Chronic Disease

Key Feature 2: Regularly reassess adherence (compliance) to the treatment plan (including medications).
Skill: Clinical Reasoning
Phase: History, Follow-up

Ischemic Heart Disease

Key Feature 4: In a patient with stable ischemic heart disease manage changes in symptoms with self-initiated adjustment of medication (ex: nitroglycerin) and appropriate physician contact (ex: office visits, phone calls, emergency department visits), depending on the nature an severity of symptoms.
Skill: Clinical Reasoning
Phase: Treatment

Key Feature 5: In the regular follow-up care of patients with established ischemic heart disease, specifically verify the following to detect complications and suboptimal control:

• Symptom control
• Medication adherence
• Impact on daily activities
• Lifestyle modification
• Clinical screening (i.e., symptoms and signs of complications)

Skill: Clinical Reasoning, Patient Centered
Phase: History, Diagnosis

Once a patient has been diagnosed with ischemic heart disease, they have a chronic symptomatic disease that warrants ongoing treatment of the main symptom: angina. Many patients will be started on a daily beta-blocker because they work by decreasing the heart's effort and its subsequent oxygen requirement and associated angina when it is oxygen starved. Calcium channel blockers would be second-line if a beta-blocker is contraindicated or not sufficient for additional therapy. 

Despite daily medications to help prevent cardiac ischemia, patients may still develop acute episode of cardiac ischemia pain or angina. For these, the patient needs to be advised to take a nitrate medication (usually a tab of sublingual nitroglycerin under the tongue, every 5 min as needed up to 3 doses) for relief of the acute symptoms. Alternatively, the patient can be advised to take a prophylactic dose before exertion to prevent the onset of angina. 

Beyond having an understanding of how to take medications as indicated, another major component of patient education involves counselling about when and where to receive followup medical care. For the patient with stable ischemic heart disease, UpToDate suggests follow-up every 6 to 12 months for ischemic heart disease, which should include a review of:

• Any change in the frequency, severity, or pattern of angina
• Tolerance of and compliance with the medical program
• Any change in baseline physical activity
• The development of new or worsened comorbid illnesses
• Modification of risk factors
• Physical examination of the cardiovascular system
• Investigations to monitor other cardiovascular risk factors such as blood glucose or lipid profile, as indicated. 

The above things to think about really apply in a general sense to the management of many chronic diseases.

For the patient experiencing acute angina that is either not responding to nitroglycerin or that is much more severe than typical episodes of angina for them, they should be advised to call an ambulance for emergency medical care of what could be a heart attack. Patients may also choose to attempt to call their clinician(s) or a medical information line if they have any uncertainty about what they ought to be doing should their symptoms change, but this should only be for situations that do not involve ongoing chest pain. Any acute episode of angina that is not going away despite abortive therapy warrants emergent medical attention in an emergency care setting.

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Undertake an appropriate addiction history and focused physical exam
• Assess and manage common comorbidities including chronic pain, abscess, endocarditis, HIV, hepatitis and mental illness
• Describe the processes of codependence and enabling in the context of addiction, and can identify these processes when happening in a therapeutic relationship

Key Feature 5: Given a non-compliant patient, explore the reasons why, with a view to improving future adherence to the treatment plan.
Skill: Patient Centered
Phase: History

All patients should be screened for substance use, be it during a new consultation or periodically from time-to-time as substance use patterns naturally can change over time. Patients who screen positive for a potential substance use disorder deserve a dedicated comprehensive substance use assessment. The following is my approach to gathering an addiction focused history and physical examination. This assessment helps to identify the presence, severity, and complications of substance use disorders.

