Ingest

Helicobacter pylori for primary care

PCSG — Tue, 06 Jan 2026 15:14:43 +0000

Dr Charlie Andrews talks to Dr Jan Bornschein.

Chapters

(00:00:02) - Invent
(00:00:32) - H. Pylori management
(00:01:54) - H. Pylori and stomach cancer
(00:07:47) - Diabetes dyspepsia: tests available for non-in
(00:15:37) - H. Pylori test in peptic ulcer disease
(00:21:58) - H. Pylori in gastroesophageal reflux
(00:23:04) - Does helicobacter have a positive effect on reflux?
(00:25:11) - H. Pylori disease 7, Parents and children
(00:28:36) - H. Pylori management, first line treatment
(00:37:25) - Bismuth based quadruple therapy
(00:46:32) - Gastric cancer retesting

The 12 Days of Gut-mas

PCSG — Tue, 23 Dec 2025 17:21:42 +0000

Based on a popular well known Christmas carol this episode reminds us about prescribing thoughtfully, recognising key red flags, and keeping often-missed diagnoses like bile acid diarrhoea, coeliac disease and liver disease on the radar. The episode also reinforces the importance of early-life microbiome influences and structured differential diagnosis for abdominal symptoms in primary care.

Prescribing and de-prescribing • Taper PPIs rather than stopping abruptly to avoid rebound acid hypersecretion, driven by upregulated gastrin during PPI therapy. • Always link NSAID use and H. pylori status to ulcer risk, and remember: gastric ulcers typically cause pain with meals, duodenal ulcers 2–3 hours after eating. Diagnosis, tests and red flags • Use three coeliac test “groups”: serology (tTG/EMA, with total IgA checked), genetics (HLA‑DQ2/DQ8) and duodenal biopsies; ensure patients eat gluten for at least six weeks pre‑testing and to endoscopy. • Actively screen for GI red flags: dysphagia and weight loss (upper GI), PR bleeding and unexplained iron‑deficiency anaemia (lower GI), and escalate for urgent investigation. Practical tools and endoscopy indications • Use the Bristol Stool Chart (types 1–7) routinely in consultations to standardise conversations about stool form and avoid ambiguous “food analogies.” • Remember the three main indications for endoscopy: diagnostic (e.g. dyspepsia, chronic diarrhoea), surveillance (Barrett’s, polyp follow‑up) and therapeutic (RFA/EMR in Barrett’s, polyp removal). Conditions to consider and not miss • Keep bile acid diarrhoea prominent in the differential for IBS‑D: up to ~40% of IBS‑D patients may have it, particularly with ileal disease/resection, Crohn’s, or post‑cholecystectomy. • Maintain a broad GI bleeding differential beyond cancer (e.g. gastritis, peptic ulcer, Mallory–Weiss tear, haemorrhoids/fissures, liver disease/coagulopathy, IBD, angiodysplasia, diverticular disease). Liver disease, microbiome and early life • Remember major causes of liver failure in primary care: excess alcohol, paracetamol overdose, DILI, autoimmune hepatitis, Wilson’s disease, haemochromatosis, viral hepatitis B/C and progressive MASLD. • Support breastfeeding where possible to promote a healthy infant microbiome (HMOs favouring bifidobacteria) and recognise how birth mode and early microbes shape immune development and later allergy/immune risk. Structuring abdominal symptom assessment • For undifferentiated abdominal symptoms, consciously work through a core list: IBS, lactose intolerance, coeliac disease, gastroenteritis, SIBO, IBD, diverticular disease, colorectal cancer, peptic ulcer disease, gallstones/biliary colic, pancreatic insufficiency and medication‑related causes (e.g. metformin, NSAIDs, antibiotics). • Use these categories to guide targeted history, examination, basic tests and thresholds for referral back to gastroenterology or specialist services.

Chapters

(00:00:04) - The 12 Days of Gutmas
(00:01:04) - PPIs
(00:02:19) - How to manage gastric and duodenal ulcers on
(00:03:40) - Celiac disease tests 6, Interventions
(00:05:33) - GI red flags on Christmas Day
(00:07:48) - The main indications for endoscopy
(00:09:07) - 7 causes of liver failure on Christmas Day
(00:10:17) - Healthy gut microbiome 8 days after Christmas
(00:12:03) - Bile acid diarrhea
(00:13:52) - 10 causes of abnormal gastrointestinal bleeding
(00:15:34) - The microbiome of the body
(00:17:55) - 12 causes of abdominal dysrhythmia
(00:19:59) - 12 Days of Gutmas

The Microbiome, Our Health and Wellbeing

PCSG — Mon, 09 Jun 2025 19:09:14 +0000

Dr Charlie Andrews talks to Dr James Kinross, PhD, FRCS

Dr. Kinross is a senior lecturer in surgery at Imperial College in London. He is also a practicing colorectal surgeon in the NHS with a clinical interest in the prevention and treatment of colon cancer. He leads a team of amazing researchers working to better define how the microbiome causes cancer and other chronic diseases of the gut. He is increasingly interested in how the gut microbiome develops in newborn babies and the implications on our long-term health. He is the author of the well know book DARK MATTER.

Here are the key learnings for primary care on the microbiome from the attached transcript of the Ingest podcast with James Kinross:

Key Learnings for Primary Care on the Microbiome

1. What the Microbiome Is and Why It Matters

Definition: The microbiome is the collection of all microscopic organisms (bacteria, viruses, fungi, etc.) and the environment they inhabit within a specific niche in the body, such as the gut, skin, or lungs.
Symbiosis: The microbiome has a symbiotic relationship with the host, evolved over millennia. It is not static but dynamic and changes throughout life.
Personalization: Each person’s microbiome is unique, impacting how individuals respond to treatments and develop diseases[1].

