Your Tube

Roger Jones

doi:10.3399/bjgp14X682069

The human alimentary tract is a thing of wonder. It is 9 metres long, with a mucosal area the size of a tennis court. The gut microbiome contains more bacteria (10¹⁴) than there are cells in the body. It has its own nervous system, the little-understood enteric nervous system, which contains 90% of the body’s serotonin. In many systems of thought, the gut was believed to be the centre of wellbeing and the seat of the emotions. Thus the potential victim of some deadly predator will feel his bowels turn to water, and most Premiership footballers have reported being gutted. It is the location of a number of chronic diseases, including inflammatory bowel disease, gastro-oesophageal reflux disease, diverticulitis disease, and irritable bowel syndrome and, taken as a whole, cancers of the gut represent the commonest group of cancers. The gut is inextricably linked with the global epidemics of non-communicable diseases. In this issue we focus on gastrointestinal disorders.

Our Clinical Intelligence section contains three important messages for practice. First, in pregnant women with inflammatory bowel disease, disease remission is a prognostic indicator of good outcomes for mother and baby: these patients should be encouraged to continue their medications during pregnancy and breastfeeding. Second, the measurement of faecal calprotectin has emerged as a useful test to differentiate functional from organic lower bowel problems, particularly in separating irritable bowel syndrome from inflammatory bowel disease. Its use is likely to be associated with reduced secondary-care referrals and colonoscopy. Third, in older patients presenting with persistent symptoms of sore throat and swallowing problems, particularly if there is cervical lymphadenopathy, the diagnosis of oropharyngeal cancer, rather than tonsillitis, should be considered. Increasing age, smoking, and alcohol consumption are all risk factors for this condition.

In their interview study, Lecky and colleagues identify a number of factors which may deter patients from providing adequate stool samples for investigation, and recommend ways in which the procedure could be improved. This is likely to be particularly relevant to the national screening programme for colorectal cancer, which still has a disappointing uptake in many parts of the country. Alazawi and colleagues’ study of a large population in east London provides valuable new data on the prevalence of abnormal liver function tests and their subsequent investigation in general practice, as well as identifying Bangladeshi ethnicity as an independent risk factor for non-alcoholic fatty liver disease.

In her editorial Julia Darzi emphasises the importance of being ‘nutrition aware’ in primary care, pointing out the importance of assessing various aspects of nutrition, including obesity. However, the recognition of obesity is not quite as straightforward as we may think. In an interesting study of trainees and qualified GPs, (Robinson, et al), participants were asked to comment on photographs of healthy weight, overweight, and obese young males and to say whether they would be likely to make a brief intervention for weight loss. They tended to systematically underestimate body mass index and were correspondingly less likely to suggest an intervention, underlining the importance of measuring, rather than guessing, patients’ weights.

In the policy arena, three editorials examine changes within the health service. In my editorial I suggest we should take integration further than most current schemes propose, and tackle some of the problematic interprofessional relationships still making life difficult in general practice and hospital medicine. In an interesting analysis of the Law Commission’s review of the regulation of health and social care, Jamie Hunt describes a new era of professional regulation with the potential to affect many of us, while David Misselbrook teases out some of the ethical and practical implications of the Royal College of Surgeons recent report Building a Culture of Candour.

In other parts of this issue you will find a stimulating discussion of the role of chaperones, the disincentives experienced by young doctors considering general practice as a career, and the importance of relationship-based care in the future health service. We also touch on the Scottish referendum, reflect on the recent RCGP Annual Conference, and report the results of the RCGP Research Paper of the Year award.