Physicians should not remain imprisoned in their own specialty but look at the patient as a whole-Peter Trewby


 AZNMC & RCP London International Medical Conference

Physicians should not remain imprisoned in
their own specialty but look at the patient
as a whole-Peter Trewby

In patients suffering from diabetes and liver disease,
cirrhosis is the commonest cause of death

Now complete viral cure is achievable, cure reduces risk of liver
failure, HCC and it also improves survival- Prof. Saeed Hamid

LAHORE: Prof. Peter Trewby from UK was the first speaker on the first session on Day-2 of the International Medical Conference jointly organized by Azra Naheed Medical College and Royal College of Physicians London held here from February 26-28th 2016.. This session was chaired by Prof. Arif Mehmood Siddiqui while Prof. M. Atif Qureshi was the moderator for this session.

Peter Trewby’s presentation was on “General medical conditions presenting as Gastrointestinal and Liver Diseases”. He pointed out that at times we remain imprisoned within our own specialty which is a great disadvantage for the patient. We order too many investigations. Diseases like Depression, Anxiety, Unhappiness, Boredom, and Bereavement are some of the medical disorders which present with abdominal pain, altered bowel habit, nausea, and vomiting, irritable bowel symptoms. The patients say that they feel fire in their Bely and butterflies in their stomach. The gut is used as an organ to express emotions. The question arises how we should manage these patients.  They complain of vomiting, family history of stool problems but no weight loss.

Dr. Peter Trewby

Continuing Dr. Peter Trewby said that while managing such patients what I do is take history and physical examination without the mother. Give positive diagnosis of reflex habitual vomiting. Order routine blood tests including pregnancy test and check H.Pylori. Prescribe timed anti-emetics and proton pump inhibitors to break the cycle. Re-establish food as a pleasure and aim at steady reductionin frequency of vomiting but do not do endoscopy. In depressed patients whole gut transit time correlates with severity of depression. Some of the questions which should be asked to the patient include Do you feel guilty, worthless or indecisive? Do you have difficulty in concentrating? Ask questions about food, appetite, sex and other outside interests. Are you always tired? Try to diagnose politely and discuss the triggers like child birth, redundancy, menopause, bereavement, separation, leaving home, what happened and why? Listen to the patient, talk and explain. Start with symptomatic treatment like anti emetics, anti spasmodic.

Speaking about the common systemic conditions that present with GI manifestations Dr. Peter Trewby mentioned Depression, Diabetes, COPD, Heart Failure, CNS Disease and Pregnancy. The patients may also present as surgical emergency with acute abdominal pain, constipation, diarrhoea. These are some of the most disabling symptoms like nausea and vomiting. Delayed gastric emptying further impairs glucose control. Unusual symptoms may be due to altered autonomic sensation. Treatment is with diet and good blood glucose control. Think of symptomatic and specific treatment including Gastric drainage procedures. Recognize the fluctuating nature of patient’s symptoms as they come and go. In patients suffering from diabetes and liver disease, cirrhosis is the commonest cause of death. He then referred to the symptomatic and specific treatment of diabetes. If nothing works then think of gastric drainage procedures, subtotal collectomy for constipation and gastric pacing with gastro paresis. GI symptoms could also be due to Addison’s disease. He also mentioned about hypothyroidism in constipation and acromegaly.  In pregnancy, piles, constipation and reflex, appendicitis should be kept in mind. Patients with acute fatty liver and pregnancy may present with nausea, severe reflex, hypertension and eclampsia. In case of HELLP syndrome, deliver the baby and give steroids. There could be spontaneous subdural and intra cerebral haematoma in HILLP Syndrome. COPD is quite common. Chronic intestinal pseudo-obstruction can also present as surgical emergency. These patients have high incidence of peptic ulcer, weight loss and poor nutrition.

Photographed during the international medical conference organized by
AZNMC in collaboration with RCP London at Lahore recently from
(L to R) are Prof. Akbar Chaudhry, David Warrell, Prof Talat Naheed
and Prof. John A. Wass from UK.

In heart diseases the patients may have nutritional problems, breathless when eating. They may also suffer from malabsorption, bowel congestion and weight loss. There could be aortic valve disease associated with bleeding from caecal A-V malformations. He also talked about heart failure and liver necrosis in heart failure, the patient may have intracranial space occupying lesions, prophyria. Other symptomatic  disease which cause  abnormal liver function include pneumonia, sepsis, renal diseases,  post operative conditions and scleroderma. Some of the drugs like Erythromycin, Herbal drugs, Co-amoxicillin, Amidoarone, Glue, Diclofenac and anti epileptic drugs, diet drinks, also cause liver diseases. Cold drinks and antibiotics, Mefenamic acid and SSRIs also lead to diarrhoea. His conclusions were that while considering gastrointestinal and liver diseases, break from your specialist shackles, remember the heart, lungs. Ask the patient what he eats and drinks? Remember drugs, diabetes, pregnancy and endocrine systems but above all remember the relation between the mind and the gastrointestinal tract.

