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Developments in primary care gastroenterology

Richard Stevens
MA BM BCh DRCOG FRCGP
GP
East Oxford Health Centre
Oxford
Chairman
Primary Care Society for Gastroenterology

Dyspepsia is associated with high - some would say disproportionate - drug costs. Accordingly this has been a favourite target for prescribing advisors, but with the first of the proton pump inhibitors (omeprazole) coming off patent and generics shortly becoming available, this cost may fall. However, as the use of these agents continues to rise it is uncertain whether this will greatly affect the total sum spent (around £450 million per annum in the UK).

Taken as a whole, gastroenterological cancers are relatively common. Colorectal cancer fulfils all the criteria of a condition that is suitable for screening, and any such screening programme will have some impact on general practitioners. It is likely that some programmes will be set up in the next few years, although the form they will take continues to be debated.

Existing screening programmes are organised at either practice level (cervical screening) or health authority level (breast screening), but for any new screening programme the primary care trust (PCT) may be the appropriate level of organisation. Cancers of the stomach and oesophagus are notoriously difficult to diagnose early and are consequently associated with poor prognoses. Making an impact on these malignancies is probably dependent on having rapid access to diagnostic facilities.

Access to gastroenterological investigations, principally endoscopy, is patchy and often unacceptably slow. The new NHS structures allow for improvement through increased flexibility, possibly using general practitioner and nurse endoscopists working in community-based units. There is a real prospect for PCT-wide strategies for conditions such as dyspepsia and rectal bleeding to be developed that can link the available resources to criteria for referral, investigation, management and treatment.

Management of Helicobacter pylori in primary care
The publication of the Maastricht 2-2000 guidelines on the management of Helicobacter pylori in primary care is potentially highly significant.(1) These are consensus statements drawn up by international experts, including representatives from primary care.

After examining the evidence a number of recommendations were made and graded according to the supporting evidence. The key recommendations are set out in Table 1.

[[NIP07_table1_69]]

As always, it is hard to interpret such a set of recommendations. Are they pointing out best practice according to the evidence or are they meant as guidelines for immediate implementation?

Current practice in the UK probably falls far short of these standards, and there are considerable resource implications. For example, breath testing is not routinely available to GPs, and stool antigen testing almost never available. Similarly, if all patients starting nonsteroidal anti-inflammatory drugs (NSAIDs) were tested for H. pylori and, if necessary, had H. pylori eradicated, there would be significant drug budget implications.

Irritable bowel syndrome
Irritable bowel syndrome (IBS) is a common condition, affecting up to 17% of the UK population. It has a significant impact on quality of life and important resource implications for the NHS. Some estimates indicate that about half of all referrals to gastroenterology outpatients are for functional conditions. Significant numbers of patients are also seen in other departments such as gynaecology and surgery. Indeed, excessive rates of surgical procedures are reported in IBS patients.(2)

The problems for the GP are to make a diagnosis that is comfortable for both the patient and the doctor and to manage the symptoms adequately. There are a number of systems for classifying IBS that can be used to make the diagnosis in young patients who do not have any alarm symptoms.

The latest of these are the Rome II criteria, devised mainly as a research tool,(3) and many GPs may find patients who they consider have IBS but who fall outside this definition.

The mainstay of management is still to give the patient an adequate explanation of the condition and to address their concerns. Noncolonic features such as tiredness, back pain, urinary and gynaecological symptoms are sometimes associated with the condition. At present, drug treatment can be targeted only at symptom relief.

The Primary Care Society for Gastroenterology has produced evidence-based guidelines for managing IBS in general practice.(4) These guidelines include a meta-analysis of the efficacy of drug treatments in treating the symptoms of IBS.

Table 2 summarises the evidence for therapies in IBS. The quality of therapeutic trials in IBS is variable, large placebo effects occur, and most trials have been conducted on secondary care populations.

