This episode of Ingest discusses why we should be testing more strategically, treating more effectively first time, and always confirming eradication of Helicobacter pylori, because it is a lifelong gastric pathogen and a key modifiable risk factor for peptic ulcer disease and gastric cancer.

Why H. pylori matters

• H. pylori is now regarded globally as an infectious pathogen, not a commensal; when found in adults it should be eradicated, as it always causes chronic active gastritis and is the main risk factor for peptic ulcer disease and gastric cancer.

• Although the UK is in a very good position in that gastric cancer incidence is among the lowest and the prevalence of H. Pylori has also dropped because of the treatment plus the awareness over the last 25 years, it has now got a bit neglected. There is no valid UK data on prevalence and the general infection rates in the adult population for the last 15, 20 years. We don't quite know what's going on, with higher rates in migrants from high‑prevalence regions and strong family clustering.

Who to test in primary care

• Test-all groups include:

                  • Dyspepsia (test early rather than repeatedly escalating PPI and diet alone; NNT ≈14 for symptom benefit).

                  • Proven peptic ulcer disease (no empiric “treat for H. pylori” without confirming infection).

                  • Unexplained iron‑deficiency anaemia and idiopathic thrombocytopenic purpura, where H. pylori can drive disease even without visible ulcers.

                  • First‑degree relatives of gastric cancer patients and anyone with incidental H. pylori on biopsy for other indications.

• Do not test:

                  • Children without clear indications; asymptomatic children should generally be left until early adulthood before consideration of testing.

                  • Patients with isolated reflux/heartburn, as H. pylori does not cause reflux symptoms and reflux and dyspepsia should be distinguished.

How to test and avoid false negatives

• Preferred non-invasive tests in primary care are urea breath test or stool antigen (ELISA‑based assays with good performance; stool tests are cheaper and more convenient for many patients).

• Blood antibody tests are only for limited scenarios (e.g. acute bleeding) because they cannot distinguish past from active infection and must not be used for test‑of‑cure.

• To minimise false negatives:

                  • Stop PPIs for at least 2 weeks before any test other than serology; H. pylori density falls on PPIs and can give falsely negative histology, rapid urease test, breath test, and stool antigen.

                  • Avoid antibiotics for 4 weeks before testing, and wait at least 4 weeks after completing eradication therapy before test‑of‑cure.

How to treat in UK primary care

• Current UK first‑line remains clarithromycin‑based triple therapy with a PPI plus amoxicillin (or metronidazole if penicillin‑allergic), but first‑line failure is around 30% in UK registry data, largely due to resistance.

Practical optimisation points for GPs:

• Use longer courses: 14 days is preferred over 7 days to significantly improve eradication rates.

• Use stronger acid suppression: at least high‑dose PPI (e.g. omeprazole 40 mg twice daily) during therapy; better acid suppression improves antibiotic efficacy.

• Check prior antibiotic history and avoid regimens containing clarithromycin, metronidazole or levofloxacin if the patient has had those agents previously for any indication.

• Emphasise adherence: eradication drops sharply with <90% adherence, and metronidazole‑related side effects commonly undermine compliance.

• Never repeat the same eradication regimen twice; at minimum, change at least one antibiotic if a course fails.

Second line, rescue, and follow‑up

• After first‑line failure (confirmed by testing), switch regimen rather than “re‑doing” the same triple therapy; bismuth‑based quadruple therapy (including the newer combination capsule plus separate PPI) achieves >90% eradication but has high pill burden and cost.

• Consider early advice-and-guidance or referral to gastroenterology once two regimens have failed, supplying detailed previous antibiotic regimens and dates; endoscopy with culture‑guided therapy is often the next step but is resource‑intensive and centralised in the UK.

• Every treated adult should have a documented test‑of‑cure using a valid non‑serological test, despite current UK dyspepsia guidance wording; symptom response is not a reliable marker of eradication, and true reinfection after proven cure appears to be very rare.

Prescribing and de-prescribing • Taper PPIs rather than stopping abruptly to avoid rebound acid hypersecretion, driven by upregulated gastrin during PPI therapy. • Always link NSAID use and H. pylori status to ulcer risk, and remember: gastric ulcers typically cause pain with meals, duodenal ulcers 2–3 hours after eating. Diagnosis, tests and red flags • Use three coeliac test “groups”: serology (tTG/EMA, with total IgA checked), genetics (HLA‑DQ2/DQ8) and duodenal biopsies; ensure patients eat gluten for at least six weeks pre‑testing and to endoscopy. • Actively screen for GI red flags: dysphagia and weight loss (upper GI), PR bleeding and unexplained iron‑deficiency anaemia (lower GI), and escalate for urgent investigation. Practical tools and endoscopy indications • Use the Bristol Stool Chart (types 1–7) routinely in consultations to standardise conversations about stool form and avoid ambiguous “food analogies.” • Remember the three main indications for endoscopy: diagnostic (e.g. dyspepsia, chronic diarrhoea), surveillance (Barrett’s, polyp follow‑up) and therapeutic (RFA/EMR in Barrett’s, polyp removal). Conditions to consider and not miss • Keep bile acid diarrhoea prominent in the differential for IBS‑D: up to ~40% of IBS‑D patients may have it, particularly with ileal disease/resection, Crohn’s, or post‑cholecystectomy. • Maintain a broad GI bleeding differential beyond cancer (e.g. gastritis, peptic ulcer, Mallory–Weiss tear, haemorrhoids/fissures, liver disease/coagulopathy, IBD, angiodysplasia, diverticular disease). Liver disease, microbiome and early life • Remember major causes of liver failure in primary care: excess alcohol, paracetamol overdose, DILI, autoimmune hepatitis, Wilson’s disease, haemochromatosis, viral hepatitis B/C and progressive MASLD. • Support breastfeeding where possible to promote a healthy infant microbiome (HMOs favouring bifidobacteria) and recognise how birth mode and early microbes shape immune development and later allergy/immune risk. Structuring abdominal symptom assessment • For undifferentiated abdominal symptoms, consciously work through a core list: IBS, lactose intolerance, coeliac disease, gastroenteritis, SIBO, IBD, diverticular disease, colorectal cancer, peptic ulcer disease, gallstones/biliary colic, pancreatic insufficiency and medication‑related causes (e.g. metformin, NSAIDs, antibiotics). • Use these categories to guide targeted history, examination, basic tests and thresholds for referral back to gastroenterology or specialist services.

