CCE: GI Disorders Management Strategies

July 10, 2009

Prompt referral can be crucial when first-line therapies for any GI disorder are unsuccessful, according to top specialists.

Prompt referral can be crucial when first-line therapies for any GI disorder are unsuccessful, according to top specialists.

"If you are not getting the kind of response that you like, send the patient to a specialist-sooner, rather than later," says Mark Pimentel, MD, director of the GI Motility Program at Cedars-Sinai Medical Center in Los Angeles.

If acid-suppression doesn't work for a patient with reflux disease, for example, there is usually a reason. "Sometimes the reason is very simple, and sometimes . . . very treacherous, like cancer of the esophagus," Pimentel says. Blood in the stool or weight loss, especially in a young person, should trigger a consultation with a specialist, he adds, as should altered bowel function in patients over 50.

Experts from this month's Clinical Centers of Excellence also offered diagnosis and treatment guidelines for a number of common GI disorders:

Constipation. Primary constipation should resolve within 6 to 8 weeks if fiber intake is increased to 13 to 20 g daily with either a supplement or through diet. "It is also helpful and reasonable to try a nonfiber laxative, such as milk of magnesia," says Adil Bharucha, MD, a professor of gastroenterology at the Mayo Clinic in Rochester, Minnesota. Improvement with laxative use, however, does not necessarily exclude a secondary cause.

The most common secondary cause is medication--particularly opiates and anticholinergics, says Bharucha. Other secondary causes include colon cancer, endocrine disorders (including diabetes mellitus and hypothyroidism), neurologic disorders (such as Parkinson's disease), and eating disorders.

Bharucha adds that many primary care doctors are not widely attuned to the possibility of pelvic floor dysfunction. "The constipation may not be because it is taking longer for the residue to get through the colon, he says, "but because the pelvic floor muscles don't function like they should." Pelvic floor dysfunction can be diagnosed with a simple balloon expulsion test and managed with biofeedback and exercises to coordinate abdominal and pelvic floor muscle movements.

Irritable bowel syndrome. A good history is essential for complaints of apparent irritable bowel syndrome, says David Metz, MD, associate chief of the GI Division of Clinical Affairs at the University of Pennsylvania. He recommends a limited workup with calcium measurement to exclude celiac disease, thyroid disorders, and microscopic colitis. "Empiric therapy works to a point," Metz says.

Changes in dietary fiber as well as medications and biofeedback are often useful. "This is a functional disorder. There is nothing wrong, per se, with the colon," says Anil Rustgi, MD, chief of Penn's GI division. "If there are difficulties, I think a gastroenterologist can be used as a secondary referral."

Inflammatory bowel disease. IBD should be considered when a patient has abdominal pain, bloody diarrhea, or fever. "Many primary care physicians just aren't comfortable treating IBD--and they shouldn't be," says Metz, who refers IBD patients to specialists within the GI division.

Liver disease. "People get anxious about liver disease," says Metz. Patients with abnormal liver enzymes should be referred for full testing. Specialists are also needed to determine when and how to list patients for transplants. "We have clinics that do this and then return them for ongoing primary care, but we still see them once a year to see how they are doing."

Fecal incontinence. Older patients and women are more likely to develop fecal incontinence, most often due to weakened sphincters or nerve damage. Nerve malfunction can occur in patients with diabetes or history of stroke. Other causes include Crohn's disease, radiation treatment, rectal prolapse, and rectocele.

Referral for manometry, ultrasound, proctosigmoidoscopy, defecocraphy, or electromyography can help determine the cause, says Bharucha. Meanwhile, patients should be advised that spicy or fatty foods, caffeine, artificial sweeteners, dairy products, and cured or smoked meat can worsen fecal incontinence.