Download WINTER 1998 - Jackson Siegelbaum Gastroenterology

WWW .
GICARE. COM
W HAT ’ S N EW
W INTER 1998
AND
U SEFUL
IN
HEPATITIS C: I am reminded of
the history of AIDS treatment when looking
at the present situation of hepatitis C. As
you know, we only have one drug available,
interferon (IFN). Treatment is for one year
but produces long term suppression in only
10-15% of patients. Pretty bad for any
treatment. Oral Ribavirin is coming but is
still not approved by the FDA for this use.
A recent large European study with this
combined drug therapy improved the long
term response rate to about 50% - shades of
AIDS, poor results with the single drug
AZT but significant improvement with
multi-drug programs. The two viruses
share some of the same devious mutation
attributes which allow them to avoid single
drug therapy. Our office has received permission to enroll patients in this IFNRibavirin program. We expect to be operational this month and will treat both
naïve (untreated) and IFN failures. We are
excited about this program.
GI
probable relapse.
LIVER TRANSPLANT: My practice is now seeing fairly good results. Almost all of our patients go to Pittsburgh.
We did have a number of deaths some years
back, but the present results and long term
follow-up are now excellent. I am impressed that the University of Pittsburgh
seems to get livers for our patients faster
than is reportedly nationally. I am not sure
if it is pure luck or the fact that we are a
good referrer or a combination of both.
Kay Liddick, RN is our liver disease/
transplant coordinator. She takes yearly
courses, some at Pittsburgh, to keep up
with the changes in the field.
As an aside, there was a state-ofthe-art lecture at the recent liver meetings
in Chicago that reviewed xenografs in a pig
liver transplant program. The problem, of
course, is that there are far more patients
needing transplants than there are donor
livers. Researchers are working through
the specific steps in xenograf rejection and
now understand a great deal about them.
The insertion of human genes into pig embryos and selective breeding holds the
promise of an unlimited supply of donor
livers and other organs too. Exciting business.
Practical Point - We now follow the
HCV-RNA quantitative titer, as well as the
ALT. Always get HCV-RNA by the PCR
method. It is far more sensitive than the
double branched DNA. This latter test is
usually labeled HCV-RNA (bDNA). Some
major labs, even Smith-Kline, still use this
older, less sensitive technology. Low initial
H. PYLORI TREATMENT:
viral load seems to predict a more favorable
Metronidazole
resistance is increasing
response. Under interferon therapy, comwhich,
in
turn,
can
lead to clarithromycin
plete loss of HCV-RNA within the first
month of treatment predicts a likely good resistance, at least in one report.
outcome whereas failure to do so indicates
JSGI
•
F. Wilson Jackson, MD
•
Steven P. Siegelbaum, MD
•
Paul Lacey, MD
•
John Michel, DO
•
David Mize, MD
•
Adnan Ahmad, DO
•
Tina Navitsky, CRNP
•
Lisa Stokes, CRNP
•
Deborah B. Matisse, CRNP
•
Lisa Scicchitano, RN, BSN
Office manager
I NSIDE
THIS ISSUE :
W HAT ’ S NEW
U SEFUL IN GI
O N -L INE
AND
1
3
WWW .
GICARE. COM
W HAT ’ S N EW
P AGE 2
AND
U SEFUL
IN
GI C ONTINUED
Because of that, I usually have been using amoxicillin in place of Metronidazole as little or no resistance is seen with
amoxicillin. I prefer the two week program of triple therapy using BID dosage of a PPI, amoxicillin and clarithromycin.
Unlike European studies, US reports do not find one week eradication rates of over 90% which is now the benchmark for any
H. pylori treatment.
Practical Point - Give two weeks of triple therapy for H. pylori.
HEMOCHROMATOSIS: The gene for hemochromatosis is the most common nasty gene mutation there is. It is
present in the heterozygous form in 10-15% of the population and in the homozygous expressed form in 1 in 200 individuals.