Dr. Kinross is a senior lecturer in surgery at Imperial College in London. He is also a practicing colorectal surgeon in the NHS with a clinical interest in the prevention and treatment of colon cancer. He leads a team of amazing researchers working to better define how the microbiome causes cancer and other chronic diseases of the gut. He is increasingly interested in how the gut microbiome develops in newborn babies and the implications on our long-term health. He is the author of the well know book DARK MATTER.

Here are the key learnings for primary care on the microbiome from the attached transcript of the Ingest podcast with James Kinross:

Key Learnings for Primary Care on the Microbiome

1. What the Microbiome Is and Why It Matters

• Definition: The microbiome is the collection of all microscopic organisms (bacteria, viruses, fungi, etc.) and the environment they inhabit within a specific niche in the body, such as the gut, skin, or lungs.
• Symbiosis: The microbiome has a symbiotic relationship with the host, evolved over millennia. It is not static but dynamic and changes throughout life.
• Personalization: Each person’s microbiome is unique, impacting how individuals respond to treatments and develop diseases[1].

2. Microbiome Development and Early Life

• Early Colonization: The microbiome starts developing in utero, influenced by the mother’s microbiome, and is further shaped by birth route, breastfeeding, and early environmental exposures.
• Critical Window: Early life is a critical period for microbiome development. Disruption, especially through antibiotic use, can have long-term effects on immune system development and disease risk[1].
• Antibiotics Impact: Repeated or broad-spectrum antibiotic use in early life can lead to persistent changes in the microbiome, increasing the risk of immune-mediated diseases (e.g., allergies, asthma, eczema), obesity, and other non-communicable diseases[1].

3. Microbiome and the Immune System

• Immune Regulation: The microbiome plays a crucial role in shaping both the innate and adaptive immune systems. It influences how the body recognizes and responds to threats.
• Disease Risk: Early disruption of the microbiome can increase susceptibility to autoimmune diseases, allergies, and chronic conditions later in life.
• Gene-Environment-Microbiome Interaction: Disease risk is not just about genes and environment but also involves the microbiome (GEM interaction), which is highly personalized and dynamic[1].

4. Probiotics, Prebiotics, and Diet

• Probiotics: There is evidence supporting the use of probiotics, especially multi-strain, high-dose formulations, during and after antibiotic courses. However, probiotics must be taken consistently for weeks to have an effect.
• Prebiotics and Diet: Feeding the microbiome with a high-fiber, plant-based diet is crucial for maintaining a healthy gut ecosystem. Processed foods and sugary drinks should be minimized, especially during illness or antibiotic treatment[1].
• Practical Advice: Clinicians should recommend probiotics and dietary changes as part of a holistic approach to gut health, but the evidence for specific strains is still evolving[1].

5. Microbiome Testing

• Direct-to-Consumer Testing: Online microbiome tests are not currently recommended due to lack of standardization, robust interpretation, and actionable outcomes.
• Clinical Use: Microbiome analysis is best used in a targeted, clinical context, interpreted by specialists, and as part of a longitudinal assessment rather than a one-off snapshot[1].

6. Future Directions and Interventions

• Probiotic Formularies: The development of evidence-based probiotic formularies will help guide clinical use.
• Fecal Microbiota Transplantation (FMT): FMT is currently approved for recurrent Clostridium difficile infection but may have a broader role in the future for other conditions, with more targeted and capsule-based delivery methods.
• Postbiotics and Synthetic Biology: Emerging therapies include postbiotics (microbial metabolites) and engineered microbes for targeted treatments, though these are still in development[1].

7. Complexity and Clinical Action

• Superorganism Concept: Humans are superorganisms, with the vast majority of genetic material in our bodies being microbial.
• Clinical Translation: While the microbiome is complex and still being understood, it is increasingly relevant to clinical practice, particularly in managing non-communicable diseases and guiding personalized treatments[1].

Summary Table

These insights highlight the importance of considering the microbiome in primary care decision-making, especially regarding antibiotic stewardship, diet, and personalized patient management[1].

Sources [1] transcript-The-Microbiome-Our-Health-and-Wellbeing.pdf

Key Learnings from this episode.

Patient Experience and Diagnostic Challenges

• Dr. Bartlett’s symptoms began with severe, intermittent abdominal pain, starting in 2001, but he did not seek medical help for several years due to a combination of stoicism, not wanting to trouble others, and a belief in the commonality of benign causes.
• Over 15 years, he experienced repeated misdiagnoses, primarily being labeled as having irritable bowel syndrome (IBS) despite atypical features (severe pain, minimal bowel habit change, and no systemic symptoms).
• Multiple opinions and investigations (including ultrasounds and CT scans) failed to identify the underlying cause, with a key scan being misread by local radiologists.
• The correct diagnosis of a small bowel neuroendocrine tumour was only made after a tertiary centre re-examined previous scans, highlighting the importance of specialist review and persistence in unexplained cases.

