Management of gastrointestinal disease. Returning it to primary care.

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VOL 50: MAY • MAI 2004d Canadian Family Physician • Le Médecin de famille canadien 685

Editorials

Management of gastrointestinal disease

Returning it to primary care

Nigel W. Flook, ^MD, ^CCFP

aiting lists across Canada continue to grow for gastroenterology consultations and endoscopies. Th ere are many com- plex reasons for the long delays our patients expe- rience, but human resources will remain a critical issue in the years to come. Fewer than 500 gastroenterologists are available to assist more than 32 million Canadians.

Chronic gastrointestinal (GI) disorders are common in primary care, and the prevalence of some, such as gastroesophageal reflux disease (GERD), is increasing. Th e most common gastrointestinal malignancies are colorectal cancer (CRC), gastric cancer, pancreatic cancer, and esophageal cancer.

Th ese cancers are rare in younger people, but the incidence of each increases with age. Our popula- tion is aging, and Canadians are living longer with chronic illnesses and long-term treatments, many of which can cause side eﬀ ects, including upper and lower GI symptoms. If these trends continue, Canadian primary care will be increasingly domi- nated by GI disorders.

Th is increased workload, along with both legitimate and unrealistic expectations and fears, will increase referrals to gastroenterologists. These fears often centre on the relationships between common GI problems and much less common GI malignancies. The linkage between Helicobacter pylori infection and both peptic ulcers and gastric adenocarcinoma (along with limitations in public funds available for noninvasive H pylori testing) have shifted patients’ investigations toward endoscopy. Th e new guidelines¹ for CRC screening will add further pressure to already limited resources as patients line up for screening endoscopies. Th e relationship between chronic GERD, Barrett esophagus, and esophageal adenocarcinoma will add substantial pressure for consultations.^2,3 Surveillance of patients with histories of inﬂ ammatory bowel disease (IBD) will similarly increase referrals.

Considerable overlap can be found in the symptoms of serious GI diseases and the symptoms of benign or functional GI diseases. Symptoms alone cannot distinguish endoscopy-negative GERD and mild esophagitis from high-grade erosive esophagitis. Symptoms cannot be used to reliably discrimi- nate peptic ulcer disease from functional dyspepsia or GERD.⁴ Symptoms of irritable bowel syndrome (IBS) can be diﬃ cult to distinguish from IBD, dyspepsia, hepatobiliary disease, celiac disease, or even GI malignancy.⁵ Th is uncertainty does little to boost the conﬁ - dence of patients or their primary care physicians.

We do have the resources

Despite these concerns, about 30 000 Canadian primary care physicians are able to address these challenges. Clearly articulated clinical practice guidelines, eﬀ ective medications, accurate noninvasive investigations, and evidence-based primary care management plans are available to support primary care physicians who want to raise their threshold for referring patients with GI symptoms.

Th e CanDys Working Group published a management plan that supports primary care assessment and management of dyspepsia (Table 1).⁶ Th e Carbon 13 Urea Breath Test (C13UBT) is recommended in cases where testing is required for H pylori. Physicians can access the C13UBT throughout Canada,⁷ but patients must pay for the test in most parts of the country. Th e CanDys plan allows primary care physicians to manage most patients without referral, and it helps physicians identify those who would potentially beneﬁ t from endoscopy.⁶

An interesting strategy called “once in a lifetime”

endoscopy has been developed to determine the need for endoscopy in chronic GERD patients. Th e strategy calls for endoscopy after 5 to 10 years of GERD symptoms to identify patients who have Barrett esophagus. Patients who have Barrett esophagus aiting lists across Canada continue to

grow for gastroenterology consultations and endoscopies. Th ere are many com- plex reasons for the long delays our patients expe-

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686 Canadian Family Physician • Le Médecin de famille canadien dVOL 50: MAY • MAI 2004

Editorials

will need endoscopic surveillance every few years to watch for dysplastic changes signaling the develop- ment of adenocarcinoma of the esophagus.² Most patients (96%) with chronic GERD symptoms will not have Barrett esophagus and can be safely managed in primary care without further endoscopy, unless there is a substantial change in their condition.⁴

Th e Rome II Criteria, along with alarm features and age, can be used to identify patients whose clinical picture suggests IBS.⁵ Observing stability in the symptoms over time strengthens the working diagnosis. Th e ability to monitor our patients over long periods is a powerful primary care tool. Fear of missing IBD and malignancy is at the root of many unnecessary referrals for IBS patients who could be diagnosed and managed in primary care. Are we not as skilled as gastroenterologists in addressing the psychosocial issues that accompany half of IBS cases?⁷ Do we lack the skills to distinguish the clinical presentation of CRC and IBD from the symptoms of IBS? I believe primary care physicians are expert in these matters and have the skills to distinguish these conditions, particularly when we pro- vide services over longer periods.