History

1. What substances does the patient use ever? (Note: If a patient endorses any sort of opioid use, it's particularly important to clarify whether they drink alcohol and use benzodiazepines, both of which significantly increase the risk of opioid overdose.)
2. Route of substance administration (ex: IV, oral, smoking, snorting, IM, rectal)
3. Quantity used 
4. Frequency used
5. Age of initiation
6. Time of last use
7. Tolerance 
8. Withdrawal history
9. Overdose history (personal, witnessed)
10. Treatment history
    1. Pharmacologic (ex: OAT, nicotine replacement)
    2. Outpatient (ex: counselling, day treatment program, support groups)
    3. Inpatient (ex: detox, rehab)
11. Abstinence history (along with treatment history, this is very useful information in planning next steps)
    1. Protective factors (i.e., What helped them achieve this?)
    2. Precipitating factors (i.e., What led to relapse?)
12. Comorbidities or medical complications secondary to substance use (ex: chronic pain, mental illness)
13. Obtaining a complete medication history, as would always be done as part of a consult, but also confirming the patient has been taking any medication prescribed specifically for treatment of a substance use disorder such as methadone (in BC we can look on PharmaNet, a record of all of the substances a patient has received from a pharmacy within the province). Also important is looking for prescriptions the patient may be receiving from other clinicians.
14. Per usual, gathering a social history, considering issues such as stable housing, finances, and social supports*
15. Assessing a patient's motivation and stage of change regarding their substance use disorder. Depending on where a patient is at, this advises a clinician on the most appropriate interventions that a patient may be more likely to consider. Addressing substance use disorders is not cut-and-dry, and if a patient is totally not ready for change yet, being assertive about cessation of substance use could do more harm through damaging patient rapport.
    1. Precontemplative: Patient is not ready to quit. Appropriate intervention includes: Asking the patient what they think about their substance use, including ascertaining their knowledge about the associated risks, along with the benefits they derive, from use of the substance. A neutral conversation without judgment can help a patient be more informed about their substance use, and it may plant a seed to create motivation for substance use cessation. It is important to avoid argument about the benefits of stopping substance use if a patient is in this stage of change. Simply make an offer to help the patient when they are ready to reduce or cease using.
    2. Contemplative: Patient is considering quitting but not now. Appropriate intervention includes: Explore the patient's ambivalence, providing information to help clarify the pros and cons of substance use and what may be done to support them should they wish to make a change. 
    3. Preparation: Patient has decided they want to quit, and is planning to do so within the next month or so. Appropriate intervention includes: Smart goal setting, exploring in what way the patient could benefit from supports that could be made available, and helping the patient identify high risk situations in which it may be hard not to use and helping to create strategies to mitigate those anticipated challenges.
    4. Action: The patient is actively in the process of behaviour modification. Appropriate intervention includes: Providing support and positive reinforcement, and discusses the successes and pitfalls that occur along the way. 
    5. Maintenance: The patient has previously made changes to their pattern of substance use and are having success in maintaining their substance use goals. It is important to recognize the high risk of relapse when it comes to any drug or process addiction. Appropriate intervention includes: Continuing support and positive reinforcement, and being available to help should relapse occur. Frame relapses as learning opportunities to create new strategies to overcome factors that led to the relapse.

Physical Examination

1. ​General inspection
2. Vital signs
3. Mental status examination
4. Cardiovascular examination (be on the lookout for a murmur suggesting endocarditis in the patient who uses IV drugs)
5. Respiratory examination
6. Head and neck examination  (pupillary size can be a helpful indicator of substance intoxication or withdrawal)
7. Abdominal examination (assess the liver and for signs of decompensated liver disease)
8. Musculoskeletal examination (when a patient describes areas of focal pain, it's important to have a high index of suspicion for infection as patients with risky substance use can be at increased risk for serious infections such as septic arthritis or osteomyelitis)
9. Dermatological examination (looking for track marks or other lesions/excoriation, and be on the lookout for abscesses or cellulitis, as indicated)

Investigations
Patients who have risk factors for infectious diseases should be screened accordingly (not to mention they deserve to be screened for cardiovascular diseases and cancers much like the general population as well). Specific risk factors that go along with substance use include intravenous drug use, intranasal drug use, and any sort of shared drug paraphernalia. Such patients warrant screening as frequently as every 3-6 months and at least once a year for HIV, HBV, and HCV. Also consider screening for anemia with a CBC and ferritin, for liver disease with liver function testing, and pulmonary function testing if they have a significant smoking history and chronic respiratory symptoms.

While I will address the treatment of the substance use disorders proper in a separate post, what I will do here is just briefly touch on the management of comorbidities that may be detected in the workup of a substance use disorder. 

1. Chronic pain and mental illness warrant a complete assessment in their own right, but often chronic pain, mental illness, and substance use all go hand and hand in a chicken or egg tragic love triangle. There may in fact be little utility in trying to get down to the route precipitants, and any co-occuring pain and psychiatric issue simply warrants comprehensive, integrated, and multidisciplinary management, as much as the patient will buy into and follow through  with.
2. Patients who inject IV drugs and who are otherwise immunocompromised are at risk for developing skin abscesses - these warrant incision & drainage with deep wound culture and antibiotic coverage. For a mild presentation that can be managed as an outpatient, empiric antibiotic coverage for MRSA could be cephalexin 500 mg PO QID + cotrimoxazole DS 2 tablets PO BID) x 10 days.
3. A high index of suspicion is warranted for endocarditis in a patient who uses IV drugs with a fever. In this case, obtain blood cultures and order a TTE as initial workup. The modified Duke criteria help with diagnostic clarity.
4. Treatment of HIV and hepatitis in a patient with substance use is similar to treatment of the same disease processes in patients without substance use, but more vigilant screening is warranted in patients with risky substance use as they are at increased risk of acquiring these infectious diseases (or alcoholic hepatitis in the setting of chronic alcohol use). Naturally, they may also pose a greater risk of further transmission to others if it was their behaviours that may have led them to contract an infectious disease in the first place. And then in general, their lives are often disorganised and it may be more difficult to provide comprehensive management of these diseases secondary to the chaos. Just like pain and mental illness, concurrently treating the comorbidities can improve outcomes for both disease processes. 