2. Microbiome Development and Early Life

Early Colonization: The microbiome starts developing in utero, influenced by the mother’s microbiome, and is further shaped by birth route, breastfeeding, and early environmental exposures.
Critical Window: Early life is a critical period for microbiome development. Disruption, especially through antibiotic use, can have long-term effects on immune system development and disease risk[1].
Antibiotics Impact: Repeated or broad-spectrum antibiotic use in early life can lead to persistent changes in the microbiome, increasing the risk of immune-mediated diseases (e.g., allergies, asthma, eczema), obesity, and other non-communicable diseases[1].

3. Microbiome and the Immune System

Immune Regulation: The microbiome plays a crucial role in shaping both the innate and adaptive immune systems. It influences how the body recognizes and responds to threats.
Disease Risk: Early disruption of the microbiome can increase susceptibility to autoimmune diseases, allergies, and chronic conditions later in life.
Gene-Environment-Microbiome Interaction: Disease risk is not just about genes and environment but also involves the microbiome (GEM interaction), which is highly personalized and dynamic[1].

4. Probiotics, Prebiotics, and Diet

Probiotics: There is evidence supporting the use of probiotics, especially multi-strain, high-dose formulations, during and after antibiotic courses. However, probiotics must be taken consistently for weeks to have an effect.
Prebiotics and Diet: Feeding the microbiome with a high-fiber, plant-based diet is crucial for maintaining a healthy gut ecosystem. Processed foods and sugary drinks should be minimized, especially during illness or antibiotic treatment[1].
Practical Advice: Clinicians should recommend probiotics and dietary changes as part of a holistic approach to gut health, but the evidence for specific strains is still evolving[1].

5. Microbiome Testing

Direct-to-Consumer Testing: Online microbiome tests are not currently recommended due to lack of standardization, robust interpretation, and actionable outcomes.
Clinical Use: Microbiome analysis is best used in a targeted, clinical context, interpreted by specialists, and as part of a longitudinal assessment rather than a one-off snapshot[1].

6. Future Directions and Interventions

Probiotic Formularies: The development of evidence-based probiotic formularies will help guide clinical use.
Fecal Microbiota Transplantation (FMT): FMT is currently approved for recurrent Clostridium difficile infection but may have a broader role in the future for other conditions, with more targeted and capsule-based delivery methods.
Postbiotics and Synthetic Biology: Emerging therapies include postbiotics (microbial metabolites) and engineered microbes for targeted treatments, though these are still in development[1].

7. Complexity and Clinical Action

Superorganism Concept: Humans are superorganisms, with the vast majority of genetic material in our bodies being microbial.
Clinical Translation: While the microbiome is complex and still being understood, it is increasingly relevant to clinical practice, particularly in managing non-communicable diseases and guiding personalized treatments[1].

Summary Table

TopicKey Points for Primary CareMicrobiome BasicsDynamic, symbiotic, unique to each person, influences health and diseaseEarly Life & AntibioticsCritical window for development, antibiotics can have long-term effectsImmune SystemShapes immune responses, affects disease risk, GEM interaction modelProbiotics & DietMulti-strain probiotics, high-fiber diet, avoid processed foodsMicrobiome TestingNot recommended direct-to-consumer, best used clinically and longitudinallyFuture InterventionsProbiotic formularies, FMT, postbiotics, engineered microbesComplexityHumans are superorganisms, microbiome is a major part of health

These insights highlight the importance of considering the microbiome in primary care decision-making, especially regarding antibiotic stewardship, diet, and personalized patient management[1].

Sources [1] transcript-The-Microbiome-Our-Health-and-Wellbeing.pdf

Neuroendocrine Cancer - The Expert Patient

PCSG — Tue, 15 Apr 2025 10:22:38 +0000

The episode features Dr. David Bartlett, a retired GP and neuroendocrine cancer patient, offering a dual perspective as both clinician and patient.

Key Learnings from this episode.

Patient Experience and Diagnostic Challenges

Dr. Bartlett’s symptoms began with severe, intermittent abdominal pain, starting in 2001, but he did not seek medical help for several years due to a combination of stoicism, not wanting to trouble others, and a belief in the commonality of benign causes.
Over 15 years, he experienced repeated misdiagnoses, primarily being labeled as having irritable bowel syndrome (IBS) despite atypical features (severe pain, minimal bowel habit change, and no systemic symptoms).
Multiple opinions and investigations (including ultrasounds and CT scans) failed to identify the underlying cause, with a key scan being misread by local radiologists.
The correct diagnosis of a small bowel neuroendocrine tumour was only made after a tertiary centre re-examined previous scans, highlighting the importance of specialist review and persistence in unexplained cases.

Clinical Red Flags and Symptomatology

Dr. Bartlett’s case underscores that neuroendocrine tumors can present with isolated, severe abdominal pain without classic red flags (vomiting, weight loss, significant bowel changes)[1].
He retrospectively identified subtle signs of carcinoid syndrome (flushing, one episode of profound diarrhoea, and skin changes), which are present in only about 10% of small bowel neuroendocrine tumour cases.
The lack of awareness about neuroendocrine tumors, even among experienced clinicians, contributed to the diagnostic delay[1].

Lessons for Primary Care and Clinicians

The story illustrates the risk of anchoring on common diagnoses (like IBS) and the need to reconsider the diagnosis when symptoms are severe, persistent, or atypical.
It highlights the value of listening to the patient’s narrative, especially when symptoms do not fit classic patterns, and the importance of considering rare conditions in the differential diagnosis.
The episode emphasises the need for ongoing education about neuroendocrine tumours and the importance of keeping rare but serious conditions on the diagnostic radar in primary care.

Management Insights

Standard treatment for small bowel neuroendocrine tumours often includes monthly somatostatin analog injections (e.g., lanreotide).
Surgical intervention may be considered, but it carries specific risks such as carcinoid crisis, requiring specialised perioperative management.
The decision for surgery is individualised, weighing potential symptomatic improvement against procedural risks.

Systemic and Human Factors

Dr. Bartlett’s experience reflects how personal traits (stoicism, reluctance to seek help) and systemic issues (misinterpretation of scans, diagnostic inertia) can delay diagnosis.
The narrative also demonstrates the importance of patient advocacy, persistence, and the value of second (or third) opinions, especially in complex or unresolved cases.