Clinical Red Flags and Symptomatology

• Dr. Bartlett’s case underscores that neuroendocrine tumors can present with isolated, severe abdominal pain without classic red flags (vomiting, weight loss, significant bowel changes)[1].
• He retrospectively identified subtle signs of carcinoid syndrome (flushing, one episode of profound diarrhoea, and skin changes), which are present in only about 10% of small bowel neuroendocrine tumour cases.
• The lack of awareness about neuroendocrine tumors, even among experienced clinicians, contributed to the diagnostic delay[1].

Lessons for Primary Care and Clinicians

• The story illustrates the risk of anchoring on common diagnoses (like IBS) and the need to reconsider the diagnosis when symptoms are severe, persistent, or atypical.
• It highlights the value of listening to the patient’s narrative, especially when symptoms do not fit classic patterns, and the importance of considering rare conditions in the differential diagnosis.
• The episode emphasises the need for ongoing education about neuroendocrine tumours and the importance of keeping rare but serious conditions on the diagnostic radar in primary care.

Management Insights

• Standard treatment for small bowel neuroendocrine tumours often includes monthly somatostatin analog injections (e.g., lanreotide).
• Surgical intervention may be considered, but it carries specific risks such as carcinoid crisis, requiring specialised perioperative management.
• The decision for surgery is individualised, weighing potential symptomatic improvement against procedural risks.

Systemic and Human Factors

• Dr. Bartlett’s experience reflects how personal traits (stoicism, reluctance to seek help) and systemic issues (misinterpretation of scans, diagnostic inertia) can delay diagnosis.
• The narrative also demonstrates the importance of patient advocacy, persistence, and the value of second (or third) opinions, especially in complex or unresolved cases.

Educational Value

• The episode serves as a reminder for clinicians to maintain a broad differential, revisit diagnoses when the clinical picture changes, and to be aware of their own cognitive biases.
• It also advocates for the inclusion of patient voices in medical education to better understand the lived experience and challenges of rare diseases like neuroendocrine cancer.

Summary Table: Key Learnings

These insights from the transcript highlight the complexities of diagnosing and managing neuroendocrine cancer, especially in primary care, and the critical role of patient experience in improving clinical practice.

John is a member of the British Society of Gastroenterology and Pancreatic Society of Great Britain and Ireland. He serves on the endoscopy and Pancreas committees for BSG and is the website lead for PSGBI.

He is also a founder member of the BSG Pancreas Clinical Research Group which is coordinating research for the society.

Key Learnings from this episode:

1. Challenges in Early Detection of Pancreatic Cancer • Pancreatic cancer is often diagnosed at an advanced stage due to the deep location of the pancreas and the lack of early symptoms. • Tumors in the body and tail of the pancreas can grow significantly before causing symptoms, often invading major arteries or veins, making them inoperable. • Tumors in the head of the pancreas may present earlier due to bile duct obstruction, leading to jaundice, but even these are often detected late.
2. Early Symptoms and Red Flags • Early symptoms are vague or absent, making early diagnosis difficult. • Possible early indicators include: • Weight loss (often a sign of advanced disease). • New-onset diabetes, particularly in individuals with a normal BMI or without typical risk factors for type 2 diabetes. • Jaundice, which is a significant red flag and often indicates a serious underlying condition. • Classic signs like painless jaundice and Courvoisier’s sign (palpable gallbladder) are important but not always present.
3. Limitations of Current Screening Methods • There is no reliable biomarker or screening test for pancreatic cancer: • CA19-9 is not suitable as a screening tool due to its lack of specificity (elevated in other conditions). • Imaging techniques like CT scans or MRIs are used but have limitations, including incidental findings that may lead to unnecessary anxiety (“scanxiety”) and over-investigation. • Screening is currently limited to high-risk groups, such as those with familial pancreatic cancer syndromes or hereditary pancreatitis.
4. High-Risk Groups for Screening • Familial pancreatic cancer accounts for less than 10% of cases. Criteria for screening include: • Multiple family members with pancreatic cancer, especially diagnosed under age 50–60. • Genetic syndromes like BRCA mutations, familial adenomatous polyposis (FAP), and Peutz-Jeghers syndrome. • Hereditary pancreatitis patients have an increased risk but are harder to screen due to pre-existing pancreatic abnormalities.
5. Emerging Research and Future Directions • Studies are exploring potential biomarkers, such as microbiome signatures in the pancreas, which might help identify high-risk individuals in the future. • Trials like the EuroPAC study focus on surveillance protocols for high-risk individuals using imaging techniques like MRI or endoscopic ultrasound. • Research into new-onset diabetes as a potential marker for pancreatic cancer is ongoing but currently has a low yield due to the high prevalence of type 2 diabetes unrelated to malignancy.
6. Considerations for Screening and Surveillance • Screening should be carefully targeted to avoid over-diagnosis and unnecessary investigations. • The psychological impact of screening (e.g., anxiety from incidental findings) must be considered. • Smoking cessation is emphasized as smoking is a significant risk factor for pancreatic cancer.
7. Advances in Treatment Approaches • PET-CT scans are increasingly used to detect systemic disease that might not be evident on standard CT scans. • Neoadjuvant treatments (therapy before surgery) are being explored for cases where systemic spread is suspected.
8. Conclusion Pancreatic cancer remains challenging to detect early due to vague symptoms and limited screening tools. Current efforts focus on identifying high-risk groups for targeted surveillance and advancing research into biomarkers and new diagnostic strategies. Early detection remains critical for improving outcomes, but significant barriers persist.

John is a member of the British Society of Gastroenterology and Pancreatic Society of Great Britain and Ireland. He serves on the endoscopy and Pancreas committees for BSG and is the website lead for PSGBI.

He is also a founder member of the BSG Pancreas Clinical Research Group which is coordinating research for the society.

