BMJ Open Gastroenterology- February blog

In the second of our BMJ Open Gastroenterology blogs I will focus on three articles, on Coeliac disease, on long-term use of proton pump inhibitors and on endoscopic ultrasound in pancreatitis. All articles have been published online within the last month. Alongside this I want to summarise a hugely important publication in Gut that will affect millions of patients across the globe, namely the international recommendations for SARS-CoV-2 vaccination of patients with inflammatory bowel disease (IBD).

In the first article this month Taylor et al look at whether adult gastroenterologists have medical inertia towards coeliac disease? In this study the authors compared referral of coeliac disease patients to those with suspected IBD, assessed whether endoscopic and histological assessment was adhering to guidelines and surveyed physician opinion on coeliac disease. Patients with coeliac disease waited an average of 48.5 days for diagnostic endoscopy, compared to 34.5 days in IBD patients. Only 40% of diagnostic endoscopies included four duodenal biopsies. Interestingly only 2/3 of gastroenterologists knew that coeliac disease has a higher prevalence compared to IBD and perhaps most surprisingly 36% of those surveyed felt that doctors were not required for the management of coeliac disease. Coeliac disease has an estimated prevalence of 1% in the UK population. The authors highlight that there is potential for medical inertia towards coeliac disease, and care must be taken to avoid complacency.

In their scoping review, Haastrup et al ask the question when does proton pump inhibitor treatment become long-term? This interesting question, which is vital when looking at the long-term effects of PPIs, found 59 studies variably defining long-term use as between >2 weeks to >7 weeks treatment duration. The authors propose some standardised definitions, including use of PPI for more than 8 weeks in those with reflux symptoms, whilst >4 weeks in patients with proven dyspepsia or peptic ulcer. Specifically, in pharmacoepidemiological studies, 6 months of therapy may be used. Studies looking at adverse effects will require a study specific definition depending on the necessary exposure time.

In our third article, Tepox-Padron et al discuss the utility of endoscopic ultrasound in idiopathic acute recurrent pancreatitis (IARP). This retrospective analysis over a 7-year period included 73 patients undergoing over 100 procedures. IARP was identified by endoscopic ultrasound in 75% of cases. The underlying cause was found in an estimated 2/3 of cases, with the most common being chronic pancreatitis (49%), lithiasic pathology (44%) and intraductal papillary mucinous neoplasm in 7%. The authors conclude that endoscopy ultrasound is a highly useful tool to identify the underlying cause of IARP and can aid with directing therapy and resolution of illness.

Finally, published in Gut, the leading article on SARS-CoV-2 vaccination for patients with IBD provides excellent consensus framework that gastroenterologists can readily apply in practice. Overall, there was agreement that patients with IBD should receive replication-incompetent vaccines, live attenuated vaccines, whilst not yet approved for SARS-CoV-2, are not safe for immunosuppressed IBD patients. Vaccination should not be delayed in patients receiving any IBD treatments but patients should be counselled that vaccine efficacy may be reduced when the patient is on systemic corticosteroids. This paper details high level of agreement internationally on the importance of vaccination in IBD patients and should be a useful resource when discussing vaccination with patients and those with concerns.

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