Ingest

• Neuroendocrine Cancer - The Expert Patient

  The episode features Dr. David Bartlett, a retired GP and neuroendocrine cancer patient, offering a dual perspective as both clinician and patient.Key Learnings from this episode.Patient Experience and Diagnostic ChallengesDr. Bartlett’s symptoms began with severe, intermittent abdominal pain, starting in 2001, but he did not seek medical help for several years due to a combination of stoicism, not wanting to trouble others, and a belief in the commonality of benign causes. Over 15 years, he experienced repeated misdiagnoses, primarily being labeled as having irritable bowel syndrome (IBS) despite atypical features (severe pain, minimal bowel habit change, and no systemic symptoms). Multiple opinions and investigations (including ultrasounds and CT scans) failed to identify the underlying cause, with a key scan being misread by local radiologists. The correct diagnosis of a small bowel neuroendocrine tumour was only made after a tertiary centre re-examined previous scans, highlighting the importance of specialist review and persistence in unexplained cases.Clinical Red Flags and SymptomatologyDr. Bartlett’s case underscores that neuroendocrine tumors can present with isolated, severe abdominal pain without classic red flags (vomiting, weight loss, significant bowel changes)[1]. He retrospectively identified subtle signs of carcinoid syndrome (flushing, one episode of profound diarrhoea, and skin changes), which are present in only about 10% of small bowel neuroendocrine tumour cases. The lack of awareness about neuroendocrine tumors, even among experienced clinicians, contributed to the diagnostic delay[1].Lessons for Primary Care and CliniciansThe story illustrates the risk of anchoring on common diagnoses (like IBS) and the need to reconsider the diagnosis when symptoms are severe, persistent, or atypical. It highlights the value of listening to the patient’s narrative, especially when symptoms do not fit classic patterns, and the importance of considering rare conditions in the differential diagnosis. The episode emphasises the need for ongoing education about neuroendocrine tumours and the importance of keeping rare but serious conditions on the diagnostic radar in primary care.Management InsightsStandard treatment for small bowel neuroendocrine tumours often includes monthly somatostatin analog injections (e.g., lanreotide). Surgical intervention may be considered, but it carries specific risks such as carcinoid crisis, requiring specialised perioperative management. The decision for surgery is individualised, weighing potential symptomatic improvement against procedural risks.Systemic and Human FactorsDr. Bartlett’s experience reflects how personal traits (stoicism, reluctance to seek help) and systemic issues (misinterpretation of scans, diagnostic inertia) can delay diagnosis. The narrative also demonstrates the importance of patient advocacy, persistence, and the value of second (or third) opinions, especially in complex or unresolved cases.Educational ValueThe episode serves as a reminder for clinicians to maintain a broad differential, revisit diagnoses when the clinical picture changes, and to be aware of their own cognitive biases. It also advocates for the inclusion of patient voices in medical education to better understand the lived experience and challenges of rare diseases like neuroendocrine cancer.Summary Table: Key LearningsThemeKey PointsDiagnostic Delay15 years from symptom onset t... Chapters (00:00:10) - Ingest(00:02:07) - David Bartlett on neuroendocrine cancer(00:05:32) - Irritable bowel syndrome, 15 years after first bout(00:12:09) - Carcinoid syndrome in small bowel neuroendocrine tumors(00:16:10) - Neuroendocrine tumour, surgery and recovery(00:20:43) - Somaostatin analogues for neuroendocrine cancer(00:25:43) - The role of the multidisciplinary team in bowel cancer care(00:28:21) - The battle with depression in your 50s(00:30:00) - General Practice and the Art of Medicine(00:33:13) - General Practice: The challenge of slowing down(00:35:35) - Neuroendocrine Cancer UK support group(00:39:28) - David's story of cancer(00:40:38) - David's Neuroendocrine Cancer Episode 1

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  43:29
• Pancreatic Conditions Part 2 - Malignant