This podcast provides key insights into managing Irritable Bowel Syndrome (IBS), emphasising a multidisciplinary and individualised approach to care. Here are the main takeaways:

1. Multidisciplinary and Integrative Care

• IBS management requires a holistic, patient-centered approach involving dietitians, behavioral therapists, and gastroenterologists. This "team sport" approach expands treatment options and tailors care to individual patient needs1.
• Integrative care, which combines dietary, psychological, and medical interventions, has been shown to improve symptoms, psychological well-being, and quality of life for IBS patients1.

2. Personalised Treatment

• IBS is not a one-size-fits-all condition. There are different subtypes of IBS (e.g., IBS-D for diarrhea-predominant or IBS-C for constipation-predominant), and treatment must be customized based on the patient's symptoms and triggers4.
• Emerging research suggests the need to identify distinct subtypes of IBS to guide more effective treatments24.

3. Dietary Management

• The low FODMAP diet is a widely recommended dietary intervention for IBS. It helps identify food triggers and manage symptoms but should not be used long-term without personalization3.
• Probiotics may also play a role in symptom relief for some patients, though their effectiveness varies3.

4. Behavioral Interventions

• Cognitive Behavioral Therapy (CBT) and gut-directed hypnotherapy are effective in managing IBS symptoms, particularly when patients are motivated to engage in these therapies1.
• Stress management is critical since stress and anxiety can exacerbate IBS symptoms15.

5. Pharmacological Therapies

• Medications are often used as complementary treatments when dietary or behavioral strategies alone are insufficient. These include antispasmodics, laxatives, or medications targeting gut-brain interaction15.
• Precision medicine is the future of pharmacological treatment, aiming to match therapies with the underlying causes of an individual's symptoms rather than just addressing the symptoms themselves1.

6. Challenges in IBS Management

• One of the most distressing symptoms for patients is bowel urgency, significantly impacting their quality of life. Research is ongoing to better understand and manage this symptom24.
• Pain management remains a critical area for improvement, as existing treatments often provide inadequate relief for abdominal pain and gut hypersensitivity in IBS patients24.

7. Patient Education and Collaboration

• Educating patients about the trial-and-error nature of IBS treatment helps set realistic expectations and reduces frustration when initial interventions do not work1.
• Shared decision-making between healthcare providers and patients ensures that treatment plans align with patient preferences and lifestyle.

In summary, effective IBS management combines personalized care with dietary, behavioral, and pharmacological strategies within an integrative framework. The podcast underscores the importance of ongoing research to refine treatments and improve outcomes for IBS sufferers.

The Ingest podcast is hosted by Dr Charlie Andrews a GPwER in gastroenterology based near Bath. Charlie works as a GP partner at Somer Valley Medical Group, trained as an endoscopist and leads the national GPwER in gastroenterology training programme, launched in 2023 in the southwest of England. Charlie is a committee member of the PCSG (Primary Care Society of Gastroenterology). For more information visit pcsg.org.uk

In this episode, Charlie Andrews discusses an innovative and extremely successful use of advice and guidance in Northumbria with gastroenterologists Matthew Warren and Richard Thomson.  Through the enhanced use of advice and guidance for all incoming referrals for secondary care input, they have demonstrated a significant reduction in waiting times for routine outpatient care.  

They discuss their advice and guidance model, and what they have learned from developing this service and the impact it has been having on their waiting times, and how it has been received by primary care colleagues (3:30).  We go on to discuss some common advice and guidance queries that Matt and Richard see (19:30) and I ask the question - what makes a good advice and guidance query? (43.30).  

Diagnosis of IBS

The episode is focused on making a diagnosis of Irritable Bowel Syndrome (IBS)and features Dr. Anton Emmanuel, a consultant gastroenterologist and Professor of neuro-gastroenterology at University College Hospital London.

Importance for Primary Care

• IBS is a common condition that primary care clinicians need to have a structured approach to diagnosing.

Topics Covered

• Causes of IBS
• Different subtypes of IBS
• Challenges in making a positive diagnosis

Clinical Pearls

Dr. Emmanuel shares several insights:

• Key questions to include in the patient history
• How to describe the condition to patients
• Practical tips for enhancing IBS diagnosis in primary care

Diagnostic Approach

The episode emphasises the importance of:

• Taking a structured approach to diagnosis
• Understanding the various presentations of IBS
• Recognizing the challenges in making a definitive diagnosis

Patient Communication

Guidance is provided on:

• Explaining IBS to patients effectively
• Addressing patient concerns and misconceptions

Additional Resources

The episode mentions useful guidance from the British Society of Gastroenterology, which listeners were encouraged to reference for more detailed information. Part 2 focusing on the management of IBS to be released soon.

bsg.org.uk/clinical-resource/british-society-of-gastroenterology-guidelines

The Ingest podcast is hosted by Dr Charlie Andrews a GPwER in gastroenterology based near Bath. Charlie works as a GP partner at Somer Valley Medical Group, trained as an endoscopist and leads the national GPwER in gastroenterology training programme, launched in 2023 in the southwest of England. Charlie is a committee member of the PCSG (Primary Care Society of Gastroenterology). For more information visit pcsg.org.uk

Useful links to accompany this episode include:

Welcome > Haemochromatosis: genetic iron overload disease (exeter.ac.uk)

Haemochromatosis - British Liver Trust

Key Learnings for Primary Care from the Ingest Podcast on Hyperferritinaemia

Key Learnings

Understanding Iron Regulation and Ferritin

• Ferritin is an acute-phase reactant and a marker of total body iron stores, but can be elevated in a range of conditions beyond iron overload, including inflammation, liver disease, and malignancy[2].
• Understanding the physiological regulation of iron is crucial for interpreting ferritin results in context.

