Abstract
The 12th Update in Gastroenterology and Hepatology for the Primary Care Practitioner is an annual course organized by the Division of Gastroenterology and Hepatology at the University of California, Davis, and held in beautiful Monterey, California. The course was geared towards primary care physicians, nurse practitioners and other allied health professionals. The goals of this symposium were to provide current information regarding the diagnosis and management of digestive diseases commonly seen in the primary care setting and to provide practical guidelines for disease management. Topics covered during this symposium included viral hepatitis, alcoholic liver disease, hepatocellular carcinoma, dysphagia, gastroesophageal reflux disease, chronic diarrhea, inflammatory bowel disease, irritable bowel syndrome, dyspepsia, gastroparesis and bariatric surgery. The course was organized into two sessions each morning, over 2 days, with three or four 30-min lectures. A brief question-and-answer session followed each lecture.
Session one
Session one focused on liver diseases. Christopher Bowlus, Associate Professor at The University of California, Davis (UC Davis), discussed the current approach to abnormal liver tests and their role within the screening, assessment and diagnosis of specific liver diseases. The take-home messages were:
• Liver ‘function’ is not easily measured;
• Liver structure (fibrosis) predicts risk of developing cirrhosis;
• The model for end-stage liver disease (MELD) score predicts liver-related mortality after cirrhosis develops.
Emphasis was placed on the overlap of clinically significant alanine aminotransferase values with current ‘normal’ values and the need to better define normal values in each individual.
The second lecture in this session was given by Lorenzo Rossaro, Professor of Internal Medicine at UC Davis, who reviewed the current indications for treatment of hepatitis C. The new approach of an ‘on-treatment’ response to determine the success and individual duration of therapy, as well as the additional benefit of adding a third drug (under investigation) to the sustained virological response (or cure), was emphasized. The importance of ‘dual’ listing for liver transplantation in order to increase access to transplants for patients in northern and central California was also discussed. UC Davis and UC San Diego had the shortest waiting time and lowest MELD scores at time of transplant in California.
The third lecture was on the management of hepatitis B virus (HBV) for primary care providers and was given by Norah Terrault, Associate Professor at UC San Francisco. The focus of her transplantation was on the different patterns of antiviral potency and the risks of drug resistance to the oral medications available for treatment: adefovir, entacavir, tenofovir (recently approved) and telbivudine. She also gave an excellent review of treatment of HBV in ‘special’ populations, such as cirrhotics, pregnant women and patients undergoing chemotherapy.
The fourth lecture highlighted the issues that are related to health disparities and strategies to overcome them in hepatocellular carcinoma (HCC). Moon Chen Jr, Professor of Hematology and Oncology at UC Davis compared AIDS with HCC in relation to etiology (both are viral – HIV and HBV), treatment with antivirals, sexual transmission and detection via a blood test. Disparity in AIDS between African–Americans and Caucasians is 15:1, while in HCC between foreign-born Asians and Caucasians it is 68:1. He emphasized the most effective strategy for HCC control to be universal HBV vaccination.
The final lecture of the liver session was given by Valentina Medici, Assistant Professor at UC Davis, on alcoholic liver disease, with an emphasis on diagnosis and management. Steroids and pentoxifylline are most commonly used for the treatment of alcoholic hepatitis, although the antioxidant and glutathione precursor S-adenosylmethionine (SAMe) is under investigation at UC Davis as a possible new drug for the condition.
Session two
Session two focused on evaluating the challenging gastrointestinal disorders of diarrhea, dysphagia and irritable bowel syndrome (IBS). This session began with a very comprehensive discussion on the approach to patients with chronic diarrhea by Otis Stephen, Assistant Professor at UC Davis. Emphasis was placed on the importance of a detailed history and a systematic approach to testing in the work-up of chronic diarrhea due to the very broad differential diagnosis. A detailed history and physical examination, together with a few targeted initial tests, can determine the underlying cause of diarrhea in at least 80% of patients. Additionally, categorizing the diarrhea into inflammatory, secretory, osmotic, steatorrheal or functional diarrhea may further aid in making the diagnosis. Measuring 24-h stool weight to determine true organic diarrhea versus functional diarrhea is also a helpful tool. The methodology and usefulness of common stool tests, such as tests for fecal leukocytes, lactoferrin, calprotectin, ova and parasites, and Clostridium difficile, were also reviewed.
The second lecture of this session was a case-based presentation on the diagnosis and treatment of dysphagia by course co-director, George Meyer. This very informative lecture covered the clinical presentation and treatment of numerous causes of dysphagia, including Zenker’s diverticulum, esophageal spasm, polymyositis, dermatomyositis, scleroderma, achalasia, Schatzki ring, esophageal malignancies, eosinophilic esophagitis and para-esophageal hiatal hernias. The globus syndrome was also addressed, emphasizing that globus is not dysphagia. Eosinophilic esophagitis, which was an uncommon diagnosis 10 years ago, is now one of the most common causes of dysphagia. It commonly presents as recurrent solid-food dysphagia in patients who are in their 20s and 30s and have a history of asthma or allergies. There are a growing number of elderly patients also being diagnosed with eosinophilic esophagitis.