Educational Value

The episode serves as a reminder for clinicians to maintain a broad differential, revisit diagnoses when the clinical picture changes, and to be aware of their own cognitive biases.
It also advocates for the inclusion of patient voices in medical education to better understand the lived experience and challenges of rare diseases like neuroendocrine cancer.

Summary Table: Key Learnings

ThemeKey PointsDiagnostic Delay15 years from symptom onset t...

Chapters

(00:00:10) - Ingest
(00:02:07) - David Bartlett on neuroendocrine cancer
(00:05:32) - Irritable bowel syndrome, 15 years after first bout
(00:12:09) - Carcinoid syndrome in small bowel neuroendocrine tumors
(00:16:10) - Neuroendocrine tumour, surgery and recovery
(00:20:43) - Somaostatin analogues for neuroendocrine cancer
(00:25:43) - The role of the multidisciplinary team in bowel cancer care
(00:28:21) - The battle with depression in your 50s
(00:30:00) - General Practice and the Art of Medicine
(00:33:13) - General Practice: The challenge of slowing down
(00:35:35) - Neuroendocrine Cancer UK support group
(00:39:28) - David's story of cancer
(00:40:38) - David's Neuroendocrine Cancer Episode 1

Pancreatic Conditions Part 2 - Malignant

PCSG — Tue, 25 Mar 2025 12:35:35 +0000

Dr Charlie Andrews talks to Dr John Leeds. John Leeds is a Consultant Pancreaticobiliary Physician and Endoscopist based at the Freeman Hospital in Newcastle and an Honorary Clinical Senior Lecturer based in the Population Health Sciences Institute at Newcastle University. He is involved in research in pancreaticobiliary disorders including benign and malignant conditions as well as outcomes from therapeutic/advanced endoscopy.

John is a member of the British Society of Gastroenterology and Pancreatic Society of Great Britain and Ireland. He serves on the endoscopy and Pancreas committees for BSG and is the website lead for PSGBI.

He is also a founder member of the BSG Pancreas Clinical Research Group which is coordinating research for the society.

Key Learnings from this episode:

Challenges in Early Detection of Pancreatic Cancer • Pancreatic cancer is often diagnosed at an advanced stage due to the deep location of the pancreas and the lack of early symptoms. • Tumors in the body and tail of the pancreas can grow significantly before causing symptoms, often invading major arteries or veins, making them inoperable. • Tumors in the head of the pancreas may present earlier due to bile duct obstruction, leading to jaundice, but even these are often detected late.
Early Symptoms and Red Flags • Early symptoms are vague or absent, making early diagnosis difficult. • Possible early indicators include: • Weight loss (often a sign of advanced disease). • New-onset diabetes, particularly in individuals with a normal BMI or without typical risk factors for type 2 diabetes. • Jaundice, which is a significant red flag and often indicates a serious underlying condition. • Classic signs like painless jaundice and Courvoisier’s sign (palpable gallbladder) are important but not always present.
Limitations of Current Screening Methods • There is no reliable biomarker or screening test for pancreatic cancer: • CA19-9 is not suitable as a screening tool due to its lack of specificity (elevated in other conditions). • Imaging techniques like CT scans or MRIs are used but have limitations, including incidental findings that may lead to unnecessary anxiety (“scanxiety”) and over-investigation. • Screening is currently limited to high-risk groups, such as those with familial pancreatic cancer syndromes or hereditary pancreatitis.
High-Risk Groups for Screening • Familial pancreatic cancer accounts for less than 10% of cases. Criteria for screening include: • Multiple family members with pancreatic cancer, especially diagnosed under age 50–60. • Genetic syndromes like BRCA mutations, familial adenomatous polyposis (FAP), and Peutz-Jeghers syndrome. • Hereditary pancreatitis patients have an increased risk but are harder to screen due to pre-existing pancreatic abnormalities.
Emerging Research and Future Directions • Studies are exploring potential biomarkers, such as microbiome signatures in the pancreas, which might help identify high-risk individuals in the future. • Trials like the EuroPAC study focus on surveillance protocols for high-risk individuals using imaging techniques like MRI or endoscopic ultrasound. • Research into new-onset diabetes as a potential marker for pancreatic cancer is ongoing but currently has a low yield due to the high prevalence of type 2 diabetes unrelated to malignancy.
Considerations for Screening and Surveillance • Screening should be carefully targeted to avoid over-diagnosis and unnecessary investigations. • The psychological impact of screening (e.g., anxiety from incidental findings) must be considered. • Smoking cessation is emphasized as smoking is a significant risk factor for pancreatic cancer.
Advances in Treatment Approaches • PET-CT scans are increasingly used to detect systemic disease that might not be evident on standard CT scans. • Neoadjuvant treatments (therapy before surgery) are being...

Chapters

(00:00:00) - Ingest
(00:00:53) - Pancreatic Cancer
(00:04:03) - New diabetes and pancreatic cancer
(00:08:01) - Pancreatic Cancer: Screening
(00:15:42) - Determining breast cancer early is hard
(00:16:03) - Pulmonary neuroendocrine tumors of the pancreas
(00:22:26) - Pancreatic cancer 20, Management
(00:29:00) - Pancreatic cancer, management principles
(00:33:48) - Primary Care Take Home: Pancreas, pain
(00:40:29) - Primary Care: Pancreas Cancer Episode 2

Pancreatic Conditions Part 1 - Benign

PCSG — Wed, 12 Mar 2025 13:04:53 +0000

He is also a founder member of the BSG Pancreas Clinical Research Group which is coordinating research for the society.