Causes of Hyperferritinaemia

• Raised ferritin can result from:
• Hereditary haemochromatosis (genetic iron overload)
• Chronic inflammatory states (e.g., infection, autoimmune disease)
• Liver disease (e.g., alcoholic liver disease, hepatitis)
• Malignancy
• Metabolic syndrome
• It is important to consider these differential diagnoses when encountering an elevated ferritin[2].

Hereditary Haemochromatosis: When to Suspect

• Primary care clinicians should suspect hereditary haemochromatosis in patients with persistently raised ferritin and transferrin saturation, especially with suggestive symptoms (e.g., fatigue, arthralgia, diabetes, liver dysfunction) or family history[2].
• Early recognition is key, as treatment can prevent complications.

How to Test

• Initial investigations should include:
• Repeat ferritin measurement to confirm persistence
• Transferrin saturation (TSAT): TSAT >45% is suggestive of iron overload
• Liver function tests and assessment for other causes of raised ferritin[2]
• If hereditary haemochromatosis is suspected, genetic testing (HFE gene) should be considered.

Who to Refer (and to Whom)

• Refer patients with confirmed iron overload (high ferritin and TSAT) or positive HFE mutation to hepatology or a relevant specialist for further assessment and management[2].
• Referral is also warranted if there are signs of organ involvement (e.g., abnormal LFTs, diabetes, cardiac symptoms).

Management Principles

• For hereditary haemochromatosis, mainstay of treatment is venesection (therapeutic phlebotomy) to reduce iron stores.
• Primary care plays a role in monitoring, supporting adherence, and managing comorbidities.
• For other causes, management is directed at the underlying condition.

Practical Tips for Primary Care

• Do not ignore isolated raised ferritin-always interpret in clinical context.
• Exclude common secondary causes (infection, inflammation, liver disease) before pursuing rare diagnoses.
• Family screening may be appropriate in hereditary haemochromatosis cases[2].
• Use local guidelines and specialist advice where available.

Melanie discusses a really pragmatic approach to patients with symptoms suggestive of diverticulitis.  We discuss risk factors, presenting features, and how to assess the patient with suspected diverticulitis.  We also discuss the difference between diverticulosis, diverticular disease and diverticulitis, and give you useful tips on what advice to give to patients who has just had a colonoscopy showing that they have diverticulosis.  

For a useful visual summary of the management of patients with diverticulosis and diverticulitis, please follow this link: visual-summary-pdf-6968965213 (nice.org.uk)

Hepatitis C is a chronic liver disease which carries significant morbidity and mortality if left untreated.  Fortunately, it is both easy to test for and the treatments available offer a fantastic cure rate of in excess of 95% with simple and relatively short tablet regimens.  

NHS England has set itself the target of eradicating the disease by 2025 through active case finding, simplifying the diagnostic process, and ensuring pathways are in place to provide rapid and effective treatments for the condition.  

Resources: 

For more information on Hepatitis C, the British Liver Trust offers useful patient-friendly leaflets and further information about the condition: Hepatitis C - British Liver Trust

The self-testing portal mentioned by Rik during the episode can be found here: Home - HepC (hepctest.nhs.uk)

Neuroendocrine cancer is the 10th most prevalent cancer in England, and the second most prevalent cancer of the GI tract, with a rapidly rising incidence (371%) over the last 20 years.  NETs are commonly diagnosed at a more advanced stage due to late diagnosis as the signs and symptoms can be vague, or mimic other more common conditions such as IBS.  Mark provides lots of useful, practical advice about when to suspect this form of cancer in primary care, which patients may be a higher risk, and what to do if you are suspicious about this form of cancer in your patient.  

Listen on to find out more.    

For more episodes about the oesophagus, you may find the following episodes of Ingest useful: Dyspepsia, Eosinophilic oesophagitis, Dysphagia and Achalasia. 

Key Learnings for Primary Care from this Ingest Podcast on Bile Acid Diarrhoea

Overview and Prevalence

• Bile acid diarrhoea (BAD), also known as bile acid malabsorption, is a significant but under-recognized cause of chronic diarrhoea in primary care. It is more common than Crohn’s disease and ulcerative colitis combined, with a prevalence of about 1% in the general population-comparable to coeliac disease[1].
• BAD is often misdiagnosed as IBS with diarrhoea (IBS-D); about one third of patients with IBS-D may actually have BAD[1].

Causes and Classification

• BAD is classified into three types:
• Type 1: Secondary to ileal disease or resection (e.g., Crohn’s disease, surgical removal of terminal ileum)
• Type 2: Primary or idiopathic (often confused with IBS-D; thought to be due to overproduction of bile acids)
• Type 3: Other causes affecting absorption, such as cholecystectomy, small intestinal bacterial overgrowth, or radiation[1].
• Post-cholecystectomy BAD is relatively common, affecting about 1 in 10 patients after gallbladder removal[1].

Clinical Presentation

• Patients typically present with chronic, watery diarrhoea (Bristol stool types 6–7), often frequent (4–12 times daily), sometimes nocturnal, and can be long-standing (sometimes decades)[1].
• There is often a long delay in diagnosis; nearly half of patients wait over five years for a correct diagnosis[1].
• BAD is frequently overlooked in differential diagnosis, with clinicians more likely to investigate for IBD, coeliac disease, or cancer[1].

Diagnosis in Primary Care

• The key is to think about BAD as a possible diagnosis, especially in patients with chronic diarrhoea where other causes have been excluded[1].
• The gold standard diagnostic test is the SeHCAT (selenium homocholic acid taurine) scan, which is widely available in the UK but not in all countries[1].
• A retention value below 15% at seven days is diagnostic; lower values indicate more severe disease[1].
• There is no simple blood test for BAD, unlike coeliac disease[1].
• Empirical trials of bile acid sequestrants may be considered if SeHCAT is unavailable or in specific cases (e.g., pregnancy), but a confirmed diagnosis is preferred to guide treatment and improve adherence[1].
• Before considering BAD, it is essential to exclude other causes of diarrhoea (negative coeliac serology, faecal calprotectin, and, depending on age, appropriate cancer screening)[1].