The third lecture of session two was an entertaining presentation on the pathophysiology and treatment options for IBS by Michael Lawson of Kaiser Permanente Medical Group. The numerous proposed mechanisms for the pathophysiology of IBS, including postinfection, motility disturbances, genetic predisposition, learned behavior and visceral hypersensitivity due to increased gut-to-brain messaging, were reviewed. The current medical treatment options for pain, diarrhea and constipation were discussed, with particular attention to adolescent IBS (ADLIBS). The therapeutic approach to ADLIBS at Kaiser Permanente involves a combination of exercise, yoga, Pilates, education, relaxation with self-guided imagery and a motivational movie. This approach significantly decreased the frequency of visits to doctors by children with IBS from this Kaiser Permanente group and increased their quality of life. Their experience suggests that a combination of education and cognitive behavioral therapy may be effective for relieving IBS, particularly in school-aged children and may help to decrease the prevalence of IBS in adults.
Session three
Session three was on day 2 of the conference and encompassed lectures on inflammatory bowel disease (IBD), gastroesophageal reflux disease (GERD) and the surgical approach to obesity. The first lecture was a comprehensive update on IBD by John McCracken, staff physician at Kaiser Permanente. The pathogenesis, initial work-up, extraintestinal manifestations, disease complications and medical treatment options for IBD were all reviewed. Emphasis was placed on ruling out C. difficile and cytomegalovirus infections, as well as evaluating for NSAID use in patients with refractory disease or in flare-ups of previously quiescent disease. There is recent evidence of an increased prevalence of C. difficile in IBD patients, including patients without prior antibiotic use. A review of medical therapy for IBD emphasized that, while prednisone is effective in inducing clinical remission, it is not effective in maintaining remission and it does not induce mucosal healing. Side effects of steroids are the leading malpractice complaint related to IBD. Hence, special efforts should be made to refrain from using prednisone if possible. The 5-aminosalicylic acid compounds, methotrexate and azathioprine, remain as effective therapies for IBD. Use of the TNF antagonists, infliximab and Humira® (adalimumab), were also reviewed.
The second lecture addressed the growing trend of bariatric surgery as an approach for obesity. This presentation by Mohammed Ali, Director of Minimally Invasive Surgery at UC Davis, encompassed the criteria for bariatric surgery, a review of the various surgical options for weight loss and the potential consequences of bariatric surgery, including micronutrient malabsorption, marginal ulcers and an – as yet unexplained – increase in suicides. While adjustable gastric banding (LAP-BAND®) is a less invasive approach, it has considerable limitations, such as significant long-term complications and poor overall weight loss, as identified in recent long-term European studies. Hence, Ali did not recommend this procedure for most patients. Potential benefits of weight loss from bariatric surgery include a significant risk reduction (>30%) for all mortality and an even greater reduction in the risk of cardiovascular mortality at 10 years. Moreover, when referring patients for bariatric surgery, Ali recommended multidisciplinary programs that will ensure long-term follow-up and provide close communication between the surgeon and the referring physician.
The third lecture of session three was a detailed discussion on the evaluation and treatment of the GERD by Juan Carlos Garcia, Clinical Director of Gastroenterology at UC Davis. Typical and atypical symptoms of GERD, complications and diagnostic testing, including endoscopy, narrow-band imaging for Barrett’s surveillance, barium studies, manometry and Bravo™ capsule, were reviewed. Advances in pH testing, including high-resolution manometry and impedance testing, have improved the detection of acid reflux, nonacid reflux and weakly acid reflux, and may help clarify their association with GERD symptoms. Current medical and surgical therapies for GERD were reviewed. Proton pump inhibitors (PPIs) are effective in the management of GERD and their increased use has been associated with a decreased number of esophageal dilations for peptic strictures over time. However, recent reports on the long-term use of PPIs suggest these medications are associated with increased rates of C. difficile, enteric infections and hip fractures. Thus, recommendations for the long-term use of PPIs need to be revised. There was also a brief discussion on the GABA agonist, baclofen, which has shown promise as an antireflux agent in patients refractory to PPIs, primarily by decreasing transient lower esophageal relaxation.
The final session focused on gastroparesis and dyspepsia. Amar Al-Juburi, Assistant Professor at UC Davis, provided a detailed discussion on the causes and management of gastroparesis. He discussed appropriate dietary modifications for gastroparesis, such as frequent, small-volume meals that are low in fat and fiber or liquid diets supplemented with vitamins and minerals. He also recommended avoidance of alcohol and tobacco. Current testing and drug therapy for gastroparesis was reviewed. Drug therapy for gastroparesis is limited by the potential side effects of promotility agents, such as metoclopramide, and limited access to alternative agents, such as domperidone, tegaserod and cisapride. Management of refractory gastroparesis with pyloric Botox® injections, percutaneous endoscopic gastrostomy/jejunostomy tube placement and novel prokinetic agents, such as levosulpiride, GM-611, and dexloxiglumide, were reviewed. Particular attention was paid to the use of a gastric electrical stimulator (Enterra device), a treatment modality currently offered for a refractory gastroparesis at UC Davis. Current data suggest that this device can improve symptoms of gastroparesis, decrease requirements for nutritional support, medications and hospitalization, and lower levels of glycosylated hemoglobin.
The final lecture of the course was an excellent presentation on dyspepsia and the effective evaluation and management of abdominal pain by Cecilia Terrado, Assistant Clinical Professor at UC Davis. This lecture encompassed a discussion on the differential diagnosis of abdominal pain and a diagnostic strategy for dyspepsia. The treatment and testing for Helicobacter pylori was covered in detail. Furthermore, excellent algorithms were provided for the evaluation and treatment of dyspepsia.
Financial & competing interests disclosure
The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this manuscript.