DDW: NOTES worth a mention

Removing a gallbladder through the mouth? That's how natural orifice translumenal endoscopic surgery (NOTES), a new surgical procedure that even its backers call "a bit unorthodox," currently being tested, would work. The doctor would insert a tube down the esophagus, make a small incision in the stomach or digestive tract to access the abdominal cavity and take the organ out.

The idea is that the procedure would be easier on patients because it is less invasive and would thus reduce recovery time, be less uncomfortable, and leave virtually no visible scarring. It could also be used for gastric bypass, fallopian tubal ligation, and ovary removal. Some operations might be done via the rectum or vagina. (See more on this subject in ACP Hospitalist.)

This initiative is from the Natural Orifice Surgery Consortium for Assessment and Research, a joint effort supported by the American Society for Gastrointestinal Endoscopy and the Society of American Gastrointestinal and Endoscopic Surgeons.

--By Paula S. Katz, special to ACP Internist

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DDW: Managing IBS

CHICAGO--Because physicians are unlikely to cure irritable bowel syndrome (IBS), their most important interventions are to listen to the patient, explain a little of the pathophysiology of IBS so the patient knows she's not crazy, set appropriate expectations, and establish an effective patient-physician relationship, said Philip Schoenfeld, MD, during "New and Emerging Approaches to the Management of IBS" at Digestive Disease Week.

Instead of just writing a prescription for Prozac when he feels it's necessary, he shows the patient an image of the body that clarifies a brain-gut connection to validate that there may be a defect in how the gut communicates with the brain. Then he says, "And here's a medicine to modify how the brain receives it." In those circumstances he said the vast majority of his patients are willing to give the medication a try.

After walking attendees through the pros and cons of currently used medications, Dr. Schoenfeld offered his take on other treatments:

Peppermint oil: This "has pretty darn good data" showing 60% of patients' symptoms are likely to improve compared with placebo. His warning: Be sure the patient doesn't bite the tablet. "It tastes horrible and gives incredible heartburn," he said.

Probiotics: Evidence isn't that good for probiotics because it's a "mishmash of information" using different strains, although he emphasized that he's not saying it is ineffective--just that data don't show effectiveness. The only one that showed efficacy, Dr. Schoenfeld said, and that he uses is Align's bifidobacterium infantis 35624.

Isphagula husk: He called this moderately effective, but urged caution because patients can get more bloated.

--By Paula S. Katz, special to ACP Internist

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DDW: Fecal incontinence

CHICAGO--Lack of physician training and enthusiasm are the main hurdles to using biofeedback to help patients suffering from fecal incontinence, said Satish Rao, MD, PhD, during a presentation at Digestive Disease Week yesterday.

Physicians hesitate despite studies that show biofeedback shows improvement relative to pelvic floor exercises and that this is a problem of brain-gut axis that can be addressed through biofeedback, he said during his presentation on "Behavioral Therapies for Fecal Incontinence."

"[They wonder] does it really work? Are we doing some voodoo?" he said.
He said physicians who want to try biofeedback should recognize that it's labor intensive and that they will need six sessions with the patient before seeing improvement. He also recommended using guidelines, establishing clear goals, and supplying supportive therapy (e.g., laxatives, diet, and exercise).

--By Paula S. Katz, special to ACP Internist

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DDW: Point-of-care Web sites

CHICAGO--ACP's online resources got a major shout out at a session on "Evidence-based Answers at the Point-of-Care" held yesterday at Digestive Disease Week.

When discussing what he called physicians' "new generation of tools" to increase quality of care and enhance physician learning, Benjamin Krevsky, MD, listed several point-of-care Web sites including ACP Medicine. In addition, he walked attendees through how to use PIER to answer a question about a patient with upper gastrointestinal bleeding. (The answer was to recognize the need for endoscopic therapy.)

Here are the other sites he recommended:

Access Medicine
Dynamic Medical
Emedicine
Essential Evidence Plus
First Consult/MDConsult
Ovid
PogoFrog
UptoDate


He said pogofrog, one of his favorites, is a Google-run site just for physicians. For example, he said a regular Google search yielded 90,000 hits for a search on a specific medical topic; the same search on pogofrog gave him 10.

--By Paula S. Katz, special to ACP Internist

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DDW: Who are your IBS patients?

They are likely problem-solvers, the ones always pitching in for the neighborhood bar-b-que or organizing the carpool to a kids event. They look for control, and when it comes to irritable bowel syndrome (IBS), that's a major stumbling block, said Jeffrey M. Lackner, a clinical psychologist specializing in working with IBS patients and director of the Behavioral Medicine Clinic at the University at Buffalo (NY). He recommended cognitive behavior therapy for patients who:

• Prefer a non-drug option,
• Have persistent IBS without significant relief from first-line treatments,
• Have moderate to severe symptoms,
• Have an impaired quality of life, or
• Display illness behaviors such as seeking reassurance or requesting testing.