Treatment

• First-line treatment is with bile acid sequestrants:
• Cholestyramine: A powder taken in 4g sachets, usually started at night on an empty stomach for best effec]]> https://www.pcsg.org.uk/wp-content/uploads/2023/08/Podcast-Cover-Episode-19-e1693386382613.png false no 00:27:37 No no https://www.pcsg.org.uk/podcast/faecal-calprotectin/?utm_source=rss&utm_medium=rss&utm_campaign=faecal-calprotectin Thu, 13 Jul 2023 10:08:47 +0000 https://www.pcsg.org.uk/?post_type=podcast&p=4797 In this episode, Charlie Andrews speaks to Dr James Turvill about faecal calprotectin use in primary care. Dr Turvill is a gastroenterologist based in York, who was instrumental in developing the NICE-approved and widely adopted York Faecal Calprotectin Care Pathway. What is calprotectin? When should we use it in primary care? How should we interpret the result? Can any medications or conditions affect the result? Listen on to find the answers to these questions!

  The care pathway can be found here: https://www.yorkhospitals.nhs.uk/seecmsfile/?id=941. It is recommended that you have a look at this either before, after or during this episode to enhance your learning. Enjoy!

  ]]> https://www.pcsg.org.uk/wp-content/uploads/2023/07/Podcast-Cover-Episode-18-e1690964936180.png false no 00:37:24 No no https://www.pcsg.org.uk/podcast/ibs-dietary-management-and-the-10-minute-consultation/?utm_source=rss&utm_medium=rss&utm_campaign=ibs-dietary-management-and-the-10-minute-consultation Thu, 25 May 2023 10:59:58 +0000 https://www.pcsg.org.uk/?post_type=podcast&p=4646 Marianne Williams is an extremely experienced dietician, innovator, digital technology advocate and winner of the NHS England Allied Health Professional of the Year prize for 2018.  

  In this episode, Marianne shares her wealth of knowledge around all things IBS to discuss initial dietary management, the low FODMAPs diet, the role of probiotics, and gives us some great advice about how we can maximise our (often short) patient consultations with newly diagnosed IBS patients.  Marianne also discusses her innovative dietetic-led gastroenterology clinic for IBS patients with us.  

  There is so much food for thought here, and so many useful nuggets of information throughout this episode.  Sit back and tuck into this feast of information! 

  Useful links/websites discussed in the episode:

  Patient Webinars website: https://patientwebinars.co.uk/

  Monash university IBS grand tour: https://www.youtube.com/watch?v=Z_1Hzl9o5ic

  Monash university app: https://www.monashfodmap.com/ibs-central/i-have-ibs/get-the-app/

  IBS symptoms, the low FODMAP diet and the Monash app that can help See updated video for Irritable Bowel Syndrome (IBS) relief: Take the Monash University Low FODMAP grand tour down under! at https://www.youtube.com/watch?v=stdYoA4G9Dg

  See more: IBS patient course: https://www.monashfodmap.com/online-training/patients-course/ 

  Website: https://www.monashfodmap.com/ 

  Monash FODMAP blog: https://www.monashfodmap ...www.youtube.com

  BSG guidelines on the management of IBS: https://gut.bmj.com/content/gutjnl/early/2021/04/27/gutjnl-2021-324598.full.pdf

  ]]> https://www.pcsg.org.uk/wp-content/uploads/2023/05/Podcast-Cover-Episode-17-e1690965096945.png false no 00:38:38 No no https://www.pcsg.org.uk/podcast/ibd-flare-management/?utm_source=rss&utm_medium=rss&utm_campaign=ibd-flare-management Mon, 24 Apr 2023 11:20:17 +0000 https://www.pcsg.org.uk/?post_type=podcast&p=4594 In this episode Charlie Andrews speaks to Dr Kevin Barrett about IBD flare management.  On average, 50% of patients will flare annually, and often the GP surgery is the first port of call.  We therefore need to know how to assess and manage patients presenting with symptomatic IBD.  Kevin Barrett, IBD clinical champion for IBD for the RCGP and Crohns and Colitis UK (2017-2021) shares his wealth of knowledge about IBD flare management.  We discuss how if can affect patient's quality of life, common symptoms of IBD flare, calprotectin testing and the management of IBD flare. 
  ]]> https://www.pcsg.org.uk/wp-content/uploads/2023/04/Podcast-Cover-Episode-16-e1690965125505.png false no 00:26:44 No no https://www.pcsg.org.uk/podcast/updated-guidance-on-fit-testing-in-primary-care/?utm_source=rss&utm_medium=rss&utm_campaign=updated-guidance-on-fit-testing-in-primary-care Fri, 24 Mar 2023 16:27:20 +0000 https://www.pcsg.org.uk/?post_type=podcast&p=4424 In this episode, Charlie Andrews speaks to Dr Kevin Monahan, lead author for the joint guidelines published by the BSG and ACPGBI in July 2022 outlining the role of FIT testing in patients with symptoms suggestive of colorectal cancer.  These guidelines have informed how we use FIT in primary care, and in this episode he asks Dr Monahan how this guideline has changed clinical practice, they discuss when it should be used and what to do if you have ongoing concerns about your patient's symptoms.  In addition, they discuss specific situations such as iron deficient anaemia, rectal bleeding, whether we can use it in younger age groups, and whether there is a role for repeat FIT testing.  