  Dr Charlie Andrews talks to Dr John Leeds. John Leeds is a Consultant Pancreaticobiliary Physician and Endoscopist based at the Freeman Hospital in Newcastle and an Honorary Clinical Senior Lecturer based in the Population Health Sciences Institute at Newcastle University. He is involved in research in pancreaticobiliary disorders including benign and malignant conditions as well as outcomes from therapeutic/advanced endoscopy.John is a member of the British Society of Gastroenterology and Pancreatic Society of Great Britain and Ireland. He serves on the endoscopy and Pancreas committees for BSG and is the website lead for PSGBI.He is also a founder member of the BSG Pancreas Clinical Research Group which is coordinating research for the society.Key Learnings from this episode:Challenges in Early Detection of Pancreatic Cancer • Pancreatic cancer is often diagnosed at an advanced stage due to the deep location of the pancreas and the lack of early symptoms. • Tumors in the body and tail of the pancreas can grow significantly before causing symptoms, often invading major arteries or veins, making them inoperable. • Tumors in the head of the pancreas may present earlier due to bile duct obstruction, leading to jaundice, but even these are often detected late. Early Symptoms and Red Flags • Early symptoms are vague or absent, making early diagnosis difficult. • Possible early indicators include: • Weight loss (often a sign of advanced disease). • New-onset diabetes, particularly in individuals with a normal BMI or without typical risk factors for type 2 diabetes. • Jaundice, which is a significant red flag and often indicates a serious underlying condition. • Classic signs like painless jaundice and Courvoisier’s sign (palpable gallbladder) are important but not always present. Limitations of Current Screening Methods • There is no reliable biomarker or screening test for pancreatic cancer: • CA19-9 is not suitable as a screening tool due to its lack of specificity (elevated in other conditions). • Imaging techniques like CT scans or MRIs are used but have limitations, including incidental findings that may lead to unnecessary anxiety (“scanxiety”) and over-investigation. • Screening is currently limited to high-risk groups, such as those with familial pancreatic cancer syndromes or hereditary pancreatitis. High-Risk Groups for Screening • Familial pancreatic cancer accounts for less than 10% of cases. Criteria for screening include: • Multiple family members with pancreatic cancer, especially diagnosed under age 50–60. • Genetic syndromes like BRCA mutations, familial adenomatous polyposis (FAP), and Peutz-Jeghers syndrome. • Hereditary pancreatitis patients have an increased risk but are harder to screen due to pre-existing pancreatic abnormalities. Emerging Research and Future Directions • Studies are exploring potential biomarkers, such as microbiome signatures in the pancreas, which might help identify high-risk individuals in the future. • Trials like the EuroPAC study focus on surveillance protocols for high-risk individuals using imaging techniques like MRI or endoscopic ultrasound. • Research into new-onset diabetes as a potential marker for pancreatic cancer is ongoing but currently has a low yield due to the high prevalence of type 2 diabetes unrelated to malignancy. Considerations for Screening and Surveillance • Screening should be carefully targeted to avoid over-diagnosis and unnecessary investigations. • The psychological impact of screening (e.g., anxiety from incidental findings) must be considered. • Smoking cessation is emphasized as smoking is a significant risk factor for pancreatic cancer. Advances in Treatment Approaches • PET-CT scans are increasingly used to detect systemic disease that might not be evident on standard CT scans. • Neoadjuvant treatments (therapy before surgery) are being... Chapters (00:00:00) - Ingest(00:00:53) - Pancreatic Cancer(00:04:03) - New diabetes and pancreatic cancer(00:08:01) - Pancreatic Cancer: Screening(00:15:42) - Determining breast cancer early is hard(00:16:03) - Pulmonary neuroendocrine tumors of the pancreas(00:22:26) - Pancreatic cancer 20, Management(00:29:00) - Pancreatic cancer, management principles(00:33:48) - Primary Care Take Home: Pancreas, pain(00:40:29) - Primary Care: Pancreas Cancer Episode 2

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  43:36
• Pancreatic Conditions Part 1 - Benign

  Dr Charlie Andrews talks to Dr John Leeds. John Leeds is a Consultant Pancreaticobiliary Physician and Endoscopist based at the Freeman Hospital in Newcastle and an Honorary Clinical Senior Lecturer based in the Population Health Sciences Institute at Newcastle University. He is involved in research in pancreaticobiliary disorders including benign and malignant conditions as well as outcomes from therapeutic/advanced endoscopy.John is a member of the British Society of Gastroenterology and Pancreatic Society of Great Britain and Ireland. He serves on the endoscopy and Pancreas committees for BSG and is the website lead for PSGBI.He is also a founder member of the BSG Pancreas Clinical Research Group which is coordinating research for the society. Chapters (00:00:01) - Ingest: pancreatic lesions(00:01:09) - Pancreas(00:05:39) - Chronic Pancreas disease, early signs and symptoms(00:11:54) - Pulmonary pancreatitis, diagnosis and management(00:17:52) - Diarrhea, weight loss(00:18:29) - Pancreatic disease, ultrasound and the best treatment(00:23:49) - Pancreatitis, chronic pancreatitis in primary care(00:26:19) - Pancreatitis 20, Surgery or drainage?(00:32:24) - Pancreatic Exocrine Insufficiency(00:38:05) - Pulmonary dysrhythmias, management tips(00:43:46) - PPI for cystic fibrosis patients 8,(00:46:16) - Pancreatic insufficiency 20, Detection and treatment(00:49:57) - Pancreatic cysts(00:55:32) - Choosing the right cyst for surgery(00:57:20) - autoimmune pancreatitis, presentation and treatment(01:03:34) - Pancreatic cancer: diagnosis and treatment(01:06:14) - Pancreatitis, part 1, unboxing

