The document outlines updated guidelines on various gastrointestinal topics, including the management of Helicobacter pylori infections, acute diarrhea in adults, colorectal cancer screening, gallstone disease, and asymptomatic pancreatic cysts. Key recommendations are provided for testing, diagnosis, and treatment strategies, with an emphasis on evidence-based practices for primary care physicians. Overall, it highlights the importance of individualized patient care and adherence to the latest clinical standards.

1. Dr Jarrod Lee
Gastroenterologist &
Advanced Endoscopist

2. 2
Scope
• Helicobacter pylori
• Acute diarrhea in adults
• CRC screening
• Gallstone disease
• Pancreatic cysts
2

3. Helicobacter
Pylori (HP)
Maastricht V
Consensus
Report 2016
ACG Clinical
Guideline 2017
3Gut 2017; Am J Gastroentrol 2017

4. HP Gastritis
• Is a distinct clinical entity and may cause dyspepsia
• Treatment relieves dyspepsia in 10% of patients compared
to placebo or acid suppression.
• Has to be excluded before ‘Functional Dyspepsia’ can
be diagnosed.
• May increase or decrease acid secretion
• Treatment may reverse or partially reverse this.
• Long term PPI treatment alters the topography;
eradication heals gastritis in long term PPI users
4

5. Indications for HP Testing
• ‘Test and treat’ strategy is appropriate for
uninvestigated dyspepsia, except for patients with
alarm symptoms or older patients.
• Aspirin and NSAIDs increase the risk of PUD in
patients with HP – should be tested in users.
• Linked to unexplained iron deficiency anemia,
idiopathic thrombocytopenic purpura and B12
deficiency – should be tested.
5

6. Diagnosis
• UBT is the best recommended non-invasive test.
Stool antigen and serology tests may also be used.
• PPI should be stopped > 2 weeks before testing;
antibiotics and bismuth should be stopped > 4 weeks
• UBT is the best option for confirmation of HP
eradication; stool antigen test is an alternative
• Biopsy based tests – new technical considerations
for diagnosis and assessment of gastritis
6

7. Treatment
• Antibiotic resistant rates are increasing
• History of prior key antibiotic use may predict resistance
• Avoid clarithromycin containing triple therapy if
clarithromycin resistance rate > 15%
• China 50%; Japan 30%
• Singapore resistance: 2016 study
• Clarithromycin 17%; 8% in 2002
• Metronidazole 48%; 25% in 2002
• Dual resistance 4.4%
7Helicobacter 2016

8. What First Line Regime?
• Non bismuth based quadruple therapy (NBQT): PPI,
amoxicillin, clarithromycin, metronidazole
OR
• Bismuth based quadruple therapy (BQT): PPI,
bismuth, tetracycline, metronidazole
• Treatment duration 14 days
• Use high dose 2nd generation PPIs
• Success rate: 85-95%
8

9. Refractory HP
• Avoid antibiotics that have been used previously
• If fail triple therapy or NBQT, give BQT or
fluoroquinolone based triple or quadruple therapy
• If fail BQT, give fluoroquinolone based therapy
• Consider other antibiotics or rifabutin if suspected
fluoroquinolone resistance
• If fail 2nd line, do culture with susceptibility testing
9

10. 10
Acute
Diarrhea in
Adults
ACG Clinical
Guideline 2016
Am J Gastroenterol 2016

11. Clinical Definition
• Passage of 3 unformed stools in 24 h
PLUS
• An enteric symptom: nausea/ vomiting, abdominal
pain/ cramps, tenesmus/ fecal urgency, moderate to
severe flatulence
• Severity: effect on daily activities
• Severe: total disability due to diarrhea
• Moderate: able to function with forced change in activities
• Mild: no change in activities
11

12. Stool Tests
• Traditional methods of diagnosis (FEME, c/s, antigen
testing) fail to reveal the aetiology in most cases
• Even stool leucocytes or lactoferrin imprecise
• Antibiotic sensitivity testing is currently not
recommended
• Low failure rate with empirical antibiotics
• Stool diagnostic tests may be used if: dysentery,
moderate-to-severe disease, symptoms >7 days
12

13. Treatment
• Oral rehydration: for all patients, need fluid and salt
• Water, juices, sports drinks, soup, saltine crackers
• ORS: for elderly or cholera like diarrhea
• Bismuth subsalicylate: antisecretory; reduces
diarrhea by 40%
• Loperamide: antimotility and antisecretory; reduces
duration of diarrhea
• Probiotics & prebiotics: not recommended for adult
• Adsorbent drugs: not recommended
13

14. Antibiotics
• Routine empirical antibiotics not recommended
• Most community acquired diarrhea is viral
• Traveller's diarrhea: shortens duration by 1-3 days
• Ciprofloxacin: 750mg once or 500mg OM x 3 days
• Levofloxacin: 500mg once or 500mg x 3 days
• Azithromycin: 1000mg once or 500mg OM x 3 days
• Use if in Southeast Asia or South Asia to cover
fluoroquinolone resistant Campylobacter
• Preferred for dysentery or febrile diarrhea
14

15. 15

16. Colorectal
Cancer
Screening
USPSTF 2016
USMSTF 2017
16

17. 2016 Guidelines
• USPSTF Guidelines published JAMA 2016
• “Screening tests are not presented in any preferred
or ranked order”
• “Goal is to maximize the total number of persons
who are screened because that will have the largest
effect on reducing colorectal cancer deaths”
17

