GI PROBLEMS/ACNE
From the American Academy of Family Physicians’ 2005 Scientific Assembly, San Francisco
| HOT TOPICS IN GASTROENTEROLOGY —Edward G. Zurad, MD, Assistant Clinical Professor of Family Medicine,
Temple University School of Medicine, Philadelphia
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| Helicobacter pylori: little or no value of testing in patients with documented nonulcerative dyspepsia; initial trial of treatment
after serologic testing recommended for patients with undifferentiated dyspepsia who have not undergone endoscopy;
educate patients about diet and substance abuse to prevent recurrences; follow-up testing—for patients who do
not respond to therapy; urea breath testing ($100-$125); H pylori stool antigen (HpSA) testing ($50-$60)
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| Alarm symptoms: consider endoscopy; age >45 yr; rectal bleeding or melena (perform bidirectional endoscopy); loss of
>10% of body weight; anorexia; difficulty or painful swallowing; abdominal mass; jaundice; positive family history of
gastric carcinoma; history of peptic ulcer disease, anorexia, or early satiety
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| Treatment regimens: 10- to 14-day regimens—1) proton pump inhibitor (PPI; eg, omeprazole, lansoprazole), metronidazole,
and amoxicillin (1 g twice daily) or clarithromycin; 2) high-dose ranitidine, clarithromycin or metronidazole, and tetracycline
or amoxicillin; quadruple therapy—1) bismuth subsalicylate (BSS; Pepto-Bismol), metronidazole, tetracycline,
and H2 -receptor antagonist for 28 days; 2) Pepto-Bismol, metronidazole, tetracycline, and PPI for 14 days; 1-wk
regimens—1) pantoprazole, amoxicillin, and clarithromycin; 2) pantoprazole, Pepto-Bismol, tetracycline, and metronidazole;
warn patients about complications (eg, diarrhea, gastric intolerance)
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| Gastroesophageal reflux disease (GERD): lowered pressure on lower esophageal sphincter and acidic gastric reflux cause
esophageal irritation; consider heartburn, chronic hoarseness, cough, and nonexercise-induced wheezing
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| Diagnosis: patient history; heartburn and regurgitation highly specific symptoms; atypical symptoms cannot make diagnosis;
no gold standard; sensitivity of pH probe 85%, specificity 95%; endoscopy lacks sensitivity in determining pathologic
reflux, but great for patients with erosive disease; limited usefulness of barium radiography; ambulatory pH
monitoring—indicated for GERD patients unresponsive to PPI therapy with classic manifestations of heartburn or atypical
chest pain; documents pattern, frequency, and duration of acid reflux; helps determine correlation between reflux episodes
and symptoms; 1) catheter-based method; intrusive; limits activity; can cause throat irritation; provides good 24-hr
data; accurate placement occurs; easy to pass; look for episodes of pH <4; can correlate pain episodes with periods of pH
<4; 2) Bravo capsule; capsule placed at time of endoscopy into lower esophagus; remains attached for ≈48 hr and disengages;
accepted by patients; 3) multichannel intraluminal impedance; for patients with persistent symptoms despite PPI
therapy; all modalities should be used with manometry if considering for PPI failure and potential surgical intervention;
helps identify patients with nonacid reflux
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| Empiric therapy of acid suppression: good approach for patients with GERD and no alarm symptoms; helpful for evaluating
patients with atypical manifestations of GERD; PPI trial—for patient with noncardiac chest pain, wheezing,
cough, throat irritation that may be related to nasopharyngeal reflux; patients with typical GERD symptoms show resolution
within 1 to 2 wk, but patients with atypical manifestations may not respond for 2 mo; standard doses of H2 -antagonists
not as effective as PPIs; PPI test (treat patient for 2 wk; sensitivity 68%-80%)
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| Lifestyle modifications: recommended; no good evidence about affect on induction of GERD-related symptoms
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| Nonerosive reflux disease (NERD): no esophageal mucosal manifestations of GERD; patients should be followed by PPI
