Ian Forgacs

Gastro-oesophageal reflux disease

Gastro-oesophageal reflux disease (GORD) is present when the passage of gastric contents into the oesophagus causes symptoms or damages the mucosa. Potent suppression of gastric acid secretion with proton pump inhibitors is a highly effective and safe treatment for many patients with symptoms associated with reflux. It would be wrong to conclude, however, that proton pump inhibitors had solved the problem of GORD. The relation between reflux symptoms, endoscopic findings, and exposure of the oesophagus to acid is not straightforward. Some patients with a convincing history of heartburn fail to respond well to proton pump inhibitors. Although symptoms may be severe, at endoscopy the oesophagus is often found to be normal, and pH studies may not disclose the cause of symptoms that persist despite treatment for acid suppression.nnApart from typical symptoms of reflux many other problems have been linked to GORD, including dysphagia, hoarseness, non-cardiac chest pain, and chronic cough. It can, however, be difficult to identify those patients who will benefit from antireflux treatment. Most serious is the increased risk of oesophageal adenocarcinoma in patients with reflux symptoms, in particular those with Barretts columnar lined oesophagus. Since the 1980s the incidence of oesophageal carcinoma has increased sixfold, more rapidly than any other common cancer.nn#### Summary pointsnnGastro-oesophageal reflux disease (GORD) is common, causes a variety of symptoms, and is associated with important diseases, including asthma and oesophageal adenocarcinomannGenetic influences and lifestyle factors such as smoking, obesity, and dietary behaviour may be involved in the development of GORDnnThe structure and function of the gastro-oesophageal junction is of key importance in reflux disease—as the condition becomes more severe, the risk of reflux during transient relaxations of the lower oesophageal sphincter rises and the volume of refluxate increasesnnRoutine endoscopy is not required for reflux symptoms in the absence of features …

Psychological approach to managing irritable bowel syndrome

> “It is more important to know what sort of person has a disease than to know what sort of disease a person has.” Hippocrates nnThe medical management of patients with irritable bowel syndrome is often unsatisfactory. Doctors are still taught that irritable bowel syndrome is a diagnosis of exclusion, and patients readily sense that they are being told that nothing is really wrong with them. Many people soon come to appreciate that the range of medical treatments available is limited in both scope and efficacy. The mood of negativity, once established, is difficult to dispel.nn#### Summary pointsnnCurrent medical treatment includes drugs that alter intestinal motility—such as antispasmodics, 5-hydroxytryptamine antagonists, antidiarrhoeals, and laxatives—and dietary changes, including fibre supplementation and identification of food intolerances.1 Response may vary, but the failure rate of these “physical” treatments is high, which may lead to the conclusion that irritable bowel syndrome has a strong psychological component. A diagnosis of exclusion has been made—again with negative, rather than positive therapeutic, connotations.nnAlthough many doctors are aware that antidepressants have been used in irritable bowel syndrome, they seem reluctant to prescribe such agents, not least because suggesting this as a valid option to patients who are clearly not depressed …

Upper gastrointestinal endoscopy performed by nurses: scope for the future?

Background: Previous researchers have shown that non-medical endoscopists can perform lower gastrointestinal endoscopy as safely and effectively as medical staff. However, it is not known if upper gastrointestinal endoscopy performed by medical and non-medical endoscopists in clinical practice yields similar results in terms of performance, patient discomfort, and satisfaction. Aim: To determine differences in the yield of diagnosis for significant disease during upper gastrointestinal endoscopy performed by nurse and medical endoscopists and to measure patient discomfort, satisfaction, and attitudes towards future endoscopy. Patients: This two part study included 3009 patients in a retrospective analysis and 480 in a prospective study. Methods: The first part of the study assessed indications for endoscopy, diagnoses, and procedures performed by medical and nurse endoscopists. In a second prospective study, 480 patients were included to determine the association between endoscopist type and sedation, patient anxiety, discomfort, satisfaction, and attitudes towards future sedation. Results: No patient refused endoscopy by either a nurse or medical endoscopist and there were no complications in either group. Nurses performed 1487 procedures and reported fewer endoscopies as “normal” than medical staff (p=0.006). Multivariate analysis showed that male sex, older age, inpatient status, dysphagia, and gastrointestinal bleeding, but not endoscopist type, were all associated with significant disease. In relation to discomfort and satisfaction, a similar proportion of patients received sedation in both groups (p=0.81). There were no differences in pre-procedure anxiety (p=0.61), discomfort during intubation (p=0.97), discomfort during examination (p=0.90), or post-procedure examination rating (p=0.79) in patients examined by medical or nurse endoscopists. Conclusion: Experienced nurses perform routine diagnostic gastroscopy safely in everyday clinical practice and with as little discomfort and as much patient satisfaction as medical staff.