*When learning about what social supports a person may or may not have, it is important to have a high index of suspicion for domestic or intimate partner violence, as well as for the possibility of codependence, which may appear at first as a very loving and supportive relationship. As defined by Wikipedia, "Codependency is a type of dysfunctional helping relationship where one person supports or enables another person's drug addiction, alcoholism, gambling addiction, poor mental health, immaturity, irresponsibility, or under-achievement." Wikipedia goes on to explain that the concept arose from Alcoholics Anonymous and that "...the term 'codependent' was first used to describe how family members of individuals with substance abuse issues might actually interfere with recovery by overhelping." It may be important to involve a patient's partner or main support(s) in the patient's clinical care so as to communicate ways in which helping behaviours may actually be causing more harm than good. Counselling to address these issues both as individual and as couples therapy may be helpful.

Key Feature 3a: In patients with chronic disease: Actively inquire about pain.
Skill: Clinical Reasoning
Phase: History

Key Feature 3b: In patients with chronic disease: Treat appropriately by:

• Titrating medication to the patient's pain
  
• Taking into account other treatments and conditions
  (ex: watching for interactions)
  
• Considering non-pharmacologic treatment and
  adjuvant therapies
  

Skill: Clinical Reasoning
Phase: Treatment, Hypothesis generation

Palliative Care

Key Feature 4: In patients with pain, manage it (ex: adjust dosages, change analgesics) proactively through frequent reassessments and monitoring of drug side effects (ex: nausea, constipation, cognitive impairment). 
Skill: Clinical Reasoning
Phase: Treatment, Follow-up

The standard general approach to pain control is based on the World Health Organization's Pain Ladder, with the diagram and information below coming from "Palliative medicine: A case-based manual" by Doreen Oneschuk, Neil Hagen, and Neil MacDonald. The "ladder" was designed with cancer pain in mind, but it tends to provide the framework for pain management for people with all sorts of acute and chronic sources of pain. The basic idea is that for mild pain you start with non-opioid medications, with specific choice depending on the type of pain and patient characteristics. It is important to actively inquire not just about the presence of pain, but also about the quality of the pain in patients in order to treat it most effectively. Not illustrated as part of the pain ladder but equally important are also nonpharmacological interventions that can be useful in alleviating pain. As pain increases in severity, the choice of pain medication and/or dose ought to increase accordingly. Adjuvants (medications originally developed for reasons other than to improve pain, but that can also alleviate pain as a secondary effect, depending on the type of pain) can also be very useful when indicated. Poor pain control can have a significant negative impact on quality of life, and we have lots of tools in the box to work to mitigate this source of distress. It is important to continue to reassess patients experiencing pain or receiving therapy for it, to ensure that pain is in fact controlled, as well as to monitor for side and adverse effects.

Nonpharmacological therapies to consider starting, in the context of mild pain and patients who are motivated to try them, or to consider adding on to pharmacological treatments for added pain relief, could include:

• Application of heat or cold
• Exercise
• Massage
• Relaxation therapies (including meditation, guided imagery, music and art therapy, animal therapy)
• Acupuncture

There are of course many others beyond this brief list. In the setting of cancer, for example, radiation therapy may be an option (although much less benign) to improve pain control.

Common non-opioid medications for mild pain include acetaminophen and NSAIDs (ex: naproxen, ibuprofen, diclofenac, ketorolac). 