Chapters

(00:00:01) - Ingest: pancreatic lesions
(00:01:09) - Pancreas
(00:05:39) - Chronic Pancreas disease, early signs and symptoms
(00:11:54) - Pulmonary pancreatitis, diagnosis and management
(00:17:52) - Diarrhea, weight loss
(00:18:29) - Pancreatic disease, ultrasound and the best treatment
(00:23:49) - Pancreatitis, chronic pancreatitis in primary care
(00:26:19) - Pancreatitis 20, Surgery or drainage?
(00:32:24) - Pancreatic Exocrine Insufficiency
(00:38:05) - Pulmonary dysrhythmias, management tips
(00:43:46) - PPI for cystic fibrosis patients 8,
(00:46:16) - Pancreatic insufficiency 20, Detection and treatment
(00:49:57) - Pancreatic cysts
(00:55:32) - Choosing the right cyst for surgery
(00:57:20) - autoimmune pancreatitis, presentation and treatment
(01:03:34) - Pancreatic cancer: diagnosis and treatment
(01:06:14) - Pancreatitis, part 1, unboxing

IBS Part 2 - Management

PCSG — Sun, 09 Feb 2025 17:18:23 +0000

Charlie Andrews talks to Dr Chris Black about the management of IBS.

This podcast provides key insights into managing Irritable Bowel Syndrome (IBS), emphasising a multidisciplinary and individualised approach to care. Here are the main takeaways:

1. Multidisciplinary and Integrative Care

IBS management requires a holistic, patient-centered approach involving dietitians, behavioral therapists, and gastroenterologists. This "team sport" approach expands treatment options and tailors care to individual patient needs1.
Integrative care, which combines dietary, psychological, and medical interventions, has been shown to improve symptoms, psychological well-being, and quality of life for IBS patients1.

2. Personalised Treatment

IBS is not a one-size-fits-all condition. There are different subtypes of IBS (e.g., IBS-D for diarrhea-predominant or IBS-C for constipation-predominant), and treatment must be customized based on the patient's symptoms and triggers4.
Emerging research suggests the need to identify distinct subtypes of IBS to guide more effective treatments2 4.

3. Dietary Management

The low FODMAP diet is a widely recommended dietary intervention for IBS. It helps identify food triggers and manage symptoms but should not be used long-term without personalization3.
Probiotics may also play a role in symptom relief for some patients, though their effectiveness varies3.

4. Behavioral Interventions

Cognitive Behavioral Therapy (CBT) and gut-directed hypnotherapy are effective in managing IBS symptoms, particularly when patients are motivated to engage in these therapies1.
Stress management is critical since stress and anxiety can exacerbate IBS symptoms1 5.

5. Pharmacological Therapies

Medications are often used as complementary treatments when dietary or behavioral strategies alone are insufficient. These include antispasmodics, laxatives, or medications targeting gut-brain interaction1 5.
Precision medicine is the future of pharmacological treatment, aiming to match therapies with the underlying causes of an individual's symptoms rather than just addressing the symptoms themselves1.

6. Challenges in IBS Management

One of the most distressing symptoms for patients is bowel urgency, significantly impacting their quality of life. Research is ongoing to better understand and manage this symptom2 4.
Pain management remains a critical area for improvement, as existing treatments often provide inadequate relief for abdominal pain and gut hypersensitivity in IBS patients2 4.

7. Patient Education and Collaboration

Educating patients about the trial-and-error nature of IBS treatment helps set realistic expectations and reduces frustration when initial interventions do not work1.
Shared decision-making between healthcare providers and patients ensures that treatment plans align with patient preferences and lifestyle.

In summary, effective IBS management combines personalized care with dietary, behavioral, and pharmacological strategies within an integrative framework. The podcast underscores the importance of ongoing research to refine treatments and improve outcomes for IBS sufferers.

Abdominal Pain in Children

PCSG — Thu, 07 Nov 2024 15:26:51 +0000

Charlie Andrews talks to Dr Anthony (Tony) Wisken, Consultant Paediatric Gastroenterologist in Bristol.

The Ingest podcast is hosted by Dr Charlie Andrews a GPwER in gastroenterology based near Bath. Charlie works as a GP partner at Somer Valley Medical Group, trained as an endoscopist and leads the national GPwER in gastroenterology training programme, launched in 2023 in the southwest of England. Charlie is a committee member of the PCSG (Primary Care Society of Gastroenterology). For more information visit pcsg.org.uk

Chapters

(00:00:05) - INGEST
(00:01:02) - Chronic abdominal pain in children
(00:07:47) - Pediatric gastroenterology, pain in the tummy
(00:13:13) - Reflux in children, 6 years and older
(00:15:26) - Headache and abdominal pain in children, age 6
(00:21:34) - Idiopathic bowel syndrome in children
(00:24:51) - Tummy pain 11, constipation
(00:31:08) - Mesenteric adenitis 20, Cancer
(00:35:06) - Functional GI disorders, the role of ultrasound
(00:38:57) - Obstructive bowel disease in teenagers
(00:45:41) - Gallstones in children, anaesthesia and surgery
(00:47:01) - Celiac disease, tests and how to manage it
(00:49:40) - Top 3 Take Homes for kids
(00:51:51) - H. Pylori in children's tummy pain
(00:55:37) - 3 take home points from the abdominal pain episode

Getting It Right First Time. Gastro Innovation in Northumbria

PCSG — Thu, 17 Oct 2024 11:13:18 +0000

With significant waiting lists and growing demand for secondary care services, Advice and Guidance is being increasingly explored as one potential solution to this problem.

In this episode, Charlie Andrews discusses an innovative and extremely successful use of advice and guidance in Northumbria with gastroenterologists Matthew Warren and Richard Thomson. Through the enhanced use of advice and guidance for all incoming referrals for secondary care input, they have demonstrated a significant reduction in waiting times for routine outpatient care.

They discuss their advice and guidance model, and what they have learned from developing this service and the impact it has been having on their waiting times, and how it has been received by primary care colleagues (3:30). We go on to discuss some common advice and guidance queries that Matt and Richard see (19:30) and I ask the question - what makes a good advice and guidance query? (43.30).