in step-down approach (ie, reduce PPIs or use H2 -antagonists); PPIs should be given 30 to 60 min before first meal; dual-
dose PPI therapy (eg, PPI in morning and later in day before meal, or H2 -antagonist in evening)
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| Surgical therapy: effective in patients with recalcitrant extraesophageal manifestations of GERD; patients who have not
responded to PPIs unlikely to respond to surgical intervention (counsel patients)
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| Guidelines for considering endoscopy: warning signs include difficulty or painful swallowing, weight loss, bleeding,
choking, and vomiting; consider screening for Barrett’s esophagitis if symptoms present for >5 yr
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| Other endoscopic modalities: nonacid reflux can be detected by combined pH monitoring; can cause injury to distal esophagus;
radiofrequency balloon catheter—delivers radiofrequency energy through balloon and 4 needles to create true
sphincter in gastroesophageal junction; EndoCinch procedure—approved by Food and Drug Administration (FDA); series
of stitches in lower esophagus creates pleat to prevent reflux and acid flow into distal esophagus; plicator system—approved
by FDA; positioned within 1 cm of gastroesophageal junction; grasps and retracts full thickness of gastric wall;
implant allows serosa-to-serosa plication; Enteryx procedure—injection of liquid copolymer into sphincter forms permanent
implant
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| Barrett’s esophagus: distal squamous epithelium in distal esophagus replaced by columnar metaplastic process; precursor
to esophageal adenocarcinoma; prognosis poor; acquired condition (secondary to chronic untreated GERD); location of
metaplasia usually in distal 2 to 3 cm; short-segment (<3 cm) Barrett’s esophagus believed to be associated with development
of dysplasia and carcinoma; median survival <1 yr after diagnosis of cancer; risk factors—GERD; higher risk in
whites than blacks; higher risk in men; higher risk with age >45 yr; diagnose with esophagogastroduodenoscopy (EGD)
and biopsy
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| Indications for endoscopy: symptoms lasting >5 yr, particularly in patients >50 yr of age; erosive esophagitis obscures
squamocolumnar junction; consider repeating endoscopy after 2 to 3 mo of treatment with PPI or H2 -antagonist; treat patients
with GERD for 2 to 3 mo before performing endoscopy; dysplasia—can occur in patients with underlying esophagitis,
but not ideal risk factor for development of adenocarcinoma; patients with high-grade dysplasia should have 4-
quadrant biopsies every 2 cm (perform endoscopy every 3 mo; experienced pathologist must evaluate specimens); for patients
with low-grade dysplasia, surveil every 6 to 12 mo (every 1-2 yr with 2 negative endoscopic results); dysplasia and
cancer can develop in short segment; no role for radiologic intervention in surveillance of Barrett’s esophagus, but can be
helpful in balloon dilatation postsurgically or after photoablation therapy; increased risk for colon cancer in Barrett’s
esophagus (consider colon cancer screening)
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| Misoprostol and double-dose H2 -antagonists: effective at reducing risk for gastric and duodenal ulcers; misoprostol,
PPIs, and H2 -antagonists effective in preventing nonsteroidal anti-inflammatory drug (NSAID)-induced complications;
lower doses of misoprostol can be helpful; misoprostol-induced diarrhea occurs with low and high doses
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| Ultraslim upper-GI endoscopy: transnasal endoscopy; diameter 4 to 5 mm; easily used and can be performed in office without
sedation at index presentation; educate patients and providers; well tolerated; similar diagnostic yield compared to conventional
EGD; reduces cost and patient risk; patients can return to work same day; allows patient to watch and
communicate; physicians must be trained on how to deal with conscious patient; due to anatomic distortion in some patients,
5% of patients cannot undergo endoscopy; consider patient apprehension
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| Gastric cancer: H pylori likely to play role in induction of gastric carcinomas; transnasal endoscopy may help identify