Use of faecal occult blood tests in symptomatic patients

Despite serious reservations expressed during consultation, the National Institute for Health and Care Excellence (NICE) has recently issued referral guidance for suspected colorectal cancer in which faecal occult blood testing (FOBT) is recommended for certain low risk symptomatic patients.1 2 We believe that this will lead to false reassurance and delayed investigations. We should like to point out that:

CARING FOR AND ABOUT ACUTE GENERAL MEDICINE

A seismic change has occurred in the delivery of acute general medicine over the past five years, and nowhere has its impact been more dramatic than on the consultant general physician. Concern has recently been expressed about how consultant physicians are coping with the various demands on them,1 and last year the Royal College of Physicians has commissioned a national survey of all physicians responsible for receiving acute medical emergencies.2 This survey is timely as it not only provides data on the workload of consultants but also evaluates several initiatives that have been tried to address the problems of organising the care of emergency patients.nnGone are the days when consultants “on take” might be able to keep a remote hand on the tiller: they are now much more clearly accountable for the emergency service. This has brought with it a range of additional pressures at a time when the expectations of patients are higher, the demands of senior hospital managers greater, and the working patterns of junior doctors radically changed. These additional, external pressures include, in particular, a sustained rise in the number of acute medical admissions across Britain at a time when the number of hospital beds has continued to fall. The ability to squeeze …

Conference report: improving outcomes for gastrointestinal cancer in the UK

On 7 December 2015, the British Society of Gastroenterology and the Royal College of Physicians held a joint conference: GI cancer in the UK: can we do better? The meeting was timely as, although outcomes for patients with most gastrointestinal cancers in the UK have steadily improved in the past 10u2005years, survival figures remain substantially worse than in many other comparable nations.nnAfter defining the scale of the problem, the issues around early diagnosis were discussed. Screening as prevention has huge potential where there are defined premalignant conditions. Uptake into the Bowel Cancer Screening Programme (BCSP) is variable but in some areas remains low. It is hoped that with the National Screening Committee recommendation to replace the guaiac faecal occult blood test (gFOBT) with the faecal immunochemical test (FIT), the planned age extension and the continued roll-out of bowel scope screening by the National Health Service (NHS) will extend the value of the programme further.nnThe view from primary care suggested that many factors affect the decision to make a referral for suspected cancer. Lack of direct access to testing was highlighted as a concern, as was the compounding issue of the many patients who delay seeking care. The Independent Cancer Force is the latest of several bodies calling for general practitioners (GPs) to be able to refer ‘direct to test’. However, a particular concern from secondary care relates to further stretching of diagnostic resources already under pressure—and how that can be addressed in times of austerity. Waiting times for endoscopy have begun to rise, yet capacity to expand is limited. Training, recruitment and retention of clinical staff were all highlighted as key issues limiting the availability of these procedures. Various practical ways to improve detection with endoscopy were proposed, as were possible ways to support and retain staff.nnWhile …

Referee's half-time analysis

Honest, I was over the moon when asked to review this paper for the BMJ . Of course, I had to ask the boss if it was OK to review it (but she said it was alright). I dunno quite how I managed to do the review—it sort of just hit my head, Brian, and found the back of the net. I was dead gutted to find out I was only getting fifty quid for what was an hours work. Me agent said I shouldnt get out of bed for less than eighty thousand quid a week. But wot I thought was… its not often a player gets to be a referee and hold up a yellow or red card and get …

Percutaneous endoscopic gastrostomy feeding: Author's reply

endoscopic gastrostomy tube will not necessarily prevent this as these tubes may themselves be pulled out by a determined patient-indeed, some authorities believe that psychosis and dementia are relative contraindications to insertion.8 Thus percutaneous endoscopic gastrostomy is not the end of the line for nasogastric feeding but an example of one of several useful techniques that may be considered for long term enteral feeding. Nasoenteral tubes will continue to provide the main route of access for most patients requiring enteral nutrition.