Clinical management

Are you overprescribing for reflux?

• Infancy- Regurgitation in infancy is common, transient and part of normal physiology in otherwise well, thriving infants. Proton pump inhibitors (PPIs) are equal to a placebo for resolution of suspected reflux (symptoms are caused more often by volume than acid).

  
  

• Adulthood- PPIs are overprescribed and often underlying contributing factors aren’t addressed.

WiseGP Actions

In someone with isolated symptoms of gastro-oesophageal reflux, reflect on whether you default to prescribing medication too early.

1. In infants, having ruled out red flags/ other associated symptoms, do you normalise reflux and offer reassurance? Do you explore how the parents are coping? (Perinatal anxiety is common and often not recognised.)

   
   

2. In adults, taking a holistic focus, exploring and addressing potential triggers could be a better approach to improve long-term outcomes.

   Should this be the focus of your first appointment?

   
   

   • Dietary (fatty/ fried/ spicy foods, excess alcohol/ coffee, carbonated drinks)

   • Eating behaviours (too fast, large portions, past satiety/ close to bedtime)

   • Medication (anti-inflammatories, antihypertensives, erectile dysfunction medicines)

   • Lifestyle (weight gain, tight garments, belts, smoking, excess alcohol) 

   • Psychological risk factors (stress, anxiety, hypervigilance) 

Read more about the research informing this GEM:

https://www.bmj.com/content/385/bmj-2022-074588.full

https://doi.org/10.3399/bjgp24X737349

How much can you trust a negative FIT?

• A negative FIT can help to identify people at low risk of colorectal cancer (CRC). The NICE FIT study, a double-blinded study including almost 10,000 people referred for colonoscopy on a suspected CRC pathway, found only 0.4% with a negative FIT had CRC.

   

• From those found to have CRC, around 1:10 have a negative FIT, so in people with persistent lower GI symptoms and a negative FIT, we should consider further investigation.

   

• Scottish guidelines suggest a repeat FIT after 6 weeks if the first FIT is negative and the patient remains symptomatic. There is some evidence this can improve FIT sensitivity to 97%, though specificity is reduced. The British Society of Gastroenterology guidelines don’t currently recommend repeat use of FIT, citing a need for more research.

   

• Bowel cancer screening FIT tests have a higher threshold for someone to test positive (80 to 150 µg Hb/g faeces) compared to the FIT tests we request in symptomatic patients (10 µg Hb/g faeces).

WiseGP Actions

1. Reflect on how you manage a negative FIT test result and what safety netting advice you offer...

   • Do you advise patients with ongoing GI symptoms to seek further review if their FIT test is negative, when you file their result? Could you have a set text message to send to patients who test FIT negative?

2. If a patient attends with lower GI symptoms who has recently had a negative FIT as part of bowel cancer screening, do you request a repeat test? You should, given the threshold for a positive result is much lower in symptomatic patients- a learning point you could share with your colleagues?

Read more about the research informing this GEM here:

bjgp.org

The Association of Coloproctology of Great Britain and Ireland (ACPGBI) and the British Society of Gastroenterology (BSG) have published a new guideline around faecal immunochemical testing (FIT) in patients with signs or symptoms of suspected colorectal cancer (CRC).1 The guideline was written by a multidisciplinary team including GPs and patient representatives, and includes recommendations for both primary and secondary care. NHS England has subsequently written to all GP practices in England recommending they implement this guideline ‘in full’,2 but this has created concern among some GPs regarding a perceived shifting of risk and responsibility to primary care. This article reviews the recommendations made by the ACPGBI/BSG and considers what they mean for primary care clinicians. In the UK, CRC is the fourth most common type of cancer.3 Close to 50% of patients are currently diagnosed with stage III or IV cancer.3 Symptoms alone have a poor sensitivity for CRC, meaning a high volume of secondary care investigations are required to detect cases if symptom-based criteria alone guide referrals.1 Endoscopy services in the UK have been struggling to keep up with referral demands, and waiting times for a colonoscopy lengthened during the COVID-19 pandemic.4 It is in this context that the role of FIT has been recently evaluated, to determine whether it can safely triage referrals and better identify high-risk patients than symptoms and non-specific blood tests alone. FIT has been shown to be a valuable test for clinicians working in primary care to help triage patients presenting with lower gastrointestinal (GI) symptoms into high-or low-risk CRC groups. For example, the National Institute for Health and Care Excellence (NICE) FIT study, a double-blinded study that included close to 10 000 patients referred for colonoscopy on a suspected CRC pathway, reported that 0.4% of those with …

Amitriptyline an effective second line treatment for IBS

• A trial across 55 general practices in England aimed to determine the effectiveness of amitriptyline as a second-line treatment for irritable bowel syndrome (IBS).

• 463 participants were randomly allocated to receive low-dose amitriptyline (10mg, with dose titration up to 30mg over 3 weeks) or placebo for 6 months. The IBS Severity Scoring System (IBS-SSS) was used to assess response to amitriptyline compared to placebo.

• There was a significant improvement in the IBS-SSS after 6 months treatment with amitriptyline compared to placebo.

WiseGP Action

• For people with IBS who don’t improve with first line therapies, offer low-dose amitriptyline. See a leaflet on the rationale for using amitriptyline and a dose titration document co-developed with patients here: https://ctru.leeds.ac.uk/atlantis/

• Reflect on your clinical management of IBS cases and whether you discuss the brain-gut axis and explore/ support the management of psychological comorbidities.

• Consider signposting patients to the IBS self-care programme- perhaps you could add this link to an automated text message at your practice?

  https://www.theibsnetwork.org/the-self-care-programme/

Read more about the research informing this GEM here: https://www.sciencedirect.com/science/article/pii/S0140673623015234

www.bmj.com

### What you need to know Regurgitation is common in the first months of life, and concern of disease often prompts parents to seek medical care and advice. Treatment with proton pump inhibitors is common and increasing, but it is largely unnecessary and not supported by evidence in infancy. This article describes the clinical features that may reflect gastro-oesophageal reflux in infants and guidelines on management, which recommend against routine use of proton pump inhibitors for isolated reflux symptoms in infants. Gastro-oesophageal reflux in children is defined as the effortless passage of gastric contents to the oesophagus with or without regurgitation or vomiting.1 This is usually physiological, commonly occurs after meals, and is usually without associated symptoms in healthy infants. Daily episodes of regurgitation are particularly common in newborns and infants.2 A review found that up to a quarter of healthy infants under 1 year old were affected by two or more daily episodes of regurgitation lasting more than three weeks.2 The review also found that fussiness and infantile colic were equally prevalent and may consequently overlap with regurgitation.2 Gastro-oesophageal reflux disease (GORD), unlike physiological gastroesophageal reflux, is a pathological process in which reflux events cause persistent or severe symptoms that require treatment or when there are complications as a result of reflux.1 Clinical features that may be seen in infants with GORD include general discomfort or irritability, wheezing, refusing …