Download Minutes of the Exeter Sessional GPs Group at Darts Farm * 7 June

Minutes of the Exeter Sessional GPs Group
Darts Farm – 1 July 2014
The meeting was kindly sponsored by:
Bayer
Cathy Griffiths
Norgine
Lisa Furlong
Menarini
Wendy McOwen
Attendance:
24 members
Welcome:
Dr Megan James opened the meeting. She announced that she will be standing down
as chair following her acceptance of a partnership position. Dr Ross Hemingway has
agreed to take over as chair and this news was welcomed by those present.
Megan announced that there will not be a summer social in August but there will be
an opportunity to meet members of the committee at a pub in Topsham (probably The
Globe) after the September meeting. This will be an opportunity for the new
registrars to meet.
There is a vacancy on Exeter CCG committee for a sessional GP – the committee
meets on the second Thursday of the month every two months and attendance is paid.
There are vacancies on Devon LMC for sessional GPs and these are also paid
positions.
Ross announced the twitter page @esgps as a further communication means for the
group.
Megan thanked the reps. for sponsoring and introduced the speaker.
Clinical meeting
Gastroenterology Update – Dr Shyam Prasad – Consultant gastroenterologist
Royal Devon and Exeter Hospital
A growing speciality – a few years ago there were two consultant gastroenterologists
in RDE, now there are seven and soon there will be nine.
Family history for colorectal cancer (CRC) screening
National Guidelines agreed between colorectal surgeons and gastroenterologists were
updated in 2010.
1.
Colorectal cancer in three relatives who are first degree relatives of each other
and at least one is a first degree relative of the consulting patient. None of the
affected relatives under 50 years old (otherwise high-risk criteria apply). Clinical
genetics referral recommended. Life time risk of CRC death without surveillance is 1
in 6-10. Colonoscopy at age 50 then five yearly to age 75.
2.
Colorectal cancer in two relatives who are first degree relatives of each other
and at least one is a first degree relative of the consulting patient. Mean age less than
sixty years. Clinical genetics referral recommended. Life time risk of CRC death
without surveillance is 1 in 6-10. Colonoscopy at age 50 then five yearly to age 75.
In 1. and 2. where both parents are affected, these count as being within the firstdegree kinship.
3.
Colorectal cancer in two first degree relatives age 60+. Life time risk of CRC
death 1 in 12. Once only colonoscopy age 55 – if normal then no follow-up.
4.
Colorectal cancer in one first degree relative age under 50. Life time risk of
CRC death without surveillance 1 in 12. Once only colonoscopy age 55 – if normal
then no follow-up. Patients will query why they should wait to age 55 when the
relative already had the cancer age under 50 – this is because age 55 has been
calculated to be the most effective screening age for this patient group.
5.
All other family history of colorectal cancer – no screen required.
CEA has no effective role for screening – it is neither sensitive nor specific.
FOBs have a role in population screening but are not sensitive or specific for
screening any other groups – family history or those with symptoms.
Irritable bowel
Common – 10% of population
Variable symptoms but must include a combination of abdominal pain and altered
bowel habit with a temporal relationship between the two
Mechanisms:
 Abnormal afferent sensation (visceral sensitivity)
 Abnormal symptom perception
 Abnormal feedback to bowel (dysmotility)
Assessment:
 Red flag symptoms / signs – refer 2ww
 >45yrs and new symptoms then consider referral
 Ask for two week questionnaire of pain and bowels – otherwise only get part
of the story – usually the worse bits or the most recent
 Consider defaecatory disorder (obstetric history and careful rectal
examination)
 Exclude abdominal wall pain (Carnetts sign – abdominal pain remains the
same or increases when muscles of abdominal wall are tensed suggests an
abdominal wall origin for the pain)
 If strong family history of colo-rectal or ovarian cancer then consider referral
– possibly check Ca125 too
Rectal examination points:
 Look
 Insert finger and feel resting tone
 Ask patient to squeeze finger
 Ask patient to expel finger – if unable then suggests defaecatory disorder
Investigation:
 May want to check FBC, ferritin, CRP, TTG, TSH
 Referral not indicated for mild iron deficiency anaemia in menstruating
women
Suspected inflammatory bowel disease in patients under 45 yrs old – can get faecal
calprotectin. A neutrophilic cytosolic protein sensitive and specific for intestinal
inflammation. It is stable at room temperature. NICE recommended test. Use a
special form. Few data for use in primary care yet.
