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Dr Charlie Andrews talks to Dr Jan Bornschein.
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.
Based on a popular well known Christmas carol this episode reminds us about prescribing thoughtfully, recognising key red flags, and keeping often-missed diagnoses like bile acid diarrhoea, coeliac disease and liver disease on the radar. The episode also reinforces the importance of early-life microbiome influences and structured differential diagnosis for abdominal symptoms in primary care.
Prescribing and de-prescribing
Dr Charlie Andrews talks to Dr James Kinross, PhD, FRCS
Dr. Kinross is a senior lecturer in surgery at Imperial College in London.
Here are the key learnings for primary care on the microbiome from the attached transcript of the Ingest podcast with James Kinross:
1. What the Microbiome Is and Why It Matters
2. Microbiome Development and Early Life
3. Microbiome and the Immune System
4. Probiotics, Prebiotics, and Diet
5. Microbiome Testing
6. Future Directions and Interventions
7. Complexity and Clinical Action
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
The episode features Dr. David Bartlett, a retired GP and neuroendocrine cancer patient, offering a dual perspective as both clinician and patient.
Key Learnings from this episode.
Patient Experience and Diagnostic Challenges
Clinical Red Flags and Symptomatology
Lessons for Primary Care and Clinicians
Management Insights
Systemic and Human Factors
Educational Value
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.
Dr Charlie Andrews talks to Dr John Leeds. John Leeds is a Consultant Pancreaticobiliary Physician and Endoscopist based at the Freeman Hospital in Newcastle and an Honorary Clinical Senior Lecturer based in the Population Health Sciences Institute at Newcastle University. He is involved in research in pancreaticobiliary disorders including benign and malignant conditions as well as outcomes from therapeutic/advanced endoscopy.
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:
Dr Charlie Andrews talks to Dr John Leeds. John Leeds is a Consultant Pancreaticobiliary Physician and Endoscopist based at the Freeman Hospital in Newcastle and an Honorary Clinical Senior Lecturer based in the Population Health Sciences Institute at Newcastle University. He is involved in research in pancreaticobiliary disorders including benign and malignant conditions as well as outcomes from therapeutic/advanced endoscopy.
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.
Charlie Andrews talks to Dr Chris Black about the management of IBS.
This podcast provides key insights into managing Irritable Bowel Syndrome (IBS), emphasising a multidisciplinary and individualised approach to care. Here are the main takeaways:
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.
Charlie Andrews talks to Dr Anthony (Tony) Wisken, Consultant Paediatric Gastroenterologist in Bristol.
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
With significant waiting lists and growing demand for secondary care services, Advice and Guidance is being increasingly explored as one potential solution to this problem.
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).
Key takeaways from the IBS Part 1 episode of the PCSG Ingest podcast:
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
Topics Covered
Clinical Pearls
Dr. Emmanuel shares several insights:
Diagnostic Approach
The episode emphasises the importance of:
Patient Communication
Guidance is provided on:
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
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