Gastroenterology GP update 2022

About Dr Marius

Born in Holland and trained in Australia / New Zealand, I am an advanced interventional endoscopist specialising in gastroscopy, colonoscopy, endoscopic mucosal resection, endoscopic ultrasound and ERCP. My Clinics are at Waitemata Gastroenterology and I perform endoscopy at WHB and Waitemata Endoscopy.

COVID AND IMMUNOSUPPRESSION

Reassuringly most IBD patients or patients on immunosuppression are not at higher risk for severe covid-19 disease and are not more likely to get covid. However, prednisone dose > 20mg per day does increase risks and biological treatment may reduce risk for severe covid (PMID 33210980). It is therefore important to reassure patients that they should not stop immunosuppression for covid, as this likely will result in a flare of disease requiring steroids.

3RD VACCINATION BOOSTER

Patients on immunosuppression, however, are less likely to have an antibody response to covid vaccination. The government has just approved a 3rd dose for immunosuppressed patients at least 8 weeks after their second dose. This requires a face-to-face visit to sign a separate consent form. The risk for adverse reactions is similar to a second dose. The detailed protocols and forms are on health.govt.nz

IMPACT OF COVID ON CANCER DETECTION

The first covid lockdown resulted in a 40% decrease in cancer registrations (PMID  4327369). Although the impact is less during the current lockdown with around 200 less cancer registrations, endoscopy volumes decreased by 30%. If you are concerned about a patient on the endoscopy waitlist you can submit an addendum with your concerns. The patient may also be able to self-fund a private endoscopy.

PPIS CAN CAUSE REFLUX

Intermittent use of PPIs can make reflux worse. PPIs raise gastrin levels, resulting in acid rebound on cessation. If your patient has reflux symptoms, twice daily dose is best. Patients can try stopping PPIs but should be aware of this acid rebound, which can be managed with over-the-counter anti-acids

PROTON PUMP INHIBITOR MYTHS DEBUNKED

Often patients have concerns about PPI safety with observational studies showing possible link with osteoporosis, renal dysfunction and even dementia. A large multi-centre randomized placebo-controlled trial has shown PPIs are extremely safe. This has shown no adverse effects on kidneys, bone density or dementia. The only adverse effect of pantoprazole was an increase of enteric infections from 1 to 1.4% (PMID 31152740)

EUS FOR BILIARY PAINS

Ultrasound, CT and even MRCP can miss common bile duct stones. Endoscopic ultrasound (EUS) can have a 3x higher sensitivity for stones (PMID: 29097868). Typical biliary pain is constant pain in the RUQ, occurs 30 minutes after eating rich meals and can last for hours. Consider an EUS if your patient has ongoing biliary pains

NEW CONSTIPATION TREATMENTS

Fibre can help with bulk forming but may cause more pain due to gas formation. Besides stool softeners or stimulants, you could also try LBS-II a natural laxative with Cascara Sagrada bark extract. Prucalopride is a highly  elective pro-kinetic 5-HT4 agonist, that does not have any potential cardiac side effects like cisapride. The cost to the patient is 95NZD per month for 2mg. Studies have shown prucalopride can  significantly improve bowel function, reduce constipation-related symptoms and increase patient quality of life.

PRACTICE GASTRO UPDATE PRESENTATION

Nothings beats an interactive meeting to catch up on the latest developments in gastroenterology. I can come to your practice and provide a catered 30–60 minute presentation. To keep it interactive there are only 1-2 slides per topic with time for questions in between.

NEED SOME FRIENDLY GASTRO ADVICE?

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