Journal Watch

Below are some of the articles, which, over the past six months, have caught my eye either due to their general gastroenterological interest and/or their applicability in primary care. – Dr Jamie Dalrymple

Dysphagia in older adults

A recent article in Gut suggesting that capsaicinoids may improve the swallowing response in older adults is welcome news.  Currently there is no pharmacological treatment for oropharyngeal dysphagia (OD) but this may change.  This study showed that stimulation of transient receptor potential vanilloid type 1 with capsaicinoids reduced laryngeal penetrations by 50.% (p<0.05) and pharyngeal residue by 50.% (p<0.05), and shortened the time of laryngeal vestibule closure (p<0.001), upper esophageal sphincter opening (p<0.05) and maximal hyoid and laryngeal displacement when compared with thickeners and no treatment in the older adult.

Laia Rofes et al .  Natural capsaicinoids improve swallow response in older patients with oropharyngeal dysphagia Gut 2013;62:1280-1287

 

Clinical guidelines for the management of Lynch Syndrome (HNPCC)

Lynch syndrome (LS) is not commonly seen in primary care but as GPs with a special interest we are more likely to come across this condition in our clinical practice.   Lynch syndrome, previously known as Hereditary non-polyposis colorectal cancer, is characterised by the development of colorectal cancer, endometrial cancer and various other cancers at an early age.

Guidelines are designed to describe the most appropriate treatment for families with this condition with the objective of answering 10 questions

1. – How can the identification of LS be improved?
2. – What is the optimal surveillance protocol for LS?
3. – Hoe effective is the surveillance of endometrial and ovarian cancer?
4. – What is the role of prophylactic hysterectomy with and without oophorectomy?
5. – What is the effectiveness of surveillance of other cancers?
6. – What is the appropriate surgical treatment for CRC?
7. – Does environmental and lifestyle factors influence the development of adenomas or CRC in LS?
8. – What is the role of aspirin?
9. – What is the role of genetic counseling in LS?
10. – What are the psychological implications of genetic testing and surveillance in LS?

To answer these questions the authors employed a systematic literature review and then discussed the evaluation of the studies at a number of workshops.  The paper makes a number of recommendations based on their deliberations and the full text can be accessed free and on-line at (http://gut.bmj.com/content/early/2013/02/20/gutjnl-2012-304356.full)

In summary this condition is not considered and under diagnosed in the appropriate circumstances.  However genetic testing may have psychological consequences and these need to be considered.  They concluded that prospective controlled studies should be undertaken to improve further the care of these families.

Hans F A Vasen¹ et al

Revised guidelines for the clinical management of Lynch syndrome (HNPCC): recommendations by a group of European experts Gut 2013;62:812-823

 

Anxiety and sigmoidoscopy

The conclusions of a study published in the Southern Medical Journal in April of this year will not surprise any of us who are endoscopists or indeed anyone with a modicum of common sense.  Patients with high levels of anxiety have more pain and discomfort during a screening sigmoidoscopy and this is inversely related to the level of satisfaction.  There is nothing like an article that states the obvious in statistics!

Carter XW et al Role of anxiety in the comfort of nonsedated average-risk screening sigmoidoscopy Southern Medical Journal;2013;106 (4):280-4

 

How long does it take to eradicate H.pylori?

A paper from Canada suggests that we should be treating H.pylori for up to 14 days.  The authors report that in the real world this improved the eradication rates and was well tolerated.  They also reported that a multivariate analysis showed that adding yoghurt to the regime did not improve side effects nor did it have any effect on eradication rates.  Perhaps this should be considered if the standard 7-day regime does not clear Hp.

Fallone C, Barkun A, Szilagyi A, Herba K, Sewitch M, Martel M, Fallone S. Prolonged treatment duration is required for successful Helicobacter pylori eradication with proton pump inhibitor triple therapy in Canada. Canadian Journal of Gastroenterology 2013;27 (7):397-402

 

Vitamin D deficiency and alcoholic liver disease

We are all familiar with giving vitamin supplements to patients with alcoholic liver disease (ALD) but what about Vitamin D.  It is well known that advanced liver disease is associated with low vitamin D levels but its influence on ADL is poorly understood.

A paper in the Journal of Hepatology examined this association and suggested that 25-hydroxyvitamin D 25(OH)D deficiency was associated with increased liver damage and might act as a biomarker as low 25(OH)D levels were associated with increased liver damage and mortality in ALD.  Furthermore, 25(OH)D may represent a potential therapeutic target for this condition.

Trépo E, et al.  Marked 25-hydroxyvitamin D deficiency is associated with poor prognosis in patients with alcoholic liver disease.Journal of Hepatology 2013;59(2):344-50.

Probiotics and diarrhoea

The probiotic debates rages on but an article published online by the Lancet in August this year suggests that they are of no use in Antibiotic Associated Diarrhoea (AAD) or in preventing Clostridium difficile diarrhoea (CDD).  This double blind trial used a combination of Lactobacilli and bifidobacteria in patients older than 65 years given one or more oral or parenteral antibiotics.  They concluded that there was no evidence that a multistrain preparation of probiotics was effective in reducing AAD or CDD.  In addition, the authors suggested that an improved understanding of the pathophysiology of AAD is needed to guide future studies.

Allen S, et al. Lactobacilli and bifidobacteria in the prevention of antibiotic-associated diarrhoea and Clostridium difficile diarrhoea in older inpatients (PLACIDE): a randomised, double-blind, placebo-controlled, multicentre trial. Lancet 2003;382:1249-1257

Helicobacter pylori infection in laryngeal diseases

As the list of diseases associated with H.pylori waxes and wanes a prospective case-controlled study from Lithuania suggests that this organism might be associated with benign laryngeal disease and laryngeal cancer.  This was quite a small study with even fewer controls but it does rekindle the controversy of the pathogenicity of H. pylori.  Much more research is required; in particular, sub-typing of H.pylori must be included in the stratification of the data.

Siupsinskiene N, et al. Helicobacter pylori infection in laryngeal diseasesEuropean Archives of Oto-Rhino-Laryngology 2013;270(8):2283-8.

Olmesartan and Sprue-like Enteropathy

It may of interest that the in July of this year, the FDA changed the Summary of Product Characteristics  (SPC) for Olmesartan to include Sprue-like Enteropathy.  This followed the publication of a study in the Mayo Clinic Proceedings.

The enteropathy may develop months to years after starting olmesartan, and sometimes requires hospitalisation. The FDA recommended that if patients taking olmesartan develop these symptoms and no other cause is found, the drug should be discontinued, and therapy with another antihypertensive started. Discontinuation of olmesartan has resulted in clinical improvement of sprue-like enteropathy symptoms in all patients.

Sprue-like Enteropathy has not been detected with angiotensin II receptor blocker (ARB) drugs other than olmesartan.

Jan Menne, MD, Hermann Haller, MD.  Olmesartan and Intestinal Adverse Effects in the ROADMAP Study.  Mayo Clinic Proceedings 2012;87(12): 1230-1231