18. Recommendations
• Start CRC screening at 50 years, stop at 75 years
• Screening for 75-85 years should be individualized
• Numerous screening tests available
• No head to head studies to demonstrate any test to be
more effective
• Clinicians should engage patients in informed
decision making about the screening strategy
• Patient’s preference
• High adherence over time
18

19. 19

20. 2017 Guidelines
• Represents AGA, ACG, ASGE
• Screening tests ranked into 3 tiers based on
performance, cost and practical consideration
• Optimizes sensitivity and cost effectiveness; leaves
opportunity to offer other tests if patient declines
20

21. Tiered Ranking of Screening Tests
21

22. First Tier Tests
• FIT
• Simple, non-invasive
• Need for annual tests
• Colonoscopy
• High sensitivity, single session diagnosis and treatment,
long interval between examination
• Needs bowel preparation; risk of perforation/ bleeding
• Over diagnosis and over treatment of small lesions
• Highly operator dependent; quality control crucial
22

23. 23

24. When to Screen – Average Risk
• Asymptomatic: 50 years
• < 50 years with colorectal bleeding symptom
• hematochezia, unexplained iron deficiency, malena with
normal OGD
• Stop at 75 years or when life expectancy < 10 years
24

25. When to Screen – Increased Risk
• 1x FDR > 60 years with CRC or AA
• Start at 40 years
• Screen every 10 years if normal
• 1x FDR < 60 years or 2x FDR any age with CRC or AA
• Start at 40 years or 10 years before youngest family was
diagnosed, whichever is earlier
• Do colonoscopy; screen every 5 years if normal
• Lynch Syndrome, Family Colon Cancer Syndrome X,
polyposis syndromes: refer to specialist
25

26. Gallstones
EASL Guidelines
2016
26Journal of Hepatol 2016,

27. Epidemiology & Natural History
• Gallstones are present in 20% of the population
• Higher incidence in females and with age
• 80% remain asymptomatic throughout life
• 20% become symptomatic over 20 years
• Develop at rate of 1-4% per year
• 50% will have recurrent pain after 1st episode
• Complications develop in at 1-3% per year after 1st
colic episode (0.1-0.3% in asymptomatic patients)
27

28. Diagnosis
• Symptomatic gallstones:
• Biliary colic: episodic attacks of severe pain in RHC or
epigastrium lasting for at least 30min
• Radiation to the right back or shoulder
• Positive reaction to analgesia
• Abdominal ultrasound: > 95% accurate
• If strong clinical suspicion and negative abdominal
ultrasound, do endoscopic ultrasound (EUS)
• Detects another 95% in normal abdominal ultrasound
28

29. Acute Cholecystitis
• Most common complication, occurs in 10% of
patients with symptomatic gallstones
• Should be suspected in:
• Severe pain lasting several hours
• Fever
• Murphy’s sign positive
• Can do ultrasound or CT scan for diagnosis
29

30. Treatment
• Biliary colic
• NSAIDs: effective pain relief and prevents progression to
acute cholecystitis
• If severe pain: add antispasmodics, opioids
• Symptomatic gallstones should be treated with
cholecystectomy
• Surgery not recommended for asymptomatic
gallstones
• Bile acid dissolution therapy not recommended
30

31. Gallbladder Polyps
• Better evaluated with EUS than abdominal
ultrasound (87-97% vs 57-76%)
• Cholecystectomy should be done if polyps > 1cm
• Cholecystectomy may be considered in:
• Patients with polyps 6-10mm and gallbladder stones
• Patients with rapidly growing polyps
• Patients with PSC and polyps (regardless of size)
• Consider surveillance in polyps 6-10mm
31

32. CBD Stones
• Present in 3-16% of patients with GB stones
• 90% symptomatic, 10% asymptomatic
• Search for CBD stones in patients with jaundice,
acute cholangitis or acute pancreatitis
• LFTs + US abdomen: determine probability of stones
• Predictors: dilated CBD, raised bilirubin, acute cholangitis,
GB stones
• If intermediate probability, do EUS or MRCP
• Proceed to ERCP if diagnosed or high probability
32

33. Other Complications
• Acute cholangitis
• Suspect based on Charcot’s triad: jaundice, RHC pain, fever
• Do FBC, CRP, LFT, US abdomen
• Confirm CBD stone with EUS if necessary
• Acute pancreatitis
• Suspect if abdominal pain, abnormal LFTs, raised amylase
• Confirm CBD stone with EUS if necessary
• Proceed to ERCP if CBD stone diagnosed
33

34. Asymptomatic Pancreatic Cysts
AGA Guidelines 2015
34

35. Initial Assessment
• Estimated 15% prevalence, 25% if > 70 years
• Most often detected incidentally or during screening
• Risk of malignant transformation 0.25% per year
• Preferred imaging modality: MRI pancreas
• High risk features:
• Size > 3cm
• Dilated main pancreatic duct
• Solid component
35

36. Further Management
• If no high risk feature, repeat MRI in 1 year, then
every 2 years up to 5 years
• If no change at 5 years, stop surveillance
• If high risk feature, do EUS-FNA
• If no concerning result, surveillance as above
• If concerning result, consider surgery as 15% will have
invasive cancer
36

37. Conclusion
• New GI guidelines
have been published
and apply primary
care
• Family physicians will
need to consider
adopting them in
their daily practice
37

38. Thank
You
Questions?
38