• Acetaminophen works on the perception of pain at the level of the brain. It tends to be used first line as it is has minimal risk of harm. It is, however, metabolised by the liver, so it should not be used in patients with impaired liver function or who consume excess alcohol (3 or more drinks daily). It is available in oral and rectal preparations, and can be taken as needed or around the clock.
• NSAIDs work by inhibiting prostaglandin synthesis, acting peripherally to decrease the release of inflammatory mediators and associated pain signals. When pain is secondary to an inflammatory process, they may theoretically be preferred over acetaminophen. They are generally safe to use short-term in the otherwise healthy person, but carry certain risks if they are taken for a prolonged period of time in a dose-dependent fashion. The main risks are gastrointestinal bleeding (which is why any patient who is going to take an NSAID regularly for more than 1 week should also be on a gastroprotective agent), renal impairment (patients with compromised renal function or who are at increased risk of this, such as patients with diabetes mellitus or the elderly, should avoid the use of NSAIDs), and abnormal hemostasis (predisposing patients to more significant bleeding should they have a reason for a bleed). NSAIDs can generally be found in any type of preparation depending on the specific agent selected. For inflammatory musculoskeletal pain, diclofenac gel can be prescribed without risk of the above adverse consequences.

For pain that is sufficiently severe and that cannot otherwise be controlled (with non-opioids, adjuncts, and nonpharmacological modalities), treatment with an opioid may be indicated. Opioids exert their analgesic effect mostly by agonising mu opioid receptors in the brain. Commonly prescribed weak opioids include codeine and tramadol, and commonly prescribed strong opioids include morphine, hydromorphone, oxycodone, fentanyl, and methadone.

General principles of opioid initiation and titration include having a regular dosing schedule (initially starting with a short-acting preparation until the baseline pain is controlled) with a prescribed breakthrough dose for pain to be taken as needed for acute exacerbations (generally prescribed to be taken as much as every 1 hour, or in the setting of opioids with a very rapid half life, up to every 30 minutes or so). The degree of pain control as reported by the patient along with the number of needed breakthrough doses in a given 24 hour period indicates whether or not there is a need to adjust the baseline opioid dose. As a general rule of thumb, if greater than 3 breakthrough doses in a 24 hour period are needed, unless this is attributed to being incident pain (aggravated by a specific event such as movement that would not otherwise be present at baseline), then an increase in the baseline opioid dose is warranted. The amount to up-titrate can be calculated by adding up the total quantity of opioid needed in the last 24 hour period (baseline and amount of breakthrough used), calculating the conversion to the new choice of opioid based on number of morphine equivalents, and dividing this quantity so that it is given over the next 24 hour period as the scheduled dose. And then a new quantity of breakthrough pain medication is prescribed, and a rule of thumb for this is dosing it at about 10% of the total daily scheduled amount of opioid to be given over the next 24 hour period. 

On the flip side, when patients report good pain control, with minimal to no use of doses required for breakthrough pain, the patient can be gradually weaned down as tolerated. 

Side effects of all opioids are generally the same (though they may occur to different degrees depending on the formulation, dose, and patient factors), and they most commonly include transient nausea, transient drowsiness, and constipation that is not transient and that lasts as long as the opioid is being taken. If they are given in a high dose too quickly, they can cause respiratory depression, but when prescribed responsibly in small doses with gradual up-titration, this concern is mitigated. For the nausea, an antiemetic can be prescribed either to be taken routinely or as needed, and for the constipation the patient will likely need to be on a regular dose of laxative medication. See my next post for more detail on these options.

Besides the above side effects that can occur when any opioid is used, there is also the phenomenon of opioid neurotoxicity that can occur. Briefly, this is a situation in which patients can develop altered mental status (ex: delirium, agitation, somnolence), vivid or unpleasant dreams, delusions/hallucinations (usually visual), and increased pain perception (ex: allodynia or hyperalgesia). Myoclonic jerks and seizures can also occur. In the setting of suspected opioid neurotoxicity, rotating to a different opioid is warranted (other options include simply changing the route by which the current opioid is delivered, decreasing the dose of the current opioid and adding an adjuvant, or just treating the toxic symptoms themselves; rotating the opioid is generally the preferred option). This is done by adding up the total number of morphine equivalents a patient has on board in a given 24 hour period, calculating the equivalent dose in the opioid to which the patient is being rotated to, reducing this dose by 25%, and dividing the dose to be scheduled throughout the day as the half-life of the new opioid indicates.

