Episode Transcript
[00:00:04] Speaker A: Welcome to this Ingest Christmas special. Ingest is the podcast series designed for primary care and brought to you by the Primary Care Society for Gastroenterology.
My name is Charlie Andrews, your host and a GP of an extended role in gastroenterology based Near Bath. This episode is slightly different from usual. So this is the 12 days of gutmas and we are going to go through the 12 days of Christmas with a gastroenterology feel to it. We're going to be going through each of the days and we're going to be picking out a really useful key learning point from each of them.
I want to say a big thank you first of all to the Minims Musical Theatre Choir who have put together the song for us. It is, I hope you'll agree, a great song. They have done a fantastic job on it and we're going to head into it and start to do some learning.
[00:01:04] Speaker B: On the first day of Christmas my true love sent to me A PPI in a pear tree.
[00:01:13] Speaker A: So our first day of Christmas is around PPIs, proton pump inhibitors, massively common prescription drug in the UK. Tens of millions of prescriptions are made of it every year.
The key learning point here is, is that it's really important to reduce the dose gradually when you're taking patients off PPIs in order to prevent rebound acid hypersecretion. When you give someone a PPI to treat acid reflux or epigastric pain, this is blocking the acid secreting cells, the parietal cells, preventing them from pumping acid into the stomach lining. As a result of that, what the body does is it upregulates gastrin. Gastrin is what stimulates acid secretion in the stomach. So when you're on a ppi, there's huge amounts of gastrin being secreted to try to overcome this blockage. So you can imagine that when you stop that ppi, you get a sudden surge of acid into the stomach. So that's why we need to come off the PPIS slowly to prevent this acid hyper secretion following withdrawal of PPIs.
So now let's move on to the second day.
So we're on day two and day two is about gastric ulcers. So two really common causes of gastric ulcers. Non steroidal anti inflammatories, accounting for about 10 to 20% of gastric ulcers and, and H pylori, accounting for 70 to 80% of gastric ulcers. So a really, really common cause and they are responsible for nearly all duodenal ulcers.
Couple of things just to remember about gastric and duodenal ulcers. So gastric ulcers produce pain with meals. Duodenal ulcers generally cause pain two to three hours after meals, something that we might remember from our medical school exams or when we were at school learning around gastric ulcers. But gastric ulcers, pain with meals, duodenal ulcers, delayed onset pain comes with that D at the beginning of duodenal delayed pain two to three hours after a meal. So let's go on to day three.
[00:03:27] Speaker B: On the third day of Christmas, my true love came to me.
Three CN tests, two gastric ulcers and a PPI in a pear tree.
[00:03:40] Speaker A: So day three is about celiac disease tests. So tests for celiac disease. There are in fact three different groups of coeliac disease tests. So it does work with the numbers. So we have serology tests. So tissue transglutaminase and EMA or endomysial antibody tests. These are serology based tests. They are IGA based tests with a hugely good sensitivity and specificity in excess of 95% for diagnosing or excluding coeliac disease. So really reliable tests and generally our first line. But they do rely on a normal IGA level and about 2 to 3% of people with coeliac disease have deficiencies. So really important to test for total IGA as well. The other key point here, remember, the patient needs to be consuming gluten for at least six weeks before the test is done. Otherwise you might end up with a false negative result and you need to advise them to carry on doing that until they've had their confirmatory endoscopy with histology.
I did say there were three different groups of tests. There certainly are. So we've seen serology, there are genetic tests, so that's HLA, DQ2 and DQ8.
This essentially tells us whether patients have susceptibility for coeliac disease. Unfortunately, about 40% of the general population also have this HLA genotype. So it is not perfect. If you don't have this HLA genotype, it's extremely unlikely that you'll develop coeliac disease. But unfortunately, if you have it, it doesn't mean that you definitely have. So a little bit confusing, but not a great test, but some role for it, certainly within pediatric guidelines. And finally, the invasive test. So the final type of test is the invasive test at endoscopy D1 and D2 biopsies. So from the duodenum to have a look at the lining of the small bowel and assessing for atrophy and villous blunting.
