Week head to sessio...

Attendees at Digestive Disease Week head to sessions on dyspepsia, weight loss and incontinence.



Nicholas J. Talley, FACP, PhD, from the Mayo Clinic in Jacksonville, Fla., walked attendees through his diagnostic reasoning during a seminar on “Management of Functional GI Disorders.”

Dr. Talley used an example of a 39-year-old man who’d been suffering from epigastric pain for six months, heartburn two to three times per week, fullness after meals and a long history of constipation. The physical exam results were normal and the patient, who had been “endoscoped twice at both ends” by colleagues, hadn’t responded to proton-pump inhibitor (PPI) treatment.

“He wants an answer,” said Dr. Talley, and the way to get there is to ask the right questions.

Most likely the patient has functional (non-ulcer) dyspepsia. His disorder does not resemble biliary pain, which is typically severe, episodic and prolonged. Could a missed peptic ulcer be the cause? This is not likely if he’s had a normal upper endoscopy. Does he have missed gastroesophageal reflux disease (GERD)? As no esophagitis was seen at endoscopy, a consideration is non-erosive reflux disease (NERD). Because only a third of non-erosive reflux cases respond to PPIs, could it be PPI-resistant NERD? If initial management for functional dyspepsia fails, an esophageal pH test off PPI may help sort this out. Because of the fullness, does he need a gastric emptying study to rule out gastroparesis? A gastric emptying study is unlikely to change initial management but may be considered in difficult cases.

Dr. Talley recommended considering different options in functional dyspepsia, such as changing the PPI (which can sometimes help), trying split dosing and adding an H2 blocker. He also advised not discounting managing the constipation, because “Patients with upper gut symptoms often experience lower gut complaints.”

Two attendees peruse a poster at Digestive Disease...

Two attendees peruse a poster at Digestive Disease Week.



Other tests to consider include excluding Helicobacter pylori (which came back negative on this patient), and giving the patient a test meal and measuring symptom onset (an experimental test for positively diagnosing functional dyspepsia under investigation). Being full after starting to eat can indicate gastric or duodenal dysfunction. Excess eosinophils in the duodenum may also be a marker for functional dyspepsia. It’s also important to recognize that the drugs that address slow gastric emptying have side effects of their own. For example, erythromycin can cause nausea and can actually make symptoms worse, Dr. Talley said.

Based on the results of his investigation, he put the patient on a low-fat diet and small regular meals and treated the constipation with an osmotic laxative. The patient’s symptoms largely settled using this simple approach.

Future research could make the path to diagnosis and treatment a bit easier. “One gene associated with functional dyspepsia (GNB3) may also be relevant in GERD,” Dr. Talley said. “Our understanding of the pathogenesis of functional dyspepsia is changing and we have several new hints. There will be many more advances.”

NASH and weight loss

Weight loss of at least 7% is the key to improving histolic features of nonalcoholic steatohepatitis (NASH), according to new studies.

During “Approaches to Weight Loss in NASH: When and How Aggressive,” presenter Kittichai Promrat, MD, said a recent study on lifestyle intervention showed a 9.3% weight reduction in patients who received a portion-control diet limited to 1,200 to 1,500 calories per day, an exercise regimen of 200 minutes/week and a behavioral modification program, versus a 0.2% weight reduction in those who met with nutritionists four times per year with no specific goals.

“Lifestyle intervention appears to be an ideal treatment for this condition,” said Dr. Promrat, of the Alpert Medical School of Brown University in Rhode Island.

The major challenge is finding a self-regulating program that will help patients maintain that weight loss, Dr. Promrat said. While those on a low-carb diet lost more fat initially, once patients reached a 7% weight loss, the amount of fat reduction was the same. It doesn’t matter which diet the patient chooses as long as it’s the one he or she can stick with.

NASH and bariatric surgery

Although morbidly obese patients who also have NASH would like a quick fix, bariatric surgery may not be the answer, said Raphael Merriman, MD, of California Pacific Medical Center Research Institute in San Francisco.

In addition to the many complications of the various types of procedures, he said there just aren’t enough data to recommend surgery for obese patients with NASH. He noted that while bariatric surgery’s main goal is weight loss, some data do show promising results in also improving NASH. For example, one study showed that an 8% weight loss led to a 39% decrease in liver fat.

Dr. Merriman noted emerging potential bariatric surgery alternatives that include an intragastric balloon, gastric pacing, transoral gastroplasty and endoluminal vertical gastroplasty.

‘Disturbing’ NAFLD finding

Primary care physicians should talk to their patients about avoiding non-alcoholic fatty liver disease (NAFLD), according to the results of a new study, which was presented at Digestive Disease Week.

NAFLD is the most common cause of abnormal liver enzymes, one of the most common causes of cirrhosis, and the 10th leading cause of death.

