Slides from my talk at gutCARE symposium 2017: Updates in GI Practice Guidelines for the Family Physician. The symposium focused on international gastrointestinal guidelines published in the last 3 years, and distilled the portions relevant to primary care. My talk covered the following topics: Helicobacter Pylori Infection, Acute Diarrhea in Adults, Colorectal Cancer Screening, Gallstones and Pancreatic Cysts.

1. Dr Jarrod Lee
Gastroenterologist &
Advanced Endoscopist

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

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
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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.
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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
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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%
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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
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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
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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
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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
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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”
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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
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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
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21. Tiered Ranking of Screening Tests
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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
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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
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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
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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)
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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
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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
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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
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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
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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
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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
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34. Asymptomatic Pancreatic Cysts
AGA Guidelines 2015
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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
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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
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37. Conclusion
• New GI guidelines
have been published
and apply primary
care
• Family physicians will
need to consider
adopting them in
their daily practice
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38. Thank
You
Questions?
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