  A link to the full guideline can be found here: https://www.bsg.org.uk/clinical-resource/faecal-immunochemical-testing-fit-in-patients-with-signs-or-symptoms-of-suspected-colorectal-cancer-crc-a-joint-guideline-from-the-acpgbi-and-the-bsg/

  ]]> https://www.pcsg.org.uk/wp-content/uploads/2023/03/Podcast-Cover-Episode-15.jpeg false no 00:31:26 No no https://www.pcsg.org.uk/podcast/abnormal-lfts-and-non-alcoholic-liver-disease/?utm_source=rss&utm_medium=rss&utm_campaign=abnormal-lfts-and-non-alcoholic-liver-disease Fri, 17 Feb 2023 14:04:28 +0000 https://www.pcsg.org.uk/?post_type=podcast&p=4066 Did you know that according to the British Liver Trust, up to 20% of the general population has non-alcoholic liver disease ('fatty liver disease') and the prevalence is predicted to rise over the coming years.  Morbidity associated with this can be significant, with a proportion of patients with fatty liver disease developing fibrosis of the liver as the disease progresses.  Diagnosing fatty liver disease and identifying those at risk of progression to fibrosis is therefore important.  In this episode I speak to Dr Helen Jarvis, a GP with a specialist interest in liver disease.  We discuss an approach to the patient with abnormal LFTs, and we look at the common causes of abnormal LFTs, with a particular focus on non-alcoholic fatty liver disease.  Helen demystifies the commonly used tests for assessing for fibrosis in fatty liver disease, and how we can empower our nursing teams to assess for fatty liver disease when abnormal LFTs are identified at chronic disease reviews.  
  ]]> https://www.pcsg.org.uk/wp-content/uploads/2023/02/Podcast-Cover-Episode-14-v2.jpeg false no 00:40:06 No no https://www.pcsg.org.uk/podcast/coeliac-disease-management-and-follow-up/?utm_source=rss&utm_medium=rss&utm_campaign=coeliac-disease-management-and-follow-up Thu, 22 Dec 2022 15:07:29 +0000 https://www.pcsg.org.uk/?post_type=podcast&p=4057 Join Charlie Andrews in this episode where he speaks to Cristian Costas about the management of people diagnosed with coeliac disease.  Cristian is a dynamic dietician who is based in Bradford.  He is passionate about coeliac disease and runs an innovative dietician-led service for those with coeliac disease in his area.  

  Cristian shares with us his top tips for supporting someone newly diagnosed with coeliac disease, including where to access support for those who are newly diagnosed, and how to avoid common dietary pitfalls.  We discuss how best to follow-up people with coeliac disease, and key interventions such as assessments for osteoporosis and vaccinations for coeliacs.  

  We know that education and the support of a dietician are key interventions that can help patients manage the gluten-free diet effectively, and in this episode, Cristian shares his passion for improving the care for those with coeliac disease.  An informative, enjoyable and inspiring listen!

  ]]> https://www.pcsg.org.uk/wp-content/uploads/2022/12/Podcast-Cover-Episode-13.jpeg false no 00:35:43 No no https://www.pcsg.org.uk/podcast/fit-testing-in-primary-care/?utm_source=rss&utm_medium=rss&utm_campaign=fit-testing-in-primary-care Tue, 06 Dec 2022 16:46:38 +0000 https://www.pcsg.org.uk/?post_type=podcast&p=4008 In primary care, we are increasingly using FIT (Faecal Immunochemical Testing) to assess the risk of bowel cancer in patients with lower gastrointestinal symptoms, whilst the latest PCN DES IIF (Impact and Investment Fund) has given FIT a prominent role in risk stratifying 2-week wait referrals to secondary care.  

  In this episode, Mo Thoufeeq, a gastroenterologist in Sheffield, talks to me about what FIT is, how it differs from previously used FOBT (and why it is a more effective test!), and how we are using FIT in both symptomatic and asymptomatic patients.  He shares his top tips about how to interpret, when to test and we discuss the tricky areas of patients with rectal bleeding and those with iron deficient anaemia.  

  Mo has a deep knowledge and understanding of FIT and provides a fantastic and relevant discussion of the topic for our primary care audience in this episode.  

  ]]> https://www.pcsg.org.uk/wp-content/uploads/2022/12/Podcast-Cover-Episode-12-V2-1.jpeg false no 00:31:27 No no https://www.pcsg.org.uk/podcast/bridging-the-gap-between-primary-and-secondary-care-in-inflammatory-bowel-disease-ibd/?utm_source=rss&utm_medium=rss&utm_campaign=bridging-the-gap-between-primary-and-secondary-care-in-inflammatory-bowel-disease-ibd Tue, 18 Oct 2022 16:04:53 +0000 https://www.pcsg.org.uk/?post_type=podcast&p=3935 In this episode, I am joined by Pearl Avery.  Pearl has a unique role - she spends part of her week as an IBD nurse specialist, and part of her week as an ANP (Advanced Nurse Practitioner) working in a GP practice.  Pearl has a fantastic understanding of both primary and secondary care and shares her experiences with me.  

  We discuss her unique and innovative role, common queries from GPs and patients from her IBD nurse specialist role (including common questions about flare management and biologic monitoring), and what she has learned about the care of people with IBD from her primary care role. 

  I felt extremely energised and enthusiastic after speaking to Pearl and took home some great top tips.  This episode really demonstrates the benefit of working collaboratives and 'bridging the gap' between primary and secondary care.  

