Gut Check

A great deal of alarm has been voiced over a recent report that some patients with no previous acid-related dyspepsia or GERD developed acid symptoms after stopping PPI therapy in a month-long trial.

Should we really be surprised by this finding? Not really. PPI use is known to cause acid rebound, and the effect is thought to be related to PPI-induced gastrin secretion (secondary to an increase in gastric pH) and to gastrin’s effect on parietal cell mass expansion, which leads to increased acid secretion.

Should we be concerned that these drugs are being given to patients who have no acid-related symptoms? Absolutely. In my opinion, a PPI is warranted only if patient history indicates that gastrointestinal symptoms are likely acid related. These drugs should not be used for every abdominal discomfort or complaint.

The real take-home message from this study is not to stop taking PPIs, but rather to take a history and not to use PPIs (or for that matter any drug) unless we have a clear understanding of what we are trying to diagnose or treat.

What do you think?

Here are ten key findings about endoscopy that were reported at Digestive Disease Week 2009, held May 30 – June 4, 2009 in Chicago:

#10. We need to drop Bisacodyl from the new Gatorade prep.
#9. Wire-guided cannulation during ERCP results in less pancreatitis.
#8. Looking carefully during endoscopy finds lesions, enhanced imaging is not what does it.
#7. Balloon enteroscopy is an important tool in managing small bowel disease and needs to become more widely available.
#6. You do not need to stop aspirin, NSAIDs, or Plavix prior to endoscopic procedures.
#5. Neoplastic Barrett’s belongs to the endoscopist not the surgeon.
#4. Under-represented ethnic populations have special digestive health issues that are not being addressed adequately.
#3. If the virtual colonoscopy is positive and the colonoscopy is negative, we cannot tell the patient to come back in 10 years; we need to repeat testing in the next year or two.
#2. We miss colon cancers during colonoscopy.
#1. Gosh things change fast, and DDW is the place to learn that!

I recently saw a patient who was referred after upper and lower endoscopies had not revealed the cause of his abdominal discomfort. What struck me was that the patient had these two exams on consecutive days. That meant two days lost from work, two days with altered diet, two trips to the endoscopy center, two days with a driver commitment, two anesthetic administrations, etc. I am not naïve to the fact that most insurers discount heavily for endoscopy procedures performed on the same day. But how do we justify the additional risk, costs, inconvenience, and impact on a patient’s quality of life by not performing needed procedures at the same time?

Perhaps I am missing something here, so I would really like to better understand the rationale for this practice. Please weigh in on the practice of same-day versus consecutive-day endoscopies.

For at least a decade, people suggested that GERD was more than just heartburn and regurgitation, that it might also account for all the wheezing, coughing, and throat clearing we were encountering in the clinic. This idea led to the notion that we should try high-dose acid-suppression therapy in these other “GERD” patients.

What has recently become clear, however, is that most of these patients don’t actually have GERD at all — and even when they do, empirical high-dose PPI therapy does not improve their non-reflux symptoms.  The latest example of this comes from an RCT just published in the New England Journal of Medicine.

Despite this evidence, the belief that GERD accounts for a large proportion of airway symptoms seems tough to crack. What do you do when you encounter a patient whose cough, hoarseness, or wheezing has been blamed on GERD?

For the past couple years, my colleagues and I have been bemoaning the state of bowel preps, especially for colonoscopies done in the afternoon. As many as one third of those preps were so poor that we had to tell patients to resume screening at intervals sooner than 7 to 10 years, for fear of missed lesions.

Thinking the problem was mainly related to the delay between the prep and the procedure, we decided this winter to split the dose (half the day before, and half 4 to 5 hours before the procedure) for all bowel preps — a practice that the ACG also now recommends. Lo and behold, the preps in our clinic are now uniformly good to excellent, regardless of whether the case is seen in the morning or afternoon.

What is your experience with bowel preps and split dosing? Have you had similar success or encountered any obstacles in implementation?