Let's go on to day four.
[00:05:35] Speaker B: On the fourth day of Christmas, my true love came to me.
Four red flags, three CF tests, two gastric ulcers and a PPI in a pear tree.
[00:05:50] Speaker A: So we're on to day four. What do we have for day four? Well, we've got four red flags, so GI red flags are really important to identify, should be a key part of our history taking whenever seeing a patient with any upper GI or lower GI symptoms.
The upper GI ones that I want to highlight are dysphagia and weight loss. So really important red flags to assess for esophageal cancer in particular, but also thinking around gastric and pancreatic cancer. And then the lower GI ones that I want to think about are PR bleeding. So rectal bleeding and unexplained iron deficiency anaemia. We certainly need to be exploring these further with more appropriate tests.
Onwards to day five.
[00:06:31] Speaker B: On the fifth day of Christmas my true love gave to me Five golden stools, four red flags, three CF tests, two gastric ulcers and a PPI in a pear tree.
[00:06:50] Speaker A: So day five, so five golden stools. Well, the Bristol stool chart doesn't have five golden stools, it has seven. So type one to type seven stool types. I always find this a really useful chart to have open when I'm discussing stool consistency with patients. It avoids the need to talk about different types of food and food consistency. So my advice, have the bristle stool chart ready when you're talking to a patient about stool consistency, you can go through it from type one to type seven and they can point and tell you what they are experiencing.
Now let's go on to the sixth day.
[00:07:27] Speaker B: On the sixth day of Christmas, my true love came to me.
Six scopes of snake in, five bottom stools, four red flags, three sea tests, two gastric ulcers and a PPI in a pear tree.
[00:07:48] Speaker A: So we've reached the sixth day. We're at the halfway mark of the six days of gutmas. So we've got six scopes of snaking. Well, this one is looking at the main indications for endoscopy and I've got six that I'm going to run through here. So there are three different groupings. So the first one is diagnostic. So a diagnostic indication for endoscopy. That could be dyspepsia for upper GI endoscopy or IBS type symptoms. So chronic diarrhea.
For a lower GI endoscopy, the next grouping is surveillance. So we use endoscopy for surveillance and we do that for things such as surveillance endoscopy for Barrett's esophagus, and that's an upper GI endoscopy or polyps surveillance. So surveying polyps in the colon, the third indication is therapeutic. And the therapeutic options that I'm going to throw at you here are radiofrequency ablation and treatment of Barrett's oesophagus. So treating that precancerous condition, Barrett's esophagus, with endoscopic treatment. So radiofrequency ablation or endoscopic mucosal resections. So they can do that via an endoscope. Very smart people can do that.
Or we've got polyp removal. So large polyps can be removed from, for example, the colon or even the stomach using therapeutic endoscopy techniques.
Let's move on to day seven.
[00:09:08] Speaker B: On the seventh day of Christmas, my true love came to me.
Seven lizards spinning, Six goats are snaking. Five golden stools, four red flags, three celiac tests, two gastric ulcers and a PPI in a battery.
[00:09:30] Speaker A: So the seventh day is dedicated to liver disease and it's about liver failure. So we're going to look at seven causes of liver failure. So firstly we've got excess alcohol intake, so alcoholic hepatitis and alcoholic disease. We've got paracetamol overdose. For our second, we have drug induced causes. For our third we have autoimmune hepatitis. For our fourth we have Wilson's disease. For our fifth, for our sixth we have haemochromatosis. And for our seventh we've got viral hepatitis, so chronic hepatitis B and C. But let's not forget progressive failure from metabolic associated liver disease. So masld, we shouldn't forget that that can also in some situations lead to liver failure.
Now we'll move on to day eight.
[00:10:21] Speaker B: On the eighth day of Christmas, my true love came to me.