IBS Part 1 - Diagnosis

PCSG — Thu, 26 Sep 2024 09:47:00 +0000

Key takeaways from the IBS Part 1 episode of the PCSG Ingest podcast:

Diagnosis of IBS

The episode is focused on making a diagnosis of Irritable Bowel Syndrome (IBS)and features Dr. Anton Emmanuel, a consultant gastroenterologist and Professor of neuro-gastroenterology at University College Hospital London.

Importance for Primary Care

IBS is a common condition that primary care clinicians need to have a structured approach to diagnosing.

Topics Covered

Causes of IBS
Different subtypes of IBS
Challenges in making a positive diagnosis

Clinical Pearls

Dr. Emmanuel shares several insights:

Key questions to include in the patient history
How to describe the condition to patients
Practical tips for enhancing IBS diagnosis in primary care

Diagnostic Approach

The episode emphasises the importance of:

Taking a structured approach to diagnosis
Understanding the various presentations of IBS
Recognizing the challenges in making a definitive diagnosis

Patient Communication

Guidance is provided on:

Explaining IBS to patients effectively
Addressing patient concerns and misconceptions

Additional Resources

The episode mentions useful guidance from the British Society of Gastroenterology, which listeners were encouraged to reference for more detailed information. Part 2 focusing on the management of IBS to be released soon.

bsg.org.uk/clinical-resource/british-society-of-gastroenterology-guidelines

Chapters

(00:00:00) - Ingest
(00:01:33) - Intense bowel dysrhythmia (IBs)
(00:04:02) - How common is ibs?
(00:06:17) - Obstructive bowel syndrome
(00:10:06) - IBS: Classification and treatment tips
(00:13:39) - Determining the diagnosis of IBS
(00:14:44) - IBS
(00:19:22) - IBS 12, Missing other comorbidities
(00:22:21) - What to ask about IBS?
(00:25:25) - IBS and secondary care,
(00:29:33) - Confirmations about inflammatory bowel disease (IBs)
(00:33:37) - Talking to the patient about ibs
(00:35:09) - IBS, the diagnosis and treatment
(00:38:11) - In the Know: Irritable bowel syndrome
(00:40:22) - Irritable Bowel Syndrome
(00:41:15) - The Primary Care Society for Gastroenterology Podcast

High Iron Levels (hyperferritinaemia)

PCSG — Fri, 09 Aug 2024 13:49:02 +0000

Dr Charlie Andrews speaks to Dr Jeremy Shearman about everything related to high iron levels (hyperferritinaemia). We discuss how iron is regulated within the body, causes of raised iron levels, and then we dive into hereditary haemochromatosis - when to suspect, how to test, who to refer (and to whom!), and how the condition is managed.

Useful links to accompany this episode include:

Welcome > Haemochromatosis: genetic iron overload disease (exeter.ac.uk)

Haemochromatosis - British Liver Trust

Key Learnings for Primary Care from the Ingest Podcast on Hyperferritinaemia

Key Learnings

Understanding Iron Regulation and Ferritin

Ferritin is an acute-phase reactant and a marker of total body iron stores, but can be elevated in a range of conditions beyond iron overload, including inflammation, liver disease, and malignancy[2].
Understanding the physiological regulation of iron is crucial for interpreting ferritin results in context.

Causes of Hyperferritinaemia

Raised ferritin can result from:
Hereditary haemochromatosis (genetic iron overload)
Chronic inflammatory states (e.g., infection, autoimmune disease)
Liver disease (e.g., alcoholic liver disease, hepatitis)
Malignancy
Metabolic syndrome
It is important to consider these differential diagnoses when encountering an elevated ferritin[2].

Hereditary Haemochromatosis: When to Suspect

Primary care clinicians should suspect hereditary haemochromatosis in patients with persistently raised ferritin and transferrin saturation, especially with suggestive symptoms (e.g., fatigue, arthralgia, diabetes, liver dysfunction) or family history[2].
Early recognition is key, as treatment can prevent complications.

How to Test

Initial investigations should include:
Repeat ferritin measurement to confirm persistence
Transferrin saturation (TSAT): TSAT >45% is suggestive of iron overload
Liver function tests and assessment for other causes of raised ferritin[2]
If hereditary haemochromatosis is suspected, genetic testing (HFE gene) should be considered.

Who to Refer (and to Whom)

Refer patients with confirmed iron overload (high ferritin and TSAT) or positive HFE mutation to hepatology or a relevant specialist for further assessment and management[2].
Referral is also warranted if there are signs of organ involvement (e.g., abnormal LFTs, diabetes, cardiac symptoms).

Management Principles

For hereditary haemochromatosis, mainstay of treatment is venesection (therapeutic phlebotomy) to reduce iron stores.
Primary care plays a role in monitoring, supporting adherence, and managing comorbidities.
For other causes, management is directed at the underlying condition.

Practical Tips for Primary Care

Do not ignore isolated raised ferritin-always interpret in clinical context.
Exclude common secondary causes (infection, inflammation, liver disease) before pursuing rare diagnoses.
Family screening may be appropriate in hereditary haemochromatosis cases[2].
Use local guidelines and specialist advice where available.

Summary Table: Approach to Hyperferritinaemia in Primary Care

StepAction/ConsiderationConfirm raised ferritinRepeat test; assess for acute illness/inflammationAssess clinical contextSymptoms, family history, risk factorsAdditional testsTransferrin saturation, LFTs, CRP/ESRExclude secondary causesInflammation, liver disease, malignancy, metabolic syndromeSuspect haemochromatosisPersistently high ferritin + TSAT >45% ± symptoms/family historyGenetic testingHFE gene mutation if indicatedReferralTo hepatology/haematology if iron overload or organ involvementManagementVenesection for haemochromatosis; treat underlying cause for secondary hyperferritinaemia

These learnings equip primary care clinicians to approach hyperferritinaemia systematically, ensuring timely diagnosis, appropriate investigation, and effective referral and management[2][5].