cases at earlier stage; 5-yr survival ≈23%
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| ACNE VULGARIS —Kristin Suzanne Tate, MD, Family Medicine Physician, Boone Hospital Center, Columbia, Missouri
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| Causes: genetic—follicular hyperkeratinization; leads to comedonal acne; inflammation—androgenic overproduction of
sebum; Propionibacterium acnes and sebum cause papular and pustular acne; emotional stress; drugs; cosmetics; friction;
diet and hygiene do not play role
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| Acne lesions: open (blackheads) and closed (whiteheads) comedones; papules; pustules; nodules; scars (atropic or hypertrophic);
cysts—not true cysts; large pustules; acne fulminans; acne conglobata—severe cystic acne; patients need
isotretinoin (Accutane) or surgical intervention;
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| Differential diagnosis: steroid acne; rosacea—onset in late 20s to early 30s; associated with telangiectasias, flushing, and
vasomotor response
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| Grading acne: grade 1—superficial; noninflammatory; comedones; no papules, pustules, nodules, or scars; grade 2—
superficial; inflammatory; papules; pustules; no nodules; no scars; palpate skin to determine whether lesion nodular;
nodules often seen in T zone (ie, along nose, perinasal and labial areas, and forehead); grade 3—superficial; papules;
pustules; comedones; nodules; palpable deep lesions; patients complain of pain and often pick at lesions; usually no
scars; grade 4—nodular cystic acne; deep; inflammatory; comedones; papules; pustules; multiple nodules; scars (catch
severe grade-3 acne to prevent scars)
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| Treatment: grade 1—topical retinoids and benzoyl peroxide first-line therapy; physician-directed extraction; consider á-
hydroxy acids and salicylic acid; grade 2—topical antibiotics and topical retinoid; benzoyl peroxide shown to decrease
resistant strains of P acnes; consider azelaic acid (Azelex); grade 3—oral antibiotics and benzoyl peroxide; patients with
large nodules often benefit from intralesional corticosteroids; hormonal therapy with oral contraceptives (OCs) for women;
in severe cases, consider Accutane; grade 4—Accutane; OCs for women; intralesional corticosteroids; incision and drainage;
surgical intervention; yttrium-aluminum garnet (YAG) laser
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| Educating patients: educate adolescents and parents; effects of therapy seen after 6 to 8 wk; educate patients about cosmetics;
sunscreen can reduce scarring
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| Topical retinoids: target microcomedones; shown to decrease inflammation and redness; patients with high sebum and oiliness
respond well to gels (start with low percentage); patients with drier skin respond better to creams; pustular flare often
seen 2 to 4 wk after starting product; decrease irritation by starting with every-other-day treatment for 2 wk; apply
tretinoin (Retin-A) at night to avoid photodegradation and to decrease photosensitivity; apply retinoid 30 min after
cleansing skin; moisturizer should be used in morning; tazarotene (Tazorac)—acetylenic retinoid; apply at night;
causes more irritation than older forms of Retin-A; same efficacy as topical tretinoin; pustular flare seen 10 to 14 days after
start of use; adapalene (Differin)—less irritating than microsized Retin-A; can be used in morning; least photosensitive
retinoid; intrinsic anti-inflammatory property; topical Accutane—once daily application at night; similar in efficacy
and side effects to tretinoin; does not affect sebum; no systemic toxicity; Azelex—comedolytic and antimicrobial properties;
good for patients who do not tolerate retinoids
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| Benzoyl peroxide: shown to minimize resistant strains of P acnes when used with antibiotics; side effects—irritation;
bleaching of hair and clothing; possible contact allergy
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| á-hydroxy acids: glycolic acid; 6% to 15% preparations available over-the-counter (OTC); effective adjuncts; prevent new
comedonal formation; higher strengths (30%-70%) used in chemical peels for in-office use only; unroof pustules; treat