In what lead researcher Sury Anand, MD, chief of gastroenterology at Brooklyn Hospital Center, called a “disturbing and significant” finding, 98% of 5,000 outpatient adults studied said their physicians had never talked to them about NAFLD. The survey also found that 95% did not know that fat in the liver could lead to serious health problems and 80% had never heard of cirrhosis.

He recommended that physicians encourage their patients to maintain healthy weight through diet and exercise to avoid NAFLD just as they would to prevent diabetes. Prevention is critical since treatment options are limited.

Fecal incontinence

Fecal incontinence is seen more commonly in women and incidence increases with age, which is why there are high rates of this condition in nursing home populations, according to Asma Khapra, MD, of Gastroenterology Associates of Northern Virginia, who presented “Fecal Incontinence and Endometriosis of the GI Tract.” Affected patients may have abnormalities in their pelvic floor structure (such as the anal sphincter muscle) and function (such as anorectal sensation) as well as systemic conditions such as stroke, multiple sclerosis or dementia.

Anorectal tests are necessary to identify defecatory disorders, according to Adil E. Bharucha, MD, of the Mayo Clinic in Rochester, Minn., who spoke on “Advances in Diagnostic Evaluation of Pelvic Floor Disorders.” During another lecture within the session on “Common Approaches to Pelvic Floor Abnormalities,” he mentioned manometry and rectal balloon expulsion, the latter of which he said is more than 85% sensitive and specific for identifying defecatory disorders.

Sometimes anorectal imaging may be necessary, he said, noting that there have been advances in ultrasound imaging. For example, he said 3-D anal ultrasound may be better than 2-D to distinguish external sphincter defects from transverse perineii and puboanalis muscle in selected patients. He said an MRI can reveal external sphincter atrophy in fecal incontinence.

Future needs include standardized techniques and an understanding of the significance of dyssynergia for manometry, more controlled studies for using MRIs, and development of noninvasive techniques to identify injury to nerves affecting the anal sphincter.

For now, biofeedback holds promise to help patients suffering from fecal incontinence. However, it’s not being used as much as it could be because of lack of physician training and enthusiasm, said Satish Rao, MD, during his presentation on “Behavioral Therapies for Fecal Incontinence and Dyssynergic Defecation Are They Effective?”

Physicians hesitate to use biofeedback despite studies that show it is even more effective than pelvic floor exercises and that this is a problem of brain-gut axis, Dr. Rao said.

“[They wonder] does it really work? Are we doing some voodoo?” he said.

He said physicians who want to try biofeedback should recognize that it’s labor-intensive and that they will need six sessions with the patient before seeing improvement. He also recommended using guidelines, establishing clear goals, and offering supportive therapy such as laxatives, diet and exercise.

Other treatment options for patients with fecal incontinence include pharmacologic therapy to treat underlying diarrheal illnesses or fecal impaction resulting in overflow incontinence. Additionally, surgical interventions, such as sphincter repair and sacral nerve stimulation, may play a role in improving anal sphincter control, according to Dr. Khapra.

Risk for hip fractures

Even taking less than one daily dose of PPIs or histamine-2 receptor antagonists (H2RA) could increase your patient’s risk of hip fractures, according to new data released at Digestive Disease Week.

The study looked at up to 10 years of exposure to PPIs and H2RAs for 33,752 cases. Fracture risk rose 12% for those taking less than one pill a day, 30% for those taking the usual dose of one pill a day, and 41% for those taking more than one pill a day among patients studied at Kaiser Permanente Northern California. Patients with hip fractures were 30% more likely than controls to have taken PPIs and 18% more likely to have taken H2RAs for at least two years.

While risk seemed greatest among patients 50 to 59 years old, the largest number of fractures occurred among the 80- to 89-year-old group, which had a lower PPI-relative risk.

“Patients taking acid suppressors should continue treatment at the lowest effective dose,” said Douglas A. Corley, MD, of Kaiser Permanente in San Francisco and the study’s lead investigator. “They should discuss treatment options with their doctor if they are at risk of osteoporosis.”

Antithrombotic cautions

The risks of giving complex antithrombotic therapy (CAT) to your patients may be higher than you think.

New data released at Digestive Disease Week showed that veterans age 60 to 99 years who were prescribed aspirin-antiplatelet therapy or aspirin-anticoagulant therapy were two to two-and-a-half times more likely to suffer significant upper GI events such as bleeding or perforation. The least harmful CAT combination was anticoagulant-antiplatelet therapy.

However, patients 60 to 69 years old who received CAT were at highest risk of experiencing upper GI events, and their risk of bleeding within one year of taking the drugs was four times higher. These patients were likely to be on aspirin-anticoagulant-antiplatelet therapy for a history of ischemic heart disease, hypertension, diabetes and peripheral artery disease.

“The observed magnitude of [upper GI events] risk suggests an unfavorable risk/benefit profile for CAT in the short term,” said lead investigator Neena S. Abraham, MD.

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