Eight infants feeding, seven livers failing. Six comes a snake in. Five golden stools, four red flags, three CF tests, two gastric ulcers and a PPI in a pear tree.
[00:10:45] Speaker A: So day eight has given us eight infants feeding. And this doesn't work with the numbers at all. But I did want to bring in the importance of feeding and the microbiome because these are important and very topical subjects and I think that they're going to become more important as time goes on.
So we know that the method of Feeding an infant is very important for promoting a healthy gut microbiome.
Breast milk is the ideal food for a healthy microbiome. And so we should be encouraging patients to breastfeed and supporting them where we can.
Breast milk creates something called HMOs, so human milk oligosaccharides, these are produced in breast milk and are not digestible by the human body, but are by the good bacteria that we want to promote in the bowel of the infant. And this is the Bifidobacteria species. So these species love human milk oligosaccharides, HMOs, they're very difficult to replicate in bottle feeding. And so what we do find is that the microbiome between a child that's bottle fed and a child that is breastfed is very different. So we want to try and encourage that really good start in life by supporting that healthy gut microbiome through breastfeeding where possible.
Onwards to the ninth day.
[00:12:07] Speaker B: On the ninth day of Christmas, my true love came to me.
Nine miles a rushing Eight infants feeding, seven liver sp Six stones of snaking, Five golden stools, Four red flags, Three celiac tests, Two gastric ulcers and a PPI in a pen.
[00:12:33] Speaker A: The ninth day gives us nine bowels of rushing. So diarrhea, really common finding in primary care and something that we deal with an awful lot within gastroenterology. And I wanted to highlight a really important cause of diarrhea, something that is perhaps under diagnosed, maybe under recognised, but that is bile acid diarrhea. We got a fantastic episode on bile acid diarrhea previously, so have a listen if you haven't heard it already. But it's an extremely common cause of IBS symptoms with diarrhea. So it's believed that up to about 40% of people with IBS D or IBS with diarrhea actually have bile acid diarrhea that could be amenable to treatment with, for example, bile acid sequestrations. The risk factors for bile acid diarrhea include ileal resection, so loss of part of the small bowel where bile acids are reabsorbed. Other ileal diseases that affect that area, such as Crohn's disease, cholecystectomy. So having the gallbladder removed can impact bile acid movement through the gut.
And obviously we've got that large umbrella of idiopathic. So we don't quite know why a lot of people get it. But there are some things that we can try and look out for in our history taking to try to identify, but we need to keep it on the radar. Bile acid diarrhea, common cause of IBS with diarrhea.
Now, let's go on to the 10th day and we've got some lords with a problem.
[00:13:58] Speaker B: On the tenth day of Christmas, my true love came to me.
Ten lords with bleeding, Nine boughs a rushing, Eight infants feeding, seven livers wailing, six of sustaining, five golden stools, four red flags, three sea attests to.
[00:14:26] Speaker A: So on day 10, we've got, as I said, some lords with a bit of an issue.
Ten lords with bleeding. So we're going to look at 10 causes of abnormal gastrointestinal bleeding. So 10 causes. Here we go. Number one, colorectal cancer, obviously needs to be really high on our agenda.
Number two, gastric and esophageal cancer. Again, another really important cause that we need to consider.
Third cause is gastritis or erosive gastritis. Fourth cause is a bleeding ulcer. So peptic ulcer disease. Another common reason that we need to be considering.
Number five is Mallory Weiss tear within the esophagus as a result of significant vomiting or retching.
Number six is haemorrhoids or anal fissures. Number seven is liver disease. So coagulopathy as a result of liver disease can lead to bleeding.
Number eight is inflammatory bowel disease, especially proctitis and ulcerative colitis, where these are fairly cardinal symptoms. Rectal bleeding. Number nine, angiodysplasia, gets more common as people get older. So vascular malformations within the small bowel, for example, and then our final cause is diverticular disease.
So now let's go on to our penultimate day, the 11th day.
