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Crohn's and post-traumatic stress
It has always seemed obvious to me that a significant proportion of patients with inflammatory bowel disease (IBD) relapse in response to stressful events or ongoing problems in their life. This paper provides further evidence that this is not a biased perspective. Perhaps more importantly it opens the door for alternative or additional ways to manage our patients. Psychological treatments have become mainstream in recent years and our current government has declared it will provide more support for so called ‘talking therapies’. Furthermore, the UK IBD standards recommend every IBD service have dedicated psychological support. If your IBD service does not have psychological support, start preparing your business case now.
The diagnostic process involves estimating probabilities of an underlying disease until the point when a definitive test, such as colonoscopy, is performed, which rules in, or rules out, the disease in question. It is unrealistic (and not necessary) to perform colonoscopy on every person presenting with an abdominal symptom. Through a process of questioning, examining and non-invasive tests, we sift out patients who need further invasive or more expensive tests. Likewise, when monitoring our patients, we cannot simply observe what is going on (like a dermatologist): we rely on questions, examination and tests to decide when to adjust treatment. Faecal calprotectin provides another non-invasive test that enables us to refine our diagnostic and therapeutic algorithms. This article explains how faecal calprotectin might enable us to be more effective while reducing the need for more expensive tests.
Care pathway for acute pancreatitis
There is a strong evidence base supporting the use of checklists to improve patient care. A care pathway is a type of checklist that ensures the clinical team delivers a minimum standard of care. This report is exactly in tune with the mission of Frontline Gastroenterology: standardising care (when it is appropriate to do so) against evidence based guidelines. The sample is small but the principle is sound and a model for others to follow. Frontline Gastroenterology encourages clinical teams to follow the example of McCallum et al and submit for publication their experience of ways of improving care through the adoption of best evidence.
By autumn next year certification of competence to perform endoscopy in the UK will require the use of the endoscopy e-portfolio. The e-portfolio is designed to enhance and quality assure training, as well as providing a log book of procedures. Those trainees and trainers not already using the e-portfolio are strongly advised to read this article and begin doing so.
Pancrealipase and postprandial diarrhoea
The final step in my management of patients with persistent loose stool is to do a plain abdominal x-ray. About half have overt constipation and a third will have solid stool, despite protestations that their stool is always loose. Before this point, all of my patients will have had a trial of pancreatic enzymes if tests have found no cause for their symptoms, and other strategies have been ineffective. A surprising number respond and relapse when the treatment is withdrawn. This pilot study supports this empiric approach: an inexpensive and safe test that transforms the life of a few patients. But be certain they have diarrhoea first; otherwise their constipation just gets worse.
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