Constipation in irritable bowel – non drug management includes fibre, fluid, mobility,
stop meds which cause constipation. Match laxative to the type of constipation – e.g.
Movicol for slow transit, senna and lactulose for elderly atonic colon, glycerol supps
for those who defaecate by digital removal. Prucalopride is a new drug – a 5HT4
agonist which is useful in cases where constipation in irritable bowel has not
responded to two laxatives.
Diarrhoea in irritable bowel – loperamide, lomotil. Tricyclic antidepressants –
amitriptyline 10mg and increase to 25mg if needed. Diet – low FODMAPS
(Fermentable Oligosaccharides, Disaccharides, Monosaccharides and Polyols – needs
dietitian referral)., lactose free. Consider bile salt malabsorption – can try
cholestyramine. Consider small bowel bacterial overgrowth – trial of antibiotics for
two weeks – metronidazole, co-amoxiclav or quinolones).
Irritable bowel with bloating and functional abdominal pain – try anti spasmodics,
diet including low FODMAPs, probiotics – muti strain / cheapest, tricyclic
antidepressants, SSRIs, relaxation, hypnotherapy, cognitive therapy.
Iron deficiency anaemia
 FBC, ferritin – beware false neg and interpret in conjunction with MCV,
coeliac serology
 History of overt bleeding, diet history, examination
 In males and non-menstruating females refer 2ww to gastroenterology
 Need upper and lower endoscopy if fit
 Transfuse if symptomatic or Hb<80g/l
 Give oral iron once or twice daily
 Check FBC and reticulocytes after one and after three months
 Continue iron for three months after Hb normalised
 Check FBC every three months for a year
 Refer back if recurrent or persistent anaemia for capsule endoscopy
Coeliac disease
1% prevalence
Serology is 85-90% sensitive – IgA based so only works if not IgA deficient
Ask about itchy or blistering rash – dermatitis herpeteformis
Must have baseline biopsy – as sometimes serology is falsely positive
Should have follow up biopsy after 12-18 months to check resolution – symptomatic,
serological or haematological improvement does not confirm efficacy of the gluten
free diet.
Aims of treatment:
 Improve symptoms
 Improve or prevent malabsorption
 Improve long term bone health

Decrease risk of complicating malignancies – lymphoma, small bowel cancer,
oesophageal cancer
Gluten free diet – needs dietitian input, lifestyle changes as exclusion must be total,
need prescription initially
Bone profile should be checked – Dexa scan
Check for other auto immune pathology – thyroid, type 1 diabetes mellitus, liver
antibodies etc
Need immunisations – flu, pneumonia, HiB
Siblings and children should have serology testing.
Various infections
Giardia
 Is indigenous
 Can be due to water supply
 Check whole family
Hepatitis E – pig farms
Seeing cryptosporidia and campylobacter but less salmonella
Housekeeping
Megan thanked Dr Prasad and reminded members to sign the attendance register.
Future ESGPG Meetings
2nd September 2014 – The Movement Disorders Clinic Dr. Sarah Jackson
7th October 2014 - Hospice Update Dr. Becky Baines
4th November 2014 - Contraceptive Update Dr. Jane Bush Lead for contraceptive
services, NDHC
2nd December 2014 - Diabetes update, Dr. Tom Fox Consultant endocrinologist
Meeting time
Please note that the meetings are now scheduled to start at 7pm with the guest speaker
planned to commence at 7.30pm.
Committee Contacts
Dr Megan James (chairman)
Dr Laura Davies (website co-ordinator)
Dr Lynne Reid (appraisal support co-ordinator)
Dr Nimita Gandhi (educational co-ordinator)
Dr Sarah Hemingway (funding co-ordinator)
Dr Anna Beazley (treasurer)
Dr Kathryn Shore (minutes’ secretary)
Dr Megan James (LMC link)
[email protected]
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