Sources [1] INGEST – PCSG - The Primary Care Society for Gastroenterology https://www.pcsg.org.uk/ingest/ [2] High Iron Levels (hyperferritinaemia) – PCSG https://www.pcsg.org.uk/podcast/high-iron-levels-hyperferritinaemia/ [3] Ingest - The Primary Care Society for Gastroenterology https://www.pcsg.org.uk/feed/podcast/ingest/ [4] Ingest | Podcast on Spotify https://open.spotify.com/show/365S1VrwrkHmMdTJcVl9eh [5] High Iron Levels (hyperferritinaemia) - Apple Podcasts https://podcasts.apple.com/gb/podcast/high-iron-levels-hyperferritinaemia/id1605807130?i=1000664825288 [6] Course: Searchable table - RCPE Education Portal https://learning.rcpe.ac.uk/course/view.php?id=1427 [7] Ingest Podcast – Apple Podcasts https://podcasts.apple.com/at/podcast/ingest/id1605807130 [8] High Iron Levels (hyperferritinaemia) - Ingest | Podcast on Spotify https://open.spotify.com/episode/1lQiNpVAQbEtBKiUVdiKXj [9] Ingest Trailer - Castos https://ingest.castos.com/episodes/ingest-trailer [10] Rheumatology-TP 1..2 - Oxford Academic https://academic.oup.com/rheumatology/issue-pdf/61/Supplement_1/43461770 [11] Ingest - Podcast Addict https://podcastaddict.com/podcast/ingest/4281648 [12] Diverticular disease and diverticulitis - Ingest - Castos https://ingest.castos.com/episodes/diverticular-disease-and-diverticulitis [13] Untitled https://www.audible.in/podcast/Ingest/episodes/B09QTRKTPN [14] Intensive Care Society State of the Art (SOA) 2022 Abstracts, 2023 https://journals.sagepub.com/doi/full/10.1177/17511437231156066 [15] Ingest - Apple Podcasts https://podcasts.apple.com/ch/podcast/ingest/id1605807130 [16] Ingest - Apple Podcasts https://podcasts.apple.com/gb/podcast/ingest/id1605807130

Diverticular disease and diverticulitis

PCSG — Thu, 27 Jun 2024 16:57:25 +0000

In this episode, Charlie Andrews speaks to Melanie Orchard, a consultant surgeon, about diverticular disease and diverticulitis. This is something that we encounter frequently in primary care, and understanding how to approach this condition is extremely important.

Melanie discusses a really pragmatic approach to patients with symptoms suggestive of diverticulitis. We discuss risk factors, presenting features, and how to assess the patient with suspected diverticulitis. We also discuss the difference between diverticulosis, diverticular disease and diverticulitis, and give you useful tips on what advice to give to patients who has just had a colonoscopy showing that they have diverticulosis.

For a useful visual summary of the management of patients with diverticulosis and diverticulitis, please follow this link: visual-summary-pdf-6968965213 (nice.org.uk)

Hepatitis C

PCSG — Fri, 10 May 2024 11:00:09 +0000

Join Charlie Andrews as he discusses Hepatitis C with hepatologist Dr Kosh Agarwal and GP and clinical champion for Hepatitis C Dr Rik Fijten. They discuss the prevalence and presentation of Hepatitis C, as well as how to test for the condition along with an overview of the treatment options available.

Hepatitis C is a chronic liver disease which carries significant morbidity and mortality if left untreated. Fortunately, it is both easy to test for and the treatments available offer a fantastic cure rate of in excess of 95% with simple and relatively short tablet regimens.

NHS England has set itself the target of eradicating the disease by 2025 through active case finding, simplifying the diagnostic process, and ensuring pathways are in place to provide rapid and effective treatments for the condition.

Resources:

For more information on Hepatitis C, the British Liver Trust offers useful patient-friendly leaflets and further information about the condition: Hepatitis C - British Liver Trust

The self-testing portal mentioned by Rik during the episode can be found here: Home - HepC (hepctest.nhs.uk)

Neuroendocrine tumours (NETs) of the gastrointestinal tract

PCSG — Sun, 10 Mar 2024 15:19:49 +0000

In this episode, Dr Charlie Andrews speaks to Professor Mark Pritchard about neuroendocrine tumours (NETs) of the gastrointestinal tract. You may be asking yourself: 'Do I really need to know about NETs in primary care, aren't they extremely rare?' The answer to that is a resounding yes, you do need to know about NETs and Mark will tell you why in this episode!

Neuroendocrine cancer is the 10th most prevalent cancer in England, and the second most prevalent cancer of the GI tract, with a rapidly rising incidence (371%) over the last 20 years. NETs are commonly diagnosed at a more advanced stage due to late diagnosis as the signs and symptoms can be vague, or mimic other more common conditions such as IBS. Mark provides lots of useful, practical advice about when to suspect this form of cancer in primary care, which patients may be a higher risk, and what to do if you are suspicious about this form of cancer in your patient.

Listen on to find out more.

Ingest Trailer

PCSG — Thu, 28 Dec 2023 14:07:08 +0000

Dr Charlie Andrews, a committee member of the Primary Care Society for Gastroenterology (PCSG), introduces Ingest, the podcast for primary care that focuses on when to suspect, how to diagnose and how to manage common gastrointestinal presentations and conditions.

Highlights from Ingest 2023

PCSG — Fri, 22 Dec 2023 10:23:08 +0000

In this episode Dr Charlie Andrews looks back at 2023 and highlights some key takeaways from Ingest in 2023.

Barrett's oesophagus

PCSG — Thu, 09 Nov 2023 16:55:27 +0000

In this episode, Charlie Andrews speaks to Dr Andrew Moore about this condition, which affects up to 1.5% of the population, with a risk of progression to cancer of 3-13% over the patient's lifetime (Cancer Research UK). They discuss the typical presenting features, who needs an endoscopy to look for Barrett's, and how the condition is managed both in primary and secondary care. The BSG guidelines mentioned by Dr Moore in the episode can be found here: https://www.bsg.org.uk/clinical-resource/bsg-guidelines-on-the-diagnosis-and-management-of-barretts-oesophagus/

For more episodes about the oesophagus, you may find the following episodes of Ingest useful: Dyspepsia, Eosinophilic oesophagitis, Dysphagia and Achalasia.