[[NIP07_table2_71]]

New drugs for treating IBS have been developed and are currently being trialled. Their effectiveness, safety and indications will come with further experience of their use. Their advent will require general practitioners to be adept at diagnosing IBS and its various subgroups.

Hepatitis C
The hepatitis C virus was first cloned in 1989, but blood products were not routinely screened until 1991. It is therefore a relatively new condition, but one that has a potentially great impact.

It is estimated that there are between 200,000 and 400,000 people in the UK who carry the virus.(5)
 
Studies of the risk factors among newly presenting patients have found that a history of intravenous injecting is the most common (40%).(6) However, the second largest group have no identifiable risk factor. Moreover, as the initial episode of the disease may be asymptomatic and go unnoticed, the first presentation is often of advanced liver disease.

One in five patients with hepatitis C will progress to cirrhosis within 20 years. The drug costs of treating the disease are high, and hepatitis C is a frequent ­indication for liver transplant.

For the GP, this means that there may be several undiagnosed cases (perhaps on average 7-14 per GP) who may go on to develop serious liver disease. Testing for hepatitis C, with all the implications that follow the diagnosis, requires thought and counselling, and it is a condition that has significant resource implications for the NHS.

In the next few years, hepatitis C is likely to have a major impact on general practice. Liver function is being measured more often in conjunction with ­monitoring such drugs as statins, and unexpected abnormalities will occur more frequently.

Access to diagnostic services
Perhaps the greatest change in primary care gastroenterology in the near future will be an organisational one. Endoscopy is the investigation of choice for many GI symptoms but is often restricted and has long waiting times.

Many of the recent or proposed changes to the NHS may alter this. PCTs are now commissioning services and can increase capacity by taking diagnostic endoscopy out of acute hospital units. With suitable patient selection, diagnostic endoscopy has been shown to be safe,(7) and a number of areas now have services that operate outside consultant-led units. These are usually staffed by GP endoscopists (of whom there are around 250 in the UK). There are obvious issues of accreditation, revalidation and adequate remuneration, which are, in part, being addressed by the development of the grade of GP with a special clinical interest.

Local guidelines and care pathways are likely to be devised around PCT resources in the future.

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References

  1. Malfertheiner P, Megraud F, O'Morain C, et al. Current concepts in the management of Helicobacter pylori infection - The Maastricht 2-2000 Consensus Report. Aliment Pharmacol Ther 2002;16:167-80.
  2. Burns DG. The risk of abdominal surgery in irritable bowel syndrome.S Afr Med J 1986;70:91.
  3. Thompson WG, Longstreth GF, Drossman DA, Heaton KW, Irvine EJ, Muller-Lissner SA. Functional bowel disorders and functional abdominal pain. Gut 1999;45 Suppl II:II43-II47.
  4. Primary Care Society for Gastroenterology. Irritable Bowel Syndrome: guidelines for general practice. Oxford: Primary Care Society for Gastroenterology; 2001.
  5. Dow BC, Coote I, Munro H, McOmish F, Yap PL, Simmonds P, et al. Confirmation of hepatitis C virus antibody in blood donors. J Med Virol 1993;41:215-20.
  6. Memon MI, Memon MA. Hepatitis C: an epidemiological review. J Viral Hepat 2002;9:84-100.
  7. Galloway JM, Gibson J, Dalrymple J. Endoscopy in primary care - a survey of current practice. Br J Gen Pract 2002;52:536-8.

Resources
Primary Care Society for Gastroenterology
T:01865 226960  F:01865 227036
W:www.pcsg.org.uk
IBS Network
T:0114 2611531
W:www.ibsnetwork.org.uk
British Society of Gastroenterology
T:020 7387 3534  F:020 7487 3734
W:www.bsg.org.uk
British Liver Trust
W:www.britishlivertrust.org.uk

Events
Primary Care Society for Gastroenterology Annual Scientific Meeting
18 October 2002
Birmingham
British Federation of Primary Care Societies
Inaugural meeting Spring 2003
Birmingham
British Society of Gastroenterology 23-26 March 2003
Birmingham