That means if you have 2000 patients in your practice, there may be 10 who might develop the bad outcomes of hemochromatosis. No treatment is necessary for the heterozygote but phlebotomy is life saving for homozygote. We can now identify the
defective gene mutation (c282Y). The test is expensive and still experimental. Routine surveillance iron studies are just as
effective. They should be done every 3-5 years. Percent iron saturation and ferritin are the key parameters. Iron saturation
above 33% in females or 40% in males, or elevation of ferritin should initiate further studies, as well as family screening.
Practical Point - The hemochromatosis gene is common. The disease is treatable. There are good and simple screening
tests available. End stage hemochromatosis belongs in the medical museum.
THE ISOLATED ELEVATED GGPT: The GGPT is a supersensitive intrahepatic obstructive chemistry. I generally
don’t get the GGPT on a routine chemistry screen because the patient and I, and perhaps you, are always left in a quandary
about what to do if it’s elevated by itself. As an isolated finding, a GGPT 2-4 times normal is generally of no concern. It may
be a mild fatty liver, a couple of alcoholic drinks the night before or just a fickle abnormal sent to annoy us. It rarely has a significant meaning. I would obtain an abdominal ultrasound to look at the common bile duct, liver and gallbladder. If there are
no symptoms, simply follow it, advise weight reduction where needed and reassure the patient. A liver biopsy is not warranted.
Practical Point - Isolated elevation of GGPT rarely predicts serious liver disease.
COLLAGENOUS COLITIS: This and its fellow traveler, microscopic colitis, are characterized generally by watery
diarrhea in older, usually female, patients. Colon mucosal biopsies are needed to make the diagnosis. Perhaps half the patients
will have an NSAID history. Always stop the NSAIDs and try the usual anti-diarrheal and bulking agents. Azulfidine and Asacol
are the first line drugs. Dipentum has a side effect of diarrhea, so it is not a good first choice. Steroids are next. Beyond that is
a long list of antidotal treatments. The disorder itself is not serious although it can be very troublesome to the patient. Of interest are two patients in the practice with collagenous colitis and serious isolated tricuspid insufficiency. There is nothing in
the literature on this association. I am in the process of putting a report together.
IRON UNLOADING IN STEATOHEPATITIS AND HEPATITIS C: You may have noticed that I have been using phlebotomy therapy in some chronic liver patients when the serum ferritin is elevated. Iron has been found to act like oxygen radical and seems to be associated with liver damage as iron is stored there. Certainly, hemochromatosis is the classic example of iron causing inflammation and cirrhosis. We know that ferritin is often high in HCV and steatohepatitis patients. Iron
reduction therapy has been found to be associated in improvement, even normalization of the ALT value, the key marker in
chronic liver disease. This is very early data and you don’t see much in the literature yet. My experience is favorable. In six
HCV patients, there has been a 66% reduction in the ALT value. These patients were also getting interferon. In nine steatohepatitis patients, however, phlebotomy with no weight reduction has resulted in 35% improvement in ALT. We need good
studies to define the full benefit, but it is a start and there appears to be benefit with minimal risk.
Practical Point - On all cases of chronic liver disease, check the serum ferritin. If elevated, consider gentle iron unloading.
SBE PROPHYLAXIS IN FLEXIBLE SIGMOIDOSCOPY: It is not recommended or needed. In upper endoscopy
and colonoscopy, we do prophylaxis only in valve replacement and previous SBE. As an aside, I published an article in Archives
of Family Practice on the course we gave some years back on scope cleaning and disinfection. My thanks to the primary care physicians and personnel who participated.
West Shore
423 North 21st St.
Suite 100
Camp Hill, PA
17011
(717) 761-0930
East Shore
Rose Garden Building
Suite 3A
2626 North 3rd St.
Harrisburg, PA
17110
(717) 238-3111
WWW.GICARE.COM
O N -L INE @
WWW .GICARE. COM