BSG guidelines on the diagnosis and management of Barrett's oesophagus - The British Society of GastroenterologyFitzgerald RC, di Pietro M, Ragunath K et al. Abstract These guidelines provide a practical and evidence-based resource for the management of patients with Barrett’s oesophagus and related early neoplasia. The Appraisal of Guidelines for Research and Evaluation (AGREE II) […]www.bsg.org.uk

Bile acid diarrhoea

PCSG — Mon, 14 Aug 2023 09:51:08 +0000

In this episode, Charlie Andrews speaks to Professor Julian Walters about bile acid malabsorption and diarrhoea. With up to a third of patients with diarrhoea-predominant IBS having underlying bile acid diarrhoea, and with diagnosis rates for this condition being low, this episode is an important one for anyone working in primary care. We explore the role and physiology of bile acids, the causes and symptoms of bile acid malabsorption, the diagnostic tests used to make the diagnosis and the treatment of this common but underdiagnosed condition. Should we use 'trial of treatment' in primary care to support the diagnosis? Are people who have had their gall bladder removed at greater risk of bile acid diarrhoea? Can bile acid sequestrants impact the absorption of other medications? These questions, and lots more, will be discussed in this episode.

Key Learnings for Primary Care from this Ingest Podcast on Bile Acid Diarrhoea

Overview and Prevalence

Bile acid diarrhoea (BAD), also known as bile acid malabsorption, is a significant but under-recognized cause of chronic diarrhoea in primary care. It is more common than Crohn’s disease and ulcerative colitis combined, with a prevalence of about 1% in the general population-comparable to coeliac disease[1].
BAD is often misdiagnosed as IBS with diarrhoea (IBS-D); about one third of patients with IBS-D may actually have BAD[1].

Causes and Classification

BAD is classified into three types:
Type 1: Secondary to ileal disease or resection (e.g., Crohn’s disease, surgical removal of terminal ileum)
Type 2: Primary or idiopathic (often confused with IBS-D; thought to be due to overproduction of bile acids)
Type 3: Other causes affecting absorption, such as cholecystectomy, small intestinal bacterial overgrowth, or radiation[1].
Post-cholecystectomy BAD is relatively common, affecting about 1 in 10 patients after gallbladder removal[1].

Clinical Presentation

Patients typically present with chronic, watery diarrhoea (Bristol stool types 6–7), often frequent (4–12 times daily), sometimes nocturnal, and can be long-standing (sometimes decades)[1].
There is often a long delay in diagnosis; nearly half of patients wait over five years for a correct diagnosis[1].
BAD is frequently overlooked in differential diagnosis, with clinicians more likely to investigate for IBD, coeliac disease, or cancer[1].

Diagnosis in Primary Care

The key is to think about BAD as a possible diagnosis, especially in patients with chronic diarrhoea where other causes have been excluded[1].
The gold standard diagnostic test is the SeHCAT (selenium homocholic acid taurine) scan, which is widely available in the UK but not in all countries[1].
A retention value below 15% at seven days is diagnostic; lower values indicate more severe disease[1].
There is no simple blood test for BAD, unlike coeliac disease[1].
Empirical trials of bile acid sequestrants may be considered if SeHCAT is unavailable or in specific cases (e.g., pregnancy), but a confirmed diagnosis is preferred to guide treatment and improve adherence[1].
Before considering BAD, it is essential to exclude other causes of diarrhoea (negative coeliac serology, faecal calprotectin, and, depending on age, appropriate cancer screening)[1].

Treatment

First-line treatment is with bile acid sequestrants:
Cholestyramine: A powder taken in 4g sachets, usually started at night on an empty stomach for best effect (contrary to original cholesterol-lowering indications)[1].
Colesevelam: Large tablets, often preferred by patients, shown in recent trials to be effective and well-tolerated[1].
Treatment is often long-term and can significantly improve quality of life[1].
Side effects are mainly gastrointestinal (bloating, constipation, taste/texture issues), and adherence can be affected by formulation and dosing[1].

Practical Points for Primary Care

Consider BAD in any patient with chronic, unexplained diarrhoea, especially if IBS-D is suspected or post-cholecystectomy[1].
Early recognition and referral for SeHCAT testing can reduce diagnostic delay and improve outcomes[1].
Exclude other common causes of diarrhoea before initiating treatment or referral[1].
Educate patients about the chronic nature of BAD and the importance of adherence to therapy[1].

Summary Table: Key Points for Primary Care

AspectKey LearningPrevalenceCommon (1% of general population), often under-recognizedWho to suspectChronic watery diarrhoea, IBS-D, post-cholecystectomy, after ileal disease/resectionDiagnosisSeHCAT scan is gold standard; empirical therapy only if testing unavailableExclusionRule out coeliac, IBD, cancer before considering BADTreatmentBile acid sequestrants (cholestyramine, colesevelam); dosing and formulation affect adherenceImpactEarly diagnosis and treatment can transform quality of life

These learnings highlight the importance of awareness, structured diagnostic approach, and appropriate management of BAD in primary care to improve patient outcomes[1].

Sources [1] transcript-Bile-acid-diarrhoea.pdf https://ppl-ai-file-upload.s3.amazonaws.com/web/direct-files/attachments/46534945/90a7f27f-40c4-4c31-8a97-0789acc1b230/transcript-Bile-acid-diarrhoea.pdf

Faecal calprotectin

PCSG — Thu, 13 Jul 2023 10:08:47 +0000

In this episode, Charlie Andrews speaks to Dr James Turvill about faecal calprotectin use in primary care. Dr Turvill is a gastroenterologist based in York, who was instrumental in developing the NICE-approved and widely adopted York Faecal Calprotectin Care Pathway. What is calprotectin? When should we use it in primary care? How should we interpret the result? Can any medications or conditions affect the result? Listen on to find the answers to these questions!

The care pathway can be found here: https://www.yorkhospitals.nhs.uk/seecmsfile/?id=941. It is recommended that you have a look at this either before, after or during this episode to enhance your learning. Enjoy!