  ]]> https://www.pcsg.org.uk/wp-content/uploads/2022/10/Podcast-Cover11-scaled-e1693386532265.jpg false no 00:31:50 No no https://www.pcsg.org.uk/podcast/inflammatory-bowel-disease-ibd/?utm_source=rss&utm_medium=rss&utm_campaign=inflammatory-bowel-disease-ibd Tue, 06 Sep 2022 09:55:34 +0000 https://www.pcsg.org.uk/?post_type=podcast&p=3897 I speak to Chris Lamb about IBD.  Chris was lead author on the BSG IBD guidelines which were published in 2019.  The full guidance can be found here:  BSG-IBD-Guidelines-2019.pdf Chris is a fount of knowledge for all things related to IBD and I have a fascinating chat with him about the guidance and how these relate to primary care - we range over all aspects of IBD from diagnosis to management and everything in between.  
  ]]> https://www.pcsg.org.uk/wp-content/uploads/2022/09/Podcast-Cover-Episode-10-e1693386562833.jpeg false no 00:34:34 No no https://www.pcsg.org.uk/podcast/chronic-diarrhoea/?utm_source=rss&utm_medium=rss&utm_campaign=chronic-diarrhoea Thu, 28 Jul 2022 18:12:11 +0000 https://www.pcsg.org.uk/?post_type=podcast&p=3800  In this episode, I speak to Professor Ramesh Arasaradnam.  Ramesh co-authored the BSG guidelines on chronic diarrhoea in 2018, and is a fount of knowledge in this area. 
  ]]> https://www.pcsg.org.uk/wp-content/uploads/2022/07/Podcast-Cover-Episode-9-e1693386640619.jpeg false no 00:42:25 No no https://www.pcsg.org.uk/podcast/functional-dyspepsia/?utm_source=rss&utm_medium=rss&utm_campaign=functional-dyspepsia Wed, 01 Jun 2022 14:23:20 +0000 https://www.pcsg.org.uk/?post_type=podcast&p=3784 Affecting up to 20% of the UK population, dyspepsia is commonly seen in primary care.  Following investigations, the majority of people (up to 89%) are found to have functional dyspepsia. As with any functional problem of the gut, such as IBS, making a confident diagnosis is sometimes challenging but extremely important for the patient, and management encompasses a range of non-pharmacological interventions.

  Pali Hungin, an extremely experienced primary care clinician and a founding member of both the PCSG and it’s European counterpart, shares his vast experience and understanding of functional dyspepsia with us in this episode.  As chair of the ROME VI primary care committee, Pali is hugely knowledgeable about this complex yet common condition.   

  ]]> https://www.pcsg.org.uk/wp-content/uploads/2022/06/Podcast-Cover-Episode-8-e1693386671941.jpeg false no 00:28:04 No no https://www.pcsg.org.uk/podcast/h-pylori/?utm_source=rss&utm_medium=rss&utm_campaign=h-pylori Fri, 22 Apr 2022 05:41:00 +0000 http://www.pcsg.org.uk/?post_type=podcast&p=3749 This edition of the podcast series Ingest published by the Primary Care Society for Gastroenterology (PCSG) features a very special guest from the world of gastroenterology. 

  Dr Charlie Andrews talks to Nobel Prize laureate Professor Barry Marshall, the Director of the Marshall Centre founded in 2007 in his honour, the Western Australian Ambassador for Life Sciences and University of WA Brand Ambassador, about his discovery of the bacterium Helicobacter pylori and its role in gastritis and peptic ulcer disease.

  Key Learnings from the Podcast

  What is Helicobacter pylori?

  • H. pylori is a microaerophilic bacterium that resides in the mucous layer of the stomach lining, not invading the bloodstream, which explains why even immunosuppressed patients do not develop sepsis from it.
  • It is classified as a Class 1 carcinogen by the WHO due to its established role in gastric cancer, and it is a primary cause of gastritis and peptic ulcer disease, alongside NSAID use[1].

  Historical Context and Impact

  • The discovery of H. pylori by Marshall and Warren in the early 1980s overturned the previous belief that the stomach was sterile and that ulcers were caused mainly by stress or lifestyle factors.
  • Their work demonstrated that a common bacterial infection was the main cause of most gastritis and peptic ulcer disease, leading to a dramatic decline in ulcer surgeries and transforming ulcer management[1].
  • The link between H. pylori and gastric cancer was established epidemiologically: areas with high H. pylori prevalence have higher rates of stomach cancer[1].

  Diagnosis in Primary Care

  Available Tests:

  Test TypeWhat it DetectsPros & ConsSerology (Blood)Antibodies to H. pyloriHighly sensitive; good for ruling out H. pylori if negative; can remain positive after eradication, so less useful for confirming active infection[1].Urea Breath TestActive infectionHighly specific for current infection; preferred in Australia for confirmation; fewer false positives[1].Stool Antigen TestActive infectionAlso highly specific; convenient for children; widely used in UK primary care[1].
  • Best Practice: Use stool antigen or breath test to confirm active infection, especially before starting eradication therapy. Serology is useful as a rule-out test-if negative, H. pylori infection is unlikely[1].
  • Caveat: Serology may remain positive for a year or more after eradication, so it should not be used to confirm cure or active infection[1].

  Treatment Considerations

  • Once diagnosed, H. pylori infection is treatable with antibiotics, which is satisfying for both clinicians and patients as it offers a clear cure pathway[1].
  • There is ongoing debate about whom to treat: treat symptomatic patients (e.g., with ulcers or dyspepsia) rather than universally treating all who test positive, especially given increasing antibiotic resistance[1].
  • The advent of proton pump inhibitors (PPIs) combined with antibiotics in the 1990s significantly improved cure rates, making outpatient management by GPs routine[1].

  Epidemiological Trends and Clinical Implications

  • The prevalence of H. pylori has declined in developed countries, but remains high in some regions and populations.
  • In the current era, not all ulcers are due to H. pylori-NSAID-induced ulcers are now common, and gastroesophageal reflux disease (GERD) is more prevalent in Western countries[1].
  • A careful history (birthp]]> https://www.pcsg.org.uk/wp-content/uploads/2022/04/Podcast-Cover-Episode-7-Colour-difference-e1695926702547.jpeg false no 00:56:29 No no