Autumn 2017 GASTROENTEROLOGY - PowerPoint Presentation

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Autumn 2017

GASTROENTEROLOGY

Recognition of the multiple symptoms associated with alcohol misuseAppreciation of the importance of a comprehensive drug and alcohol history in all patients with gastroenterological and hepatic symptoms

Explanation of the association between illicit drug use and viral hepatitisLEARNING OUTCOMES

Substances cause a range of physical problems eg vascular and carcinomatous complications of the stomach

Injecting drug users are at high risk of hepatitis B due to sharing injecting equipment and sexual contactViral hepatitis (especially hepatitis C) is common in injecting drug users and in people who snort cocaineSynthetic drugs e.g. ecstasy lead to digestive and hepatic damage, vascular complications of the stomachCONTEXT

Alcohol causes hepatitis, fibrosis and cirrhosis of the liver; colon and rectal cancerNutritional deficiencies eg vitamin B, vitamin C and iron can lead to stomatitis and glossitis

Cocaine leads to gastric ulcerations, retroperitoneal fibrosis, visceral infarction, intestinal ischemia, gastrointestinal tract perforationCONTEXT (contd)

StomatitisGlossitisReduced saliva productionEnlarged

adipose glandsLeukoplakia, erythroplakia, submucous fibrosis of oropharyngeal mucosaOral lichen planus

COMMON PRESENTATIONS

Disrupted oesophageal functionOesophagitis , gastritis, doudenitis

Oesophageal and gastric varicesMalnutrition due to altered small bowel functionAcute and chronic pancreatitisCOMMEN PRESENTATIONS (contd)

Poor diet and nutrition Poor immunity Damage to the digestive system as a result of packages of drugs being hidden in orifices

e.g. rectum, vagina or ingested Self medication in order to treat heartburn and acid indigestionGastro intestinal bleeding including Mallory-Weiss tearSPECIAL FEATURES

Patients may not consider the effect that their substance use has on their systemFear of symptoms which may be life threateningLack of detection of recognition by doctors in screening for substance use in patients presenting with gastro intestinal disorders

BARRIERS TO DETECTION

A careful history with details of current and past substance misuse is essentialDetails of alcohol use are mandatoryNausea and vomiting is caused by disorders of digestive tract and the brain

Alcohol use causes pain, nausea, vomiting and hematemesis from Mallory-Weiss tears ASSESSMENT

Opioid analgesics can cause nausea and vomiting Abdominal pain, diarrhoea and constipation are common with licit and illicit drugsAcute liver failure presents with deepening jaundice, confusion, coma and death is caused by many drugs particularly ecstasy

Cocaine can present with ischemic colitis from intestinal thrombosisASSESSMENT (contd)

Since 1988 injecting drug users have been targeted for vaccinationAvailability of vaccination and uptake remains poor so needs to be proactive A harm reduction approach is the focus of management

Diagnosis includes endoscopy, histopathological testing, x-rays, scans, routine blood testsAlcohol detoxification should be consideredTREATMENT

Reduction of harmful drugs and substitute medication eg methadone should be prescribedIf reduction is declines, reduction of harmful practices should be encouraged

Safe injecting practices, vaccination for BBV, and provision of clean injecting equipmentAll patients must be tested for hepatitis and appropriate therapy offeredTREATMENT(contd)

Vaccinate all drug users against Hepatitis A as they at risk due to poor living conditions and fecal contamination of drugs and injecting equipment

Hepatitis A is available as a single component vaccine and combined with hepatitis B Single component hepatitis A vaccine is preferable to combined hepatitis A and B vaccineFor single vaccine give 2 doses and second dose after 6-12 monthsThe second dose may be delayed for up to 3 yearsWhen deciding on the optimal regime consider if the patient will return for subsequent doses

HEPATITIS A

About 21% of injecting drug users have past or current hepatitis infectionVaccinate all drug users against hepatitis BUse accelerated 0, 7and 21 days schedule to complete the course as quickly as possible

Partners and children should be offered vaccination HEPATITIS B

Screening and diagnosis of infection enables patients to understand how they can implement life changes to slow the rate of progressionThere is no vaccine available

Consider anti viral treatment in chronic hepatitis CHEPATITIS C

Referral to specialist addiction services for further assessment, advice and treatmentThis may include motivational interviewing, group, individual or family behavioural treatments to reduce substance use

Primary care teams can advise and monitor gastrointestinal symptoms and may have the skills to manage substance problemsREFERRAL, NETWORKS AND SERVICES

Substances and associated conditions

Appleby, VJ;

Darnbrough,E;

Forrester,K; Simpson,R;

Clarke,C; Moreea

S. (2015) PTU-118 An audit of the prevalence of chronic hepatitis c and treatment outcomes in drug users attending substance misuse centres in Bradford – planning for future service provision Gut ;64:A114 doi:10.1136/gutjnl-2015-309861.233

http://

gut.bmj.com/content/64/Suppl_1/A114.1.abstract?eaf

Badrakalimuthu

, V.R,

Rumball

, D & Chawla, A (2011)

Hepatitis

C: a patient’s journey from a psychiatrists’ perspective. Advances in psychiatric treatment.

Barclay, G.A, Stewart, J.B, Day, C.P and Gilvarry, E (2008) Adverse physical effects of alcohol misuse. Advances in psychiatric treatment. Vol.14,

139-151

EASL Hepatitis C Guidelines

2016

:

http

://

www.easl.eu/research/our-contributions/clinical-practice-guidelines/detail/easl-recommendations-on-treatment-of-hepatitis-c-2016

Kumar P and Clark M (2009) Clinical Medicine. 7th

edn

. London: Elsevier

NICE (2004) Hepatitis C - pegylated interferons, ribavirin and alfa interferon (NICE technology appraisal,TA75) http://guidance.nice.org.uk/TA75

This

guidance replaces Hepatitis C - alpha interferon and ribavirin (TA14).

This

guidance is extended by Hepatitis C -

peginterferon

alfa and ribavirin

(

TA106).

http://

guidance.nice.org.uk/TA75

NICE (2006) Hepatitis B (chronic)

-

adefovir

dipivoxil

and pegylated interferon alpha-2a (NICE technology appraisal,TA96)

http://

guidance.nice.org.uk/TA96

This

guidance has been partially updated by CG165 Hepatitis B (chronic

)

NICE (2013) Hepatitis B (chronic): Diagnosis and management of chronic hepatitis B in children, young people and adults

http://

www.nice.org.uk/guidance/cg165

NICE (2010) Hepatitis C - peginterferon alfa and ribavirin (NICE technology appraisal,TA200) http://guidance.nice.org.uk/TA200Public Health England. Health Protection Report II (26) July 28 2017. Hepatitis C in the UK Annuals Report https://www.gov.uk/government/publications/health-protection-report-volume-11-2017/hpr-volume-11-issue-26-news-28-july

REFERENCES