Occult cases of celiac disease can be identiﬁ ed by personal and family history taking, along with measurement of antibodies against transglutamin- ase and careful investigation of patients presenting with low levels of iron or folic acid (page 719).

Th e new guidelines for CRC screening will allow us to target patients who need referral and con- fidently reassure those who do not.¹ Colorectal cancer is the third most common potentially fatal malignancy, so there will be a legitimate need for many endoscopic assessments of patients who have symptoms suggesting presence of CRC.

Looking for a quick ﬁ x

Effi cient use of gastroenterology resources will be increasingly important if we expect to meet our patients’ needs in the coming years. I believe primary care physicians have the necessary tools and are well positioned to be responsible for assessing and managing most patients with GI disorders without referral. Sensible clinical management plans, effective treatments, and noninvasive diagnostic tests will add confi dence to our assessment and management plans while we fi nd the right patients for referral.

We can no longer refer patients with GI symptoms simply because we want to duck responsibility or because we lack quick fi xes. Th is is particularly true when the probability of serious disease is low. We have accepted other equally diffi cult challenges in prostate- specifi c antigen testing and breast cancer screening.

Assessing and managing IBS and dyspepsia (including chronic GERD), and coordinating screening and surveillance plans for targeted GI diseases are all important activities that must be returned to primary care.

Dr Flook is President of the Canadian Society of Primary Care Gastroenterology.

Competing interests

Dr Flook has received speaker’s honoraria and is on the advisory board of AstraZeneca Canada, GlaxoSmithKline, Pfizer Canada, Novartis Pharmaceuticals Canada, Altana Pharma, and Solvay Pharma, and has received

speaker’s honoraria from Abbott Laboratories.

Correspondence to: Dr Nigel Flook, University of Alberta Hospital, 1A1.11, 8440-112 St, Edmonton, AB T6G 2B7 Th e opinions expressed in editorials are those of the authors and do not imply endorsement by the College of Family Physicians of Canada.

References

1. Flook N. Canadian colorectal cancer. Summary of screening guidelines. Can Fam Physician 2004;50:592-3.

2. Sampliner RE, Practice Parameters Committee of the American College of Gastroenterology. Updated guidelines for the diagnosis, surveillance, and therapy of Barrett’s esophagus. Am J Gastroenterol 2002;97:1888-95.

3. Axon AT, Bell GD, Jones RH, Quine MA, McCloy RF. Guidelines on appropriate indications for upper gastrointestinal endoscopy. Working Party of the Joint Committee of the Royal College of Physicians of London, Royal College of Surgeons of England, Royal College of Anaesthetists, Association of Surgeons, the British Society of Gastroenterology, and the Th oracic Society of Great Britain. BMJ 1995;310:853-6.

4. Th omson AB, Barkun AN, Armstrong D, Chiba N, White RJ, Daniels S, et al. Th e prevalence of clinically signiﬁ cant endoscopic ﬁ ndings in primary care patients with uninvestigated dyspepsia: the Canadian Adult Dyspepsia Empiric Treatment—Prompt Endoscopy (CADET-PE) study. Aliment Pharmacol Th er 2003;17(12):1481-91.

5. Holten KB, Wetherington A, Bankston L. Diagnosing the patient with abdominal pain and altered bowel habits: is it irritable bowel syndrome? Am Fam Physician 2003;67:2157-62.

6. Veldhuyzen van Zanten SJ, Flook N, Chiba N, Armstrong D, Barkun A, Bradette M, et al. An evidence- based approach to the management of uninvestigated dyspepsia in the era of Helicobacter pylori. Canadian Dyspepsia Working Group. CMAJ 2000;162(12 Suppl):S3-S23.

7. Mock T, Yatscoﬀ R, Foster R, Hyun JH, Chung IS, Shim CS, et al. Clinical validation of the Helikit: a 13C urea breath test used for the diagnosis of Helicobacter pylori infection. Clin Biochem 1999;32(1):59-63.

Available from: www.isodiagnostika.com/helikit/. Accessed 2004 Mar 12.

Table 1. Primary care dyspepsia assessment Two safety areas:

1. Thumb: is the symptom source the upper gastrointestinal tract?

(is it cardiac or other?)

2. Alarm features: “VBAD”—Vomiting, Bleeding or anemia, Abdominal mass or unexplained weight loss, Dysphagia Three key decision points

1. Are acetylsalicylic acid or nonsteroidal anti-inﬂ ammatory drugs involved?

2. Is GERD (heartburn or acid regurgitation) probable?

3. Is Helicobacter pylori test positive or negative?