Case Studies in Luminal
Gastroenterology
Adam Harris
Consultant Gastroenterologist
The Spire Tunbridge Wells
Hospital
Luminal Gastroenterology
Learning objectives:
1. Avoiding foregut complications of NSAIDs
2. Understanding new dietary option in IBS
3. Understanding latest drug treatments in
constipation
Case Study 1
87 yr old woman with OA, nocturnal joint
pains, angina & bleeding DU 1999
Needs pain relief – what do you recommend?
NSAIDs & Bleeding ulcers
• PMH of ulcer bleeding who use NSAIDs are at highest
risk (20%) of re-bleeding
• Use NSAID plus standard dose PPI
• Despite this 4-8% will re-bleed in 6 months
Chan et al. New Engl J Med 2002; 347:2104-10.
NSAIDs
High Risk of Complications
• PMH PUD or bleed
• >65 yrs
• Longterm use; high dose
• More than one NSAID
• Co-prescribed steroids, clopidogrel or
warfarin
• Serious co-morbidities
Risk of gastro-duodenal ulcer
Placebo +
Aspirin
Naproxen +
Aspirin
Celecoxib +
Aspirin
8%
27%
19%
NSAIDs & PPIs
4 points to remember:
1. PPIs decrease risk of NSAID-associated GU &
DU cf placebo
2. PPIs equally effective whether non-selective
NSAIDs or COX-2 inhibitors
3. PPI co-therapy is effective in healing &
preventing recurrent ulcers with long term
NSAIDs
4. PPIs decrease risk of NSAID-associated
bleeding
Aspirin
4 points to remember:
1. Aspirin increases risk of UGIB 4 fold
2. Aspirin + other NSAID increases risk 8
fold
3. No difference in RR with EC or “junior”
4. Eradication of H pylori decreases risk of
ulcer
Lai et al. New Engl J Med 2002; 346: 2033-38
McQuaid KR, Laine L. Am J Med 2006; 119: 624-38
Arora G et al. Clin Gastro Hepatol 2009; 7: 725-35
Case Study 2
24 yr old female with 1-2 year of recurrent
low abdominal pain, bloating & intermittent
watery diarrhoea
Unemployed & lives alone
Normal examination
Blood tests, urine & stool culture normal
Faecal calprotectin <50
Low FODMAP diet
• Fermentable, Oligo-, Di-, Mono-saccharides and
Polyols
• Comprise fructose, lactose, fructans, galactans
& polyols
• Low FODMAP diet developed at Monash
University in Melbourne, Australia
FODMAPs in diet
•
•
•
•
•
Fructose eg fruits, honey, corn syrup
Lactose eg diary
Fructans eg wheat, onion, garlic
Galactans eg beans, lentils, legumes
Polyols eg sorbitol, avocado, apricots, plums
Low FODMAP
• FODMAP CHO trigger changes in fluid content &
bacterial fermentation in bowel leading to symptoms in
susceptible individuals
• Follow low FODMAP diet to eliminate fermentable
carbohydrates; trained dietician required.
• Eliminate from diet for trial period then re-introduce each
FODMAP carbohydrate gradually & record symptoms
• Reported (by enthusiasts) that up to 70% of patients
report improvement in symptoms
Case Study 3
28 yr old woman with 5 yr history of
constipation (BO 2 x/wk) with straining &
passage of hard stool; bloating & low abdo
discomfort
No incontinence. No neurological illness.
Examination & blood tests normal.
Tried fibre, lactulose, Movicol, Senna,
bisacodyl with limited or no benefit.
Differential Diagnosis?
Differential Diagnosis?
• IBS-C
• Idiopathic Slow Transit Constipation
• Functional Outlet Obstruction
Investigation?
Colonic Transit Marker Study
IBS-C
ISTC
Functional
Outlet
Obstruction
Treatment Options
• IBS-C
linaclotide (Constella)
• ISTC
prucalopride (Resolor)
• Functional Outlet Obstruction
Further assessment; surgery; biofeedback
Prucalopride
• 5-HT4 receptor agonist with entero-colonic
kinetic activity; not a laxative
• Women only
• Works within 2-3 hours
• ↑ spontaneous bowel movements: 67% vs
39% placebo (p<0.001)
• Improves symptoms of pain, bloating,
straining & tenesmus
Prucalopride
•
•
•
•
2mg od for 28 days
If no response: do not continue
1mg od: women>65 yr; liver/renal failure
AE: nausea; headache; abdo pain;
diarrhoea
• Cost: 28 x 2mg ≈ £60
Linaclotide
• Guanylate cyclase-C agonist
• Reduces visceral hypersensitivity, increases
intestinal secretion & accelerates transit
• Treatment of moderate-severe IBS-C in adults
• One capsule (290 mcg) od 30 mins before meal
• Interaction: OCP, thyroxine
• Adverse effect: diarrhoea (<20%)
• Cost: £37.56 for 28 days
Linaclotide
• 47% decrease in abdo pain over 26 weeks
(p<0.001 vs placebo)1
• 40% improvement in bloating over 26 weeks
(p<0.0001 vs placebo)1
• Increase in spontaneous bowel movements
from 1.7 to 5.7 weekly over 12 weeks (p<0.0001
vs placebo)2
• Improvement in QoL (p<0.01 vs placebo)
1. Quigley EM et al. Aliment Pharmacol Ther 2013; 37:49-61
2. Chey WD et al. Am J Gastroenterolo 2012; 107: 1702-12
Luminal Gastroenterology
Learning objectives:
1. Avoiding foregut complications of NSAIDs
2. Understanding new dietary option in IBS
3. Understanding latest therapies in constipation