[00:15:40] Speaker B: On the 11th day of Christmas my true love gave to me 11, my proceeding 10 doors with bleeding. Nine vowels, a rushing, eight infants feeding. Seven livers failing, six drips a snake in. Five golden stools, four red flags, three Celia tests, two gastric ulcers and a PPI in a pantry.
[00:16:08] Speaker A: So we're on to day 11 and this is our penultimate day. So nearly at the end, and we're back to the microbiome. So 11 microbes seeding.
So again, I want to talk a little bit about the microbiome. It doesn't fit the numbers, but it's still really important. So, 11 microbes seeding. We certainly have a lot more than that in our. In our gut. We have trillions of microbes living within our human gut.
About 50% of cells in the human body are microbial cells, an amazing number. And we have thousands of different species of bact bacteria and microbes living within our gut alone. So huge number.
We know that birth is a really key moment for implanting a healthy microbiome.
And so the birth method can have a big impact on the early microbiome development. So if you are born via cesarean section, you will come into contact first with skin microbes, whereas if you're born via vaginal delivery, you will come into contact with vaginal microbes. And they have very different compositions.
And it's believed that the vaginal microbiome really sets a healthy microbiome at that really early stage of life. And that really early stage of life also appears to be really important for the development of the immune system. So the immune system will be coming into contact with these microbes across the gut barrier. And so the type of microbes that we have within the gut are really important for training the immune system to recognize friend from foe. And so there is some evidence that if the initial microbiome that we are presented with is not as good as it should be, so is not that sort of that vaginal microbes, bifidobacteria lactobacilli, then there is a higher risk of things like allergic and immune mediated illnesses later on in life.
And now finally, let's move on to day 12.
[00:17:59] Speaker B: On the 12th day of Christmas, my true love gave to me.
12 gats are running, 11 microseeding, 10 lords are bleeding, 9 bars are rushing, 8 infants feeding, 7 livers bathing, 6 scrubs, a snaking, 5 golden stools, 4 red flags, 3 cfs, 2 gastric ulcers and a PPI in a pantry.
[00:18:32] Speaker A: So Day 12 and this one really brings it all together, thinking about 12 causes of abdominal symptoms that all GPs need to keep in mind. So 12 conditions that we need to have on our radar whenever we see a patient with all sorts of abdominal symptoms. So first one ibs, second one, lactose intolerance can certainly happen after people have had a GI upset, for example.
Next one we've got is celiac disease, under recognized but really important.
The fourth one is gastroenteritis, really common and, you know, happens at all times of year. We see norovirus spreading through the community, so we need to also be thinking about that. But often it's a very obvious presentation. The fifth one we have is sibo, so small intestinal bacterial overgrowth.
Sixth one is inflammatory bowel disease. Number seven, diverticular disease number eight, really important colorectal cancer ulcer. Number nine is peptic ulcer disease. Number ten is gallstones and biliary colic. Don't forget abdominal pain could be a biliary cause. So we've got to have that in mind when we think about it.
Number 11 is pancreatic insufficiency. So thinking about diarrhea and weight loss, think about pancreatic insufficiency. And our final one that we shouldn't forget about is medication related causes. So things like metformin, antibiotics and non steroidal anti inflammatories.
So that is the end of the twelve days of Gutmas. I hope you've enjoyed some of the learning points.
It stimulated you to have a think about some of these things and maybe delve into some of these topics in more detail. If it has done that, then just go back to some of our episodes around things like bile acid diarrhea, celiac disease, iron deficiency, anaemia. Really really good episodes that can help deepen and broaden your knowledge about these topics. We have lots of new episodes coming out in 2026. Things like the microbiome we're going to be looking at microscopic colitis. Got all sorts of great episodes coming up for you. So finally, thank you so much for listening and I just want to say a huge thank you once again to the Minims Musical Theatre Choir for some fantastic singing and for getting involved in this project. So thank you so much and I look forward to seeing you and speaking to you in 2020.