and prevent comedones
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| Salicylic acid: β-hydroxy acid; keratolytic; anti-inflammatory; available OTC in washes and pads
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| Topical antibiotics: decrease P acnes; mild effect against sebum; emerging bacterial resistance problematic; never should
be used alone (add topical retinoid); after 4 to 8 wk, redness improves (discontinue use; maintain with retinoid); add benzoyl
peroxide; less resistance if used for <8 wk; clindamycin; erythromycin; preparations with benzoyl peroxide recommended
(apply once daily); when combining with retinoid, use retinoid at night and antibiotic in morning
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| Systemic antibiotics: tetracycline; erythromycin; sulfa-containing drugs; doxycycline; minocycline; tetracycline must be
taken 1 hr before meals and with no dairy; treat for 6 to 8 wk until inflammation improves, then decrease dose or discontinue
use and maintain with topical retinoid; do not use for >4 mo; combine with topical retinoid; if using for >8 wk, use
benzoyl peroxide; if patient relapses, do not switch antibiotic
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| Hormonal therapy: indications—patient desires contraception; acne flares premenstrually; hirsutism; androgenic alopecia;
severe sebum secretion; nodular acne; includes antiandrogens, spironolactone, estrogens combined with progesterone
(eg, desogestrel, norgestomet), and triphasics
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| Accutane: for grades 3 and 4 acne, gram-negative folliculitis, and patients with severe psychologic disturbance from acne;
contraindications—pregnancy; lactation; hepatic or renal dysfunction; never use with tetracycline; avoid aspirin and vitamin
A; ≈30% of patients relapse in 1.0 to 1.5 yr (patients can be retreated after 8-wk hiatus); laboratory work-up—
liver function tests (LFTs); serum lipids; complete blood count (CBC) at 4 wk and at 8 wk (if no abnormalities found after
8 wk, no further work-up required); discontinue if laboratory changes seen; higher relapse rate with pulse dosing; pustular
flare—occurs within 1 wk of initiating treatment; can be reduced by pretreating for 4 wk with topical retinoid;
treat with prednisolone and decrease or discontinue use and resume slowly as pustular flare resolves; System to Manage
Accutane-Related Teratogenicity (SMART) program—provider must sign letter of understanding and obtain yellow
stickers for prescription to be filled; women must sign informed-consent forms and use 2 forms of birth control; birth
control must be started 1 mo before treatment and be used during and after treatment; 2 negative in-office pregnancy tests
required
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| Physical treatment: extraction—results temporary; prior treatment with topical retinoid decreases new comedonal formation;
study found extracting comedones before using Accutane decreases inflammatory flare; aspiration—for patients with
grade-3 nodular acne; aspirate or inject base of nodules with 25-gauge needle on 10-cc syringe, then inject 0.5 mL of steroid
(eg, triamcinolone [Kenalog]) to help resolve lesion; hard nodules can be injected with 0.5 mL of Kenalog;
phototherapy—visual light alone ineffective; visual light combined with Ä-aminolevulinic acid (ALA) improves acne in 5
wk
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Educational Objectives
| The goal of this program is to educate the listener about gastrointestinal (GI) problems and acne. After hearing and assimilating
this program, the participant will be better able to:
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 | 1. Select a treatment regimen for Helicobacter pylori infection.
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| 2. Describe methods of monitoring pH in patients with gastroesophageal reflux disease.
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| 3. List risk factors for Barrett’s esophagus.
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| 4. Choose acne treatment based on severity of lesions.
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| 5. Counsel patients about acne therapy, including side effects of retinoids and isotretinoin (Accutane).
