Case Studies in Luminal Gastroenterology Adam Harris Consultant Gastroenterologist The Spire Tunbridge Wells Hospital.

Case Studies in Luminal Gastroenterology

Adam Harris

Consultant Gastroenterologist

The Spire Tunbridge Wells Hospital

Luminal Gastroenterology

Learning objectives:

1. Avoiding foregut complications of NSAIDs

2. Understanding new dietary option in IBS

3. Understanding latest drug treatments in constipation

Case Study 1

87 yr old woman with OA, nocturnal joint pains, angina & bleeding DU 1999

Needs pain relief – what do you recommend?

NSAIDs & Bleeding ulcers

• PMH of ulcer bleeding who use NSAIDs are at highest risk (20%) of re-bleeding

• Use NSAID plus standard dose PPI

• Despite this 4-8% will re-bleed in 6 months

Chan et al. New Engl J Med 2002; 347:2104-10.

NSAIDs

High Risk of Complications• PMH PUD or bleed • >65 yrs • Longterm use; high dose • More than one NSAID• Co-prescribed steroids, clopidogrel or

warfarin• Serious co-morbidities

Risk of gastro-duodenal ulcer

Placebo + Aspirin

Naproxen +Aspirin

Celecoxib +Aspirin

8% 27% 19%

NSAIDs & PPIs

4 points to remember:1. PPIs decrease risk of NSAID-associated GU &

DU cf placebo2. PPIs equally effective whether non-selective

NSAIDs or COX-2 inhibitors3. PPI co-therapy is effective in healing &

preventing recurrent ulcers with long term NSAIDs

4. PPIs decrease risk of NSAID-associated bleeding

Aspirin 4 points to remember:

1. Aspirin increases risk of UGIB 4 fold

2. Aspirin + other NSAID increases risk 8 fold

3. No difference in RR with EC or “junior”

4. Eradication of H pylori decreases risk of ulcer

Lai et al. New Engl J Med 2002; 346: 2033-38

McQuaid KR, Laine L. Am J Med 2006; 119: 624-38

Arora G et al. Clin Gastro Hepatol 2009; 7: 725-35

Case Study 2 24 yr old female with 1-2 year of recurrent low abdominal pain, bloating & intermittent watery diarrhoea

Unemployed & lives alone

Normal examination

Blood tests, urine & stool culture normal

Faecal calprotectin <50

Low FODMAP diet

• Fermentable, Oligo-, Di-, Mono-saccharides and Polyols

• Comprise fructose, lactose, fructans, galactans & polyols

• Low FODMAP diet developed at Monash University in Melbourne, Australia

FODMAPs in diet

• Fructose eg fruits, honey, corn syrup• Lactose eg diary• Fructans eg wheat, onion, garlic• Galactans eg beans, lentils, legumes• Polyols eg sorbitol, avocado, apricots, plums

Low FODMAP

• FODMAP CHO trigger changes in fluid content & bacterial fermentation in bowel leading to symptoms in susceptible individuals

• Follow low FODMAP diet to eliminate fermentable carbohydrates; trained dietician required.

• Eliminate from diet for trial period then re-introduce each FODMAP carbohydrate gradually & record symptoms

• Reported (by enthusiasts) that up to 70% of patients report improvement in symptoms

Case Study 3

28 yr old woman with 5 yr history of constipation (BO 2 x/wk) with straining & passage of hard stool; bloating & low abdo discomfort

No incontinence. No neurological illness.

Examination & blood tests normal.

Tried fibre, lactulose, Movicol, Senna, bisacodyl with limited or no benefit.

Differential Diagnosis?

Differential Diagnosis?

• IBS-C• Idiopathic Slow Transit Constipation• Functional Outlet Obstruction

Investigation?

Colonic Transit Marker Study

IBS-C ISTC Functional

Outlet

Obstruction

Treatment Options

• IBS-C

linaclotide (Constella)

• ISTC

prucalopride (Resolor)

• Functional Outlet ObstructionFurther assessment; surgery; biofeedback

Prucalopride

• 5-HT4 receptor agonist with entero-colonic kinetic activity; not a laxative

• Women only• Works within 2-3 hours• ↑ spontaneous bowel movements: 67% vs

39% placebo (p<0.001)• Improves symptoms of pain, bloating,

straining & tenesmus

Prucalopride

• 2mg od for 28 days • If no response: do not continue• 1mg od: women>65 yr; liver/renal failure• AE: nausea; headache; abdo pain;

diarrhoea• Cost: 28 x 2mg ≈ £60

Linaclotide

• Guanylate cyclase-C agonist• Reduces visceral hypersensitivity, increases

intestinal secretion & accelerates transit• Treatment of moderate-severe IBS-C in adults• One capsule (290 mcg) od 30 mins before meal• Interaction: OCP, thyroxine• Adverse effect: diarrhoea (<20%)• Cost: £37.56 for 28 days

Linaclotide• 47% decrease in abdo pain over 26 weeks

(p<0.001 vs placebo)1

• 40% improvement in bloating over 26 weeks (p<0.0001 vs placebo)1

• Increase in spontaneous bowel movements from 1.7 to 5.7 weekly over 12 weeks (p<0.0001 vs placebo)2

• Improvement in QoL (p<0.01 vs placebo)

1. Quigley EM et al. Aliment Pharmacol Ther 2013; 37:49-61

2. Chey WD et al. Am J Gastroenterolo 2012; 107: 1702-12

Luminal Gastroenterology

Learning objectives:

1. Avoiding foregut complications of NSAIDs

2. Understanding new dietary option in IBS

3. Understanding latest therapies in constipation