​Opioid options include:

• Codeine
  • Codeine is a pro-drug, which means it needs to be converted to its active form once ingested in order to have an analgesic effect. However, up to 10% of people do not have make the enzyme needed to do this, so the analgesic effect of this medication can be limited to that of a placebo effect in some people. 
• Tramadol 
  • Tramadol produces analgesia by its mu-agonist activity, but it also reduces pain through its dual action of preventing serotonin and norepinephrine reuptake as well. This means it must be used with caution in patients who are taking medications that also reduce the reuptake of serotonin (as is common with many antidepressants) as there is an increased risk of serotonin syndrome. It must also be used with caution in patients who have an increased risk of seizure. A major downside of this medication is expensive and not covered by most provincial drug plans. Although my preference is not to use codeine because it may be ineffective in some people, I would trial codeine for moderately severe pain in the outpatient population if the cost of tramadol is prohibitive for the patient in front of me.
• Morphine
  • The prototypical medical opioid, morphine is a strong opioid analgesic as it has strong affinity to the opioid mu receptor. It is a derivative of the naturally occurring opium  from the poppy plant. 90% of it is metabolised by the liver, and its metabolites (some active, some causing neurotoxic side effects) are excreted really. For patients with renal insufficiency it must be used very cautiously, or more ideally an alternative opioid should be selected. It is available in short-acting versions given every 4 hours or every 1 hour for breakthrough pain. It is also available in long-acting versions that can be given every 12 hours or once every 24 hours in its even longer-acting form.
• Hydromorphone
  • Morphine 2.0, this is a semisynthetic morphine derivative that is about 5 times more potent than morphine. It may have less neurotoxic metabolites, with a reduced risk for the associated side effects. This is my go to strong short-acting opioid. It has pretty well the same formulations available as its sister morphine.
• Oxycodone
  • Also a highly-potent semisynthetic compound, this opioid is approx 1.5-2 times as potent as morphine. Some of its activity is secondary to some of its active metabolites, and similar to codeine, this requires liver enzymes that approximately 5-10% of the population do not possess for genetic reasons. It is only available by mouth in Canada, which also limits its utility.
• Fentanyl
  • Infamous for its deadly impact on the streets in the unprecedented and ongoing Fentanyl Crisis, this opioid is undeniably helpful to the clinician who is helping patients cope with severe pain. It is approximately 100 times more potent than morphine! It has a quick onset of action, but also a short-half life, at least when it is prescribed parenterally (including through the sublingual route). While this can be beneficial for acute breakthrough pain control that is short lasting, it's permanent home in the palliative toolkit is mostly for its role in providing long-acting pain control through its transdermal application (aka the fentanyl patch). The only opioid that is administered this way, this is an excellent way of providing pain relief to patients who have stable pain control and who are unable to tolerate other forms of opioid administration (ex: if they cannot tolerate medications by mouth, this provides a pain- and hassle-free way to provide pain relief compared to repeated injection as the other alternative). The patch lasts 72 hours, and so only needs to be replaced every 3 days. It also seems to have less neurotoxic side effects than the strong opioids listed above, and so renal insufficiency is not as significant of a concern. Because the short-acting version is so very short, once a patient has stable pain control on a fentanyl patch, typically they will have one of the other strong opioids on board in a short-acting formulation for breakthrough pain. 
• Methadone
  • A synthetic opioid most known for its use in the context opioid addiction, it provides approximately 10 times the analgesic effect as morphine. The actually conversion depends on the dose being used; the relationship is not linear due to its lipophylicity and subsequent storage in the body's fatty tissues. This factor also gives it a somewhat unpredictable half-life, and can only be prescribed by physicians with special training in its use. Generally, it is prescribed to be given every 8-12 hours. It is affordable, and it is unique in that while it agonizes the mu opioid receptor, it also seemingly provides neuropathic pain relief through its activity as an NMDA (glutamate) receptor antagonist. It has no known active metabolites, so is a good choice in a patient with renal failure, and due the unique way it is stored in the body's fat, it is a good choice for the patient who receives hemodialysis. It is metabolised by the liver, so in the setting of hepatic disease, the dose ought to be adjusted cautiously.

Some adjuvants that may be useful in pain management, particularly in the palliative care setting:

• Dexamethasone is a corticosteroid that helps to reduce inflammation, particularly useful in reducing pain associated with peritumoural edema (commonly used in the setting of headache secondary to brain metastases) as well as bone pain (for which bisphosphonates are also a mainstay)
• Tricyclic antidepressants (ex: nortriptyline), rarely prescribed as antidepressants now given the superiority of newer options, they still have much utility in treating neuropathic pain, particularly that which is characterised as constant.
• Gabapentin, originally developed as an anticonvulsant, is also a mainstay in the treatment of neuropathic pain, and it may be particularly indicated in the neuropathic pain characterised as intermittent and sharp/shooting.
• Ketamine is a big gun drug that's been around the block and that has fallen out of but now back in favour with many physicians today. It is a medication often used for induction in anesthesia with associated strong analgesic properties and dissociative side effects. Typically this medication is prescribed in consultation with an anesthesiologist or other pain specialist. 
• Hyoscine for colicky bowel or genitourinary pain. Not to be used if there