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Discussed on This Program
Adapalene [Differin] Alpha hydroxy acid (AHA)
Aminolevulinic acid HCl [Levulan Kerastick] Amoxicillin [Amoxil, Amoxil Pediatric Drops, Trimox, Trimox Pediatric
Drops]
Azelaic acid [Azelex, Finacea]
Benzoyl peroxide (several trade names)
Bismuth subsalicylate (BSS) [Bismatrol, Bismatrol Extra Strength, Pepto-Bismol, Pepto-Bismol Maximum Strength, Pink
Bismuth]
Clarithromycin [Biaxin, Biaxin XL]
Clindamycin (several trade names)
Doxycycline (several trade names) Erythromycin [Akne-Mycin, A/T/S, Emgel, Eryderm 2%, Erygel, Ery Pads, Ilotycin,
Staticin, T-Stat]
Ethinyl estradiol and desogestrel [Cyclessa, Desogen, Kariva, Mircette, Velivet]
Isotretinoin (13-cis-retinoic acid) [Accutane]Lansoprazole [Prevacid]
Metronidazole (several trade names)
Minocycline HCl (minomycin) [Arestin, Dynacin, Minocin, Minocin IV]
Omeprazole [Prilosec, Prilosec OTC, Rapinex] Pantoprazole sodium [Protonix, Protonix I.V.]
Ranitidine HCl [Zantac, Zantac 75, Zantac EFFERdose, Zantac GELdose]
Salicylic acid (several trade names)
Tazarotene [Tazorac] Tetracycline HCl [Sumycin 𣝢’, Sumycin 𣡜’, Sumycin Syrup] Tretinoin (trans-retinoic acid;
vitamin A acid) [Altinac, Atragen (investigational), Avita, Renova, Retin-A, Retin-A Micro, Vesanoid]
Triamcinolone acetonide (several trade names)
Suggested Reading
Aguemon B et al: Primary antibiotic resistance and effectiveness of Helicobacter pylori triple therapy in ulcero-inflammatory
pathologies of the upper digestive tract. Acta Gastroenterol Belg 68:287, 2005; Brinker A et al: Trends in adherence
to a revised risk management program designed to decrease or eliminate isotretinoin-exposed pregnancies: evaluation of the
accutane SMART program. Arch Dermatol 141:563, 2005; Faybush EM et al: Randomized trials in the treatment of Barrett's
esophagus. Dis Esophagus 18:291, 2005; Haider M et al: Endoluminal gastroplasty: a new treatment for gastroesophageal
reflux disease. Thorac Surg Clin 15:385, 2005; Katsambas AD et al: Guidelines for treating acne. Clin
Dermatol 22:439, 2004; Martinez SD et al: Non-erosive reflux disease (NERD)--acid reflux and symptom patterns. Aliment
Pharmacol Ther 17:537, 2003; Ozawa S et al: New endoscopic treatments for gastroesophageal reflux disease. Ann
Thorac Cardiovasc Surg 11:146, 2005; Santos MA et al: Effectiveness of photodynamic therapy with topical 5-aminolevulinic
acid and intense pulsed light versus intense pulsed light alone in the treatment of acne vulgaris: comparative study.
Dermatol Surg 31:910, 2005; Scheffer RC et al: Relationship between the mechanism of gastro-oesophageal reflux and
oesophageal acid exposure in patients with reflux disease. Neurogastroenterol Motil 17:654, 2005; Thevarajah S et al:
Trends in prescription of acne medication in the US: shift from antibiotic to non-antibiotic treatment. J Dermatolog
Treat16:224, 2005; Tutuian R et al: Esophageal pH monitoring on PPI therapy: removing the blinders. Am J Gastroenterol
100:1893, 2005; Webster G: Mechanism-based treatment of acne vulgaris: the value of combination therapy. J
Drugs Dermatol 4:281, 2005; Witkowski JA et al: The assessment of acne: an evaluation of grading and lesion counting
in the measurement of acne. Clin Dermatol 22:394, 2004.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty reported
nothing to disclose.
Drs. Zurad and Tate spoke in San Francisco, at the American Academy of Family Physicians’ (AAFP) 2005 Scientific Assembly,
presented September 28 to October 2, 2005. The Audio-Digest Foundation thanks the speakers and the AAFP for
their cooperation in the production of this program.
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