In a recent blog post, ID expert Paul Sax raised the question of which sedatives should be used when scoping HIV-infected patients on ritonavir or efavirenz. Both antiretrovirals inhibit the CYP3A enzyme, which metabolizes one of our most commonly used sedatives, midazolam. Use of midazolam with either antiretroviral is technically contraindicated because of significant increases that occur in blood levels of midazolam. So how do we sedate our HIV-infected colonoscopy patients?

The same as we do all our endoscopy patients: We titrate midazolam for effect. In my mind, there is little reason to view this drug as “contraindicated” with ritonavir or efavirenz. Increased blood levels of midazolam should lead to adequate sedation at lower doses without the potential for over-sedation, assuming the midazolam is used appropriately — that is, infused at a low dose with a reassessment of effect and level of sedation before additional doses are given.

However, Paul noted in his blog that lorazepam (Ativan) and other drugs are sometimes substituted for midazolam in this situation or that the patient’s ritonavir is stopped the day before midazolam is used. Frankly, the mention of these practices surprised me and led me to conduct this informal poll…

What do you do when you encounter these patients?

Two provocative articles recently appeared in BMJ (here and here) showing that experienced, well-trained nurses are as clinically effective — but not as cost-effective — as physicians in performing diagnostic upper endoscopy and sigmoidoscopy.

This randomized trial definitively answers the question of whether nurses can deliver high-quality endoscopy, but the larger question is whether they should be performing these procedures. I think they should, but only if they’ve been trained in both the technical performance of endoscopy and the management of digestive diseases (this, by the way, goes for physicians as well!). Endoscopy is, after all, not just a procedure, but a tool used to detect, diagnose, and treat GI disease. When it is used as such, the outcomes are usually good, as demonstrated in the BMJ articles. When it is treated simply as a procedure, however, outcomes can be poor, and one is left to wonder whether the tool is being wielded simply as an income generator.

This Saturday’s Wall Street Journal featured an intriguing article on sedation-free colonoscopy, which is standard in Europe and Asia but rarely done in the U.S. One could argue that Americans are just “weenies,” but I think the blame rests solely with us doctors.

Sedation-free colonoscopy is successful in most who try it (I did!), but it does require a more careful exam to ensure that patients are comfortable. Over-distension, looping, and other problems that can cause pain must be avoided, and that means the doctor must spend more time and perform more maneuvers during each procedure. And therein lies the rub. Even though sedation-free colonoscopy is safer and cheaper for patients, most gastroenterologists already feel rushed when they see patients and don’t want to take the time to even broach the subject of sedation-free colonoscopy, let alone actually perform it.

What’s my recommendation? Discuss the availability and benefits of sedation-free colonoscopy with all your patients, and let’s let Americans know to ask for it. It’s a better way to get the exam — and you can even drive yourself home that day!

Last week, the Centers for Medicare and Medicaid Services (CMS) announced that they are not likely to cover virtual colonoscopy (CT colonography or CTC) for colorectal cancer screening in Medicare beneficiaries. The announcement came just months after the U.S. Preventive Services Task Force declined to recommend the test, citing insufficient evidence. Not surprisingly, the radiology community responded to both decisions with a firestorm of opposition, arguing that the ACRIN trial data proved the merits of CTC.

Is this a turf issue, or is the CMS simply taking a conservative stance pending more data? Read more of this post »

In response to my earlier post on PPIs and upper GI bleeding, Bahman N Shokouhi writes:

A recent article in the Canadian Medical Association Journal (published online Jan 28, 2009), suggests that this is not a class effect and that Pantoprazole does not seem to have an effect. It has been suggested that the cause of this is the effect of most PPIs on P450 2C19. Pantoprazole does not affect P450 2C19 and therefore according to the data does not reduce the effectiveness of clopidogrel. So, hopefully if we start using Pantoprazole instead of Omeprazole and other PPIs you can still continue with your calls!

However, we should remember that we do not know if any PPI clearly has a detrimental effect on Plavix’s action. Until we know whether this is a causal, class-wide effect, one easy solution would be to avoid administering Plavix and a PPI too closely together. Although both Plavix and PPIs have a sustained pharamcological and tissue effect, their serum half-lives are very short (less than a few hours). Thus any drug interaction that results in a deleterious clinical effect (if one actually occurs) would be obviated if one drug was taken in the AM and the other in the PM.