Prof. Saeed Hamid from Aga Khan University was the next speaker who talked about new developments in the treatment of chronic HCV. He opined that we need to treat this disease because it is common, chronic and potentially progressive. Complications are now becoming more common. Now complete viral cure is achievable and cure reduces risk of live failure and HCC and it also improves survival. There are over eight million patients in Pakistan. After China, Pakistan is No. 2. Majority of our patients are of Genotype 3. Mild disease is easier to treat while late treatment may impair response. He then referred to various milestones in chronic HCV therapy.  Now 100% cure is possible. Early treatment gives much better response. He also briefly mentioned about the side effects of interferon therapy.  Sofosobuvir the oral treatment is available in USA one thousand dollars per tablet while it has been made available in Pakistan at a much cheaper rates as a special case. Six months treatment with Sofosobuvir plus Ribavirin gives excellent results. However, the problem is that almost 80% of our patients are not covered by public healthcare facilities. Government is providing standard interferon with Ribavarin which should be done away with.

Giving further details about Sofosobuvir therapy, Prof. Saeed Hamid said that this drug became available in Pakistan in August 2014.So far total number of patients enrolled till January 31st 2016 are 47,035 of which 27,881 have completed the treatment. FDA of United States has so far registered about half a dozen DAAs including Sofosobuvir which is available as Sovaldi. Recently Government of Pakistan has registered quite a few Generic preparations of Sofosobuvir and fourteen companies are planning to market this drug. However, we have to be aware of the menace of spurious drugs.

The Government of Pakistan has formed a Guidelines Development Group. Its members are Dr. Saeed Hamid, Huma Qureshi, Javed Iqbal Farooqui, Rauf Memon, Ghias UN Nabi Tayyab, Muazzam Uddin, Zaigham Abbas, Zahid Azam and Dr. Hassan Mahmood. For HCV Genotype 3 the group has suggested treatment of naïve patients who do not have liver cirrhosis with Sofosobuvir plus Ribavirin for twenty four weeks. Other options include Sofosobuvir plus Ribavirin plus PEG Interferon for twelve weeks. In case of compensated cirrhosis treat with Sofosobuvir plus ribavirin for twenty four weeks or Sofosobuvir plus ribavirin plus Peg Interferon for twelve weeks. In case of compensated cirrhosis, treatment experienced patients; treatment should be with Sofosobuvir plus Ribavirin plus Peg Interferon for twelve weeks, or Sofosobuvir and Ribavirin for twenty four weeks.

Azra Naheed Medical College in collaboration with Royal College of Physicians London organized a
two day international conference at Lahore recently. Photograph shows Prof. David Warrell
mementoes to Prof. Kh. Saadiq Hussain, Dr. Moazzam Baig Mirza,
Dr. Abu Bakar and 
Prof. Bilal Bin Younis during the conference.

We need to upscale our treatment needs tremendously.  For this newer DAA combinations are urgently needed. The price of these drugs needs to be reduced further. However, the most important step is prevention of new infections which remains the key to eliminate Hepatitis C, Prof. Saeed Hamid remarked.

Prof. Atif Qureshi talked about Needle Stick Injuries.  Dr. AmirGhafoor’s presentation was on various treatment modalities for H. Pylori infection.  Standard  triple therapy, he said, includes PPIs bid, Clarithromycin 50mg bid,  Amoxicillin 1000mg or Metronidazole 50mg all given for seven to fourteen days.

This was followed by another presentation by Dr. Peter Trewby and his topic was Gastrointestinal Bleeding: Can we do better? He suggested that for managing these patients first one should take history. Is it GI bleed or small bowl obstruction? Malena black or red colour stool. Did the first vomit included blood or not? History of Epistaxis, results of previous endoscopies, use of aspirin and other drugs like beta blockers etc. Pulse, BP and BP trends, rectal examination, abdominal examination. If the patient is taking aspirin, stop it as well clopidogrel. Stop NSAIDs and also stop hypertensive medications. Discuss with hematologist about new anti coagulant therapy. Do not put urinary catheter and do not be cruel to the patient.  Look and manage co-morbidities. Do not starve the patient but feed them. Advise them to use minced meat. He then quoted William Osler who had remarked that “Patients do not die of their diseases; they die of physiological abnormalities of their disease”.

Speaking about treatment he suggested that one should reassure the patient. Use PPIs and high dose is better than small dose. Other options are Endo clips, Thermo coagulation, Sclerosant injection, and Alcohol injection and laser therapy. If the patient re-bleeds, go for emergency arterial embolization therapy but if it does not work, give a call to the Surgeon. He advised the audience not to restart aspirin until the patient is stable and the ulcer has atleast started to heal. For non-variceal upper GI haemorrhoage use PPIs before and after endoscopy. Restrict transfusion, re-start Aspirin but not too soon. On the whole with increasing use of Aspirin, NSAIDs and elderly population and increased use of alcohol, we are not going to be better in the days to come, he concluded.