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  1:08:41
• IBS Part 2 - Management

  Charlie Andrews talks to Dr Chris Black about the management of IBS.This podcast provides key insights into managing Irritable Bowel Syndrome (IBS), emphasising a multidisciplinary and individualised approach to care. Here are the main takeaways:1. Multidisciplinary and Integrative CareIBS management requires a holistic, patient-centered approach involving dietitians, behavioral therapists, and gastroenterologists. This "team sport" approach expands treatment options and tailors care to individual patient needs1. Integrative care, which combines dietary, psychological, and medical interventions, has been shown to improve symptoms, psychological well-being, and quality of life for IBS patients1.2. Personalised TreatmentIBS is not a one-size-fits-all condition. There are different subtypes of IBS (e.g., IBS-D for diarrhea-predominant or IBS-C for constipation-predominant), and treatment must be customized based on the patient's symptoms and triggers4. Emerging research suggests the need to identify distinct subtypes of IBS to guide more effective treatments24.3. Dietary ManagementThe low FODMAP diet is a widely recommended dietary intervention for IBS. It helps identify food triggers and manage symptoms but should not be used long-term without personalization3. Probiotics may also play a role in symptom relief for some patients, though their effectiveness varies3.4. Behavioral InterventionsCognitive Behavioral Therapy (CBT) and gut-directed hypnotherapy are effective in managing IBS symptoms, particularly when patients are motivated to engage in these therapies1. Stress management is critical since stress and anxiety can exacerbate IBS symptoms15.5. Pharmacological TherapiesMedications are often used as complementary treatments when dietary or behavioral strategies alone are insufficient. These include antispasmodics, laxatives, or medications targeting gut-brain interaction Chapters (00:00:01) - Ingest on Irritable Bowel Syndrome(00:02:49) - In the Know: irritable bowel syndrome (IBs)(00:04:03) - Irritable bowel syndrome, management principles(00:08:07) - How to manage irritable bowel syndrome? ((00:16:15) - How much loperamide can one give for IBS?(00:17:36) - Non-steroidal anti-inflammation for IBS?(00:24:05) - Physical and psychological therapies for abdominal pain(00:26:17) - IBS, secondary care referrals(00:32:11) - First line diabetes: An integrated approach(00:32:40) - IBS, group-based care(00:40:27) - Management of IBS 11(00:42:28) - Primary Care: IBS Episode 4

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  45:15
• Abdominal Pain in Children

  Charlie Andrews talks to Dr Anthony (Tony) Wisken, Consultant Paediatric Gastroenterologist in Bristol.The Ingest podcast is hosted by Dr Charlie Andrews a GPwER in gastroenterology based near Bath. Charlie works as a GP partner at Somer Valley Medical Group, trained as an endoscopist and leads the national GPwER in gastroenterology training programme, launched in 2023 in the southwest of England. Charlie is a committee member of the PCSG (Primary Care Society of Gastroenterology). For more information visit pcsg.org.uk Chapters (00:00:05) - INGEST(00:01:02) - Chronic abdominal pain in children(00:07:47) - Pediatric gastroenterology, pain in the tummy(00:13:13) - Reflux in children, 6 years and older(00:15:26) - Headache and abdominal pain in children, age 6(00:21:34) - Idiopathic bowel syndrome in children(00:24:51) - Tummy pain 11, constipation(00:31:08) - Mesenteric adenitis 20, Cancer(00:35:06) - Functional GI disorders, the role of ultrasound(00:38:57) - Obstructive bowel disease in teenagers(00:45:41) - Gallstones in children, anaesthesia and surgery(00:47:01) - Celiac disease, tests and how to manage it(00:49:40) - Top 3 Take Homes for kids(00:51:51) - H. Pylori in children's tummy pain(00:55:37) - 3 take home points from the abdominal pain episode

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  58:07

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