During today's session with Dr. Tillisch he said IBS patients need to learn coping strategies to manage controllable as opposed to uncontrollable factors. One way, he said, is to ask, "What can I do about this," then accept that answer or at least resign yourself to whatever that is. Cope by commiserating with friends or using relaxation techniques.

"Try to handle the unpleasantness of the problem versus solving or controlling it," he said.

--By Paula S. Katz, special to ACP Internist

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DDW: Signs of the times

Catching my eye at the meeting:

• The Internet stations are among the busiest areas at the convention center
• It looks like something you'd see at Best Buy, but not really: The high-definition endoscopy screens.
• Only at a digestive conference? BeneFiber samples in the Exhibit Hall.
  

--Paula S. Katz

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DDW: Beyond drugs for IBS

Given all the high-tech and traditional drug therapy sessions available, why did some attendees at Digestive Disease Week attend a session on "Non-pharmacologic Treatments for Functional GI?" Here were some of their answers:

"I see a lot of IBS and I'm finding drugs don't seem to work well."

"I'm looking for pathways other than drugs."

"I'm interested in multidisciplinary approaches."

During the session they found out the pros and cons of acupuncture, hypnotherapy, and herbal therapies such as peppermint oil from presenter Kirsten Tillisch, MD.

She said physicians need to know how to approach their IBS patients who are going to health stores and picking up products saying they address IBS, or try eliminating foods on their own, she said. "It's becoming really hip to eliminate gluten," she said. She said she doesn't use elimination diets without the help of a nutritionist.

She also talked about the benefits of referring patients for psychological therapy--when they're willing--as well as working closely with a few psychologists to best coordinate care.

--By Paula Katz, special to ACP Internist

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DDW: Nonalcoholic steatohepatitis

Although everyone would like a quick fix to treat nonalcoholic steatohepatitis (NASH) and its attendant problems with blood pressure and diabetes, the best bet seems to be the one that can be hardest to sell to patients: weight loss.

The question then becomes, which is the most effective way to make that happen? During today's session on "Approaches to Weight Loss in NASH: When and How Aggressive," presenter Kittichai Promrat, MD, made the case for lifestyle intervention. He said a recent study he was involved with showed a 9.3% weight reduction in patients who received a portion-control diet, a meal plan, a pedometer to measure steps, and other interventions versus 0.2% of those who did not.

The major challenge after that, he said, is finding a self-regulating program that will help patients maintain that weight loss.

Is one diet better than another? According to Dr. Promrat, the answer is no. He cited a recent study that found that while a low-carb diet reduced more fat initially, once patients reached 7% weight loss, the amount of fat reduction was the same. And because compliance is so difficult, he recommended that doctors be flexible.

"A diet that fits the patient's personal preference and can be maintained is best," he said.

Before recommending surgery...
At that same session, Raphael Merriman, MD, urged caution when looking to bariatric surgery to resolve NASH. He said that's a very real concern given that in 2008 there were more than 200,000 bariatric surgeries, what he called "a staggering number."

Although some data show promising results with certain types of bariatric procedures, he said more is needed to make the recommendation. He noted that the surgery's main goal is weight loss--not fixing NASH. In fact, not all patients undergoing the procedure have fatty liver disease.

--By Paula Katz, special to ACP Internist

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News from Digestive Disease Week: PPIs and CAT

CHICAGO--Is there a link between acid-reducing meds and hip fractures?
A new study released here today reports that taking even less than one proton pump inhibitor (PPI) or histamine-2 receptor antagonist (H2RA) could increase your patients' risk of hip fractures.

Fracture risk rose 12% for those taking less than one pill a day, 30% for those taking the usual dose of one pill a day, and 41% for those taking more than one pill a day among patients studied at the northern California Kaiser Permanente integrated health-services organization. Patients with hip fractures were 30% more likely than controls to have taken PPIs and 18% were more likely to have taken H2RAs for at least two years.

While risk seemed greatest among patients 50-59 years old, the greatest number of fractures was among the 80- to 89-year-old group, which had a lower PPI-relative risk.

"Patients taking acid suppressors should continue treatment at the lowest effective dose. However, they should discuss treatment options with their doctor if they are at risk of osteoporosis," said Douglas A. Corley, MD, of Kaiser Permanente in San Francisco, and the study's lead investigator. The study looked at up to 10 years of exposure to PPIs and H2RAs for 33,752 cases.

New CAT cautions: The risks of giving complex antithrombotic therapy (CAT) to your patients may be higher than you think.

New data released here today shows that veterans aged 60-99 who were prescribed aspirin-antiplatelet therapy or aspirin-anticoagulant therapy were two to two-and-a-half times more likely to suffer significant upper gastrointestinal events (UGIE) like bleeding or perforation. The least harmful CAT combination was anticoagulant-antiplatelet therapy.

However, younger patients (those between ages 60 and 69) who received CAT were at highest risk of experiencing UGIE, and their risk of bleeding within one year of taking the drugs was four times higher. These patients were likely to be on aspirin-anticoagulant-antiplatelet therapy for a history of ischemic heart disease, hypertension, diabetes, and peripheral artery disease.