IBS - dietary management and the 10-minute consultation...

PCSG — Thu, 25 May 2023 10:59:58 +0000

Marianne Williams is an extremely experienced dietician, innovator, digital technology advocate and winner of the NHS England Allied Health Professional of the Year prize for 2018.

In this episode, Marianne shares her wealth of knowledge around all things IBS to discuss initial dietary management, the low FODMAPs diet, the role of probiotics, and gives us some great advice about how we can maximise our (often short) patient consultations with newly diagnosed IBS patients. Marianne also discusses her innovative dietetic-led gastroenterology clinic for IBS patients with us.

There is so much food for thought here, and so many useful nuggets of information throughout this episode. Sit back and tuck into this feast of information!

Useful links/websites discussed in the episode:

Patient Webinars website: https://patientwebinars.co.uk/

Monash university IBS grand tour: https://www.youtube.com/watch?v=Z_1Hzl9o5ic

Monash university app: https://www.monashfodmap.com/ibs-central/i-have-ibs/get-the-app/

IBS symptoms, the low FODMAP diet and the Monash app that can help See updated video for Irritable Bowel Syndrome (IBS) relief: Take the Monash University Low FODMAP grand tour down under! at https://www.youtube.com/watch?v=stdYoA4G9Dg

See more: IBS patient course: https://www.monashfodmap.com/online-training/patients-course/

Website: https://www.monashfodmap.com/

Monash FODMAP blog: https://www.monashfodmap ...www.youtube.com

BSG guidelines on the management of IBS: https://gut.bmj.com/content/gutjnl/early/2021/04/27/gutjnl-2021-324598.full.pdf

IBD Flare Management

PCSG — Mon, 24 Apr 2023 11:20:17 +0000

In this episode Charlie Andrews speaks to Dr Kevin Barrett about IBD flare management. On average, 50% of patients will flare annually, and often the GP surgery is the first port of call. We therefore need to know how to assess and manage patients presenting with symptomatic IBD. Kevin Barrett, IBD clinical champion for IBD for the RCGP and Crohns and Colitis UK (2017-2021) shares his wealth of knowledge about IBD flare management. We discuss how if can affect patient's quality of life, common symptoms of IBD flare, calprotectin testing and the management of IBD flare.

Updated guidance on FIT testing in primary care

PCSG — Fri, 24 Mar 2023 16:27:20 +0000

In this episode, Charlie Andrews speaks to Dr Kevin Monahan, lead author for the joint guidelines published by the BSG and ACPGBI in July 2022 outlining the role of FIT testing in patients with symptoms suggestive of colorectal cancer. These guidelines have informed how we use FIT in primary care, and in this episode he asks Dr Monahan how this guideline has changed clinical practice, they discuss when it should be used and what to do if you have ongoing concerns about your patient's symptoms. In addition, they discuss specific situations such as iron deficient anaemia, rectal bleeding, whether we can use it in younger age groups, and whether there is a role for repeat FIT testing.

A link to the full guideline can be found here: https://www.bsg.org.uk/clinical-resource/faecal-immunochemical-testing-fit-in-patients-with-signs-or-symptoms-of-suspected-colorectal-cancer-crc-a-joint-guideline-from-the-acpgbi-and-the-bsg/

Abnormal LFTs and non-alcoholic liver disease

PCSG — Fri, 17 Feb 2023 14:04:28 +0000

Did you know that according to the British Liver Trust, up to 20% of the general population has non-alcoholic liver disease ('fatty liver disease') and the prevalence is predicted to rise over the coming years. Morbidity associated with this can be significant, with a proportion of patients with fatty liver disease developing fibrosis of the liver as the disease progresses. Diagnosing fatty liver disease and identifying those at risk of progression to fibrosis is therefore important. In this episode I speak to Dr Helen Jarvis, a GP with a specialist interest in liver disease. We discuss an approach to the patient with abnormal LFTs, and we look at the common causes of abnormal LFTs, with a particular focus on non-alcoholic fatty liver disease. Helen demystifies the commonly used tests for assessing for fibrosis in fatty liver disease, and how we can empower our nursing teams to assess for fatty liver disease when abnormal LFTs are identified at chronic disease reviews.

Coeliac disease management and follow-up

PCSG — Thu, 22 Dec 2022 15:07:29 +0000

Join Charlie Andrews in this episode where he speaks to Cristian Costas about the management of people diagnosed with coeliac disease. Cristian is a dynamic dietician who is based in Bradford. He is passionate about coeliac disease and runs an innovative dietician-led service for those with coeliac disease in his area.

Cristian shares with us his top tips for supporting someone newly diagnosed with coeliac disease, including where to access support for those who are newly diagnosed, and how to avoid common dietary pitfalls. We discuss how best to follow-up people with coeliac disease, and key interventions such as assessments for osteoporosis and vaccinations for coeliacs.

We know that education and the support of a dietician are key interventions that can help patients manage the gluten-free diet effectively, and in this episode, Cristian shares his passion for improving the care for those with coeliac disease. An informative, enjoyable and inspiring listen!

Background to FIT testing in primary care

PCSG — Tue, 06 Dec 2022 16:46:38 +0000

In primary care, we are increasingly using FIT (Faecal Immunochemical Testing) to assess the risk of bowel cancer in patients with lower gastrointestinal symptoms, whilst the latest PCN DES IIF (Impact and Investment Fund) has given FIT a prominent role in risk stratifying 2-week wait referrals to secondary care.

In this episode, Mo Thoufeeq, a gastroenterologist in Sheffield, talks to me about what FIT is, how it differs from previously used FOBT (and why it is a more effective test!), and how we are using FIT in both symptomatic and asymptomatic patients. He shares his top tips about how to interpret, when to test and we discuss the tricky areas of patients with rectal bleeding and those with iron deficient anaemia.

Mo has a deep knowledge and understanding of FIT and provides a fantastic and relevant discussion of the topic for our primary care audience in this episode.