Ingest

Dr Charlie Andrews speaks to Dr Jeremy Shearman about everything related to high iron levels (hyperferritinaemia).  We discuss how iron is regulated within the body, causes of raised iron levels, and then we dive into hereditary haemochromatosis - when to suspect, how to test, who to refer (and to whom!), and how the condition is managed.  

Useful links to accompany this episode include:

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

Haemochromatosis - British Liver Trust

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].

Causes of Hyperferritinaemia

• Raised ferritin can result from:

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].

How to Test

• Initial investigations should include:

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].

Management Principles

• For hereditary haemochromatosis, mainstay of treatment is venesection (therapeutic phlebotomy) to reduce iron stores.

Practical Tips for Primary Care

• Do not ignore isolated raised ferritin-always interpret in clinical context.

Summary Table: Approach to Hyperferritinaemia in Primary Care

These learnings equip primary care clinicians to approach hyperferritinaemia systematically, ensuring timely diagnosis, appropriate investigation, and effective referral and management[2][5].

Sources

In this episode, Charlie Andrews speaks to Melanie Orchard, a consultant surgeon, about diverticular disease and diverticulitis.  This is something that we encounter frequently in primary care, and understanding how to approach this condition is extremely important. 

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)

Join Charlie Andrews as he discusses Hepatitis C with hepatologist Dr Kosh Agarwal and GP and clinical champion for Hepatitis C Dr Rik Fijten. They discuss the prevalence and presentation of Hepatitis C,  as well as how to test for the condition along with an overview of the treatment options available.

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)

In this episode, Dr Charlie Andrews speaks to Professor Mark Pritchard about neuroendocrine tumours (NETs) of the gastrointestinal tract.  You may be asking yourself: 'Do I really need to know about NETs in primary care, aren't they extremely rare?'  The answer to that is a resounding yes, you do need to know about NETs and Mark will tell you why in this episode!  

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.    

Dr Charlie Andrews, a committee member of the Primary Care Society for Gastroenterology (PCSG), introduces Ingest, the podcast for primary care that focuses on when to suspect, how to diagnose and how to manage common gastrointestinal presentations and conditions.

In this episode Dr Charlie Andrews looks back at 2023 and highlights some key takeaways from Ingest in 2023.

In this episode, Charlie Andrews speaks to Dr Andrew Moore about this condition, which affects up to 1.5% of the population, with a risk of progression to cancer of 3-13% over the patient's lifetime (Cancer Research UK).  They discuss the typical presenting features, who needs an endoscopy to look for Barrett's, and how the condition is managed both in primary and secondary care. The BSG guidelines mentioned by Dr Moore in the episode can be found here: https://www.bsg.org.uk/clinical-resource/bsg-guidelines-on-the-diagnosis-and-management-of-barretts-oesophagus/

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

In this episode, Charlie Andrews speaks to Professor Julian Walters about bile acid malabsorption and diarrhoea. With up to a third of patients with diarrhoea-predominant IBS having underlying bile acid diarrhoea, and with diagnosis rates for this condition being low, this episode is an important one for anyone working in primary care. We explore the role and physiology of bile acids, the causes and symptoms of bile acid malabsorption, the diagnostic tests used to make the diagnosis and the treatment of this common but underdiagnosed condition. Should we use 'trial of treatment' in primary care to support the diagnosis? Are people who have had their gall bladder removed at greater risk of bile acid diarrhoea? Can bile acid sequestrants impact the absorption of other medications? These questions, and lots more, will be discussed in this episode.

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].

Causes and Classification

• BAD is classified into three types:

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].

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].

Treatment

• First-line treatment is with bile acid sequestrants:

Practical Points for Primary Care

• Consider BAD in any patient with chronic, unexplained diarrhoea, especially if IBS-D is suspected or post-cholecystectomy[1].

Summary Table: Key Points for Primary Care

These learnings highlight the importance of awareness, structured diagnostic approach, and appropriate management of BAD in primary care to improve patient outcomes[1].

Sources

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!

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