"The observed magnitude of UGIE risk suggests an unfavorable risk/benefit profile for CAT in the short term," says Neena S. Abraham, MD, lead investigator of the study, conducted with the Michael E. DeBakey VA Medical Center and Baylor College of Medicine in Houston. The study was conducted from Jan. 1, 2003 to Sept. 30, 2006.

--By Paula Katz, special to ACP Internist

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News from Digestive Disease Week: Crohn's disease

CHICAGO--IBD radiation risk: Are your patients with ulcerative colitis (UC) or Crohn's disease getting too much radiation exposure?

Patients with Crohn's--who often have complications that require radiologic tests sometimes starting at a young age--were exposed to twice as much radiation as patients with UC, according to the results of a study of 500 patients with Crohn's and UC presented here today.

Between 66% and 75% of the radiation came from CT scans, which produce more radiation than X-rays or MRIs, but do a better job diagnosing complications associated with irritable bowel disease, according to the study's lead researcher Karen Kroeker, MD, fellow with the division of gastroenterology at the University of Alberta.

She said the problem could be addressed by finding new diagnostic tools such as intestinal ultrasound that could eventually replace CT scans.

Meanwhile, she suggested doctors keep closer tabs on what their patients are experiencing. "Physicians need to be aware of how many CT scans their patients have been exposed to so that they can determine the risk of additional CT scans," she said.

The environment and Crohn's: Pollution, changes in diet, or smoking habits could be responsible for the 48.5% increase in Crohn's disease in patients under age 19, according to another study released today.

Investigators tracked nearly 6 million patients in northern France between 1988 and 2005. While the incidence of Crohn's increased 20.7% overall, that rate had stabilized after 10 years. Not so for people under age 19; that rate had a linear and dramatic increase.

Future studies should look at why Crohn's disproportionately affects young people, said Guillaume Savoye, MD, EPIMAD registry and department of gastroenterology, University Hospital, Rouen, France.

--By Paula Katz, special to ACP Internist

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News from Digestive Disease Week: Patients often in the dark about NAFLD

CHICAGO--Primary care physicians should take more initiative in talking to their patients about how they can avoid non-alcoholic fatty liver disease (NAFLD), according to the results of a new study released at Digestive Disease Week here today.

In what the lead researcher called a "disturbing and significant" finding, 98% of 5,000 outpatient adults studied said their physicians had never talked to them about NAFLD. The survey also found that 95% did not know that fat in the liver could lead to serious health problems and 80 percent had never heard of cirrhosis.

Prevention is critical since treatment options are limited for "this silent but deadly disease," said Sury Anand, MD, chief of gastroenterology at Brooklyn Hospital Center. He recommended that physicians encourage their patients to maintain healthy weight through diet and exercise to avoid NAFLD just as they limit carbohydrate intake to prevent diabetes.

NAFLD is the most common cause of abnormal liver enzymes, one of the most common causes of cirrhosis of the liver, and the 10th leading cause of death.
--By Paula Katz, special to ACP Internist

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Digestive Disease Week: Colorectal cancer detection

Digestive Disease Week is underway in Chicago this week, and our correspondent Paula Katz will be dispatching news from the meeting over the next few days. Studies on tools to detect colorectal cancer are among today's research highlights:

Fewer perforation risks: Rates of perforation, a serious complication of colonoscopy, are low and decreasing, according to the results of a new study. The study analyzed 17 abstracts that included 274,265 colonoscopies to find an accurate measure of perforation rates, which other research has found ranged from 0.01 percent to 1.1 percent. This study found that the perforation rate in therapeutic colonoscopies was 0.066 percent (one in 1,500) and .017 percent in diagnostic colonoscopies (one in 6,000) with a trend towards decreasing perforation rates for both procedures. Further studies should be done in community and university settings, stratify patients by different risk factors and indications, and follow up at day seven or 30 to capture all complications, said researcher S. M. Abbas Fehmi, MD, clinical faculty at the University of Pennsylvania School of Medicine.

Advantage deep sedation? Endoscopy found 25% more large polyps in patients who had deep sedation during colonoscopy than those who had the procedure performed under moderate conscious sedation, according to a new study. Researchers examined a database of endoscopy reports from 61 practice sites from patients who had average risk screening colonoscopy and controlled for age, gender, and race. Researcher Katherine M. Hoda, MD, senior fellow, department of gastroenterology, Oregon Health & Science University, said it's unclear if those polyps would have been found if the patients were under moderate sedation and that more studies are needed since this study was small and not randomized.

Three-year follow-up: Patients who had advanced pre-malignant polyps removed during colonoscopy had a substantial rate of advanced polyp detection at second colonoscopy, which guidelines recommend after a three-year interval, according to the results of another study. Removal of polyps with villous and high-grade features was particularly predictive of more future advanced polyps and increased susceptibility to cancer. The rate of discovering advanced polyps at the third colonoscopy was less than the second colonoscopy. However, researchers said it was still high enough to suggest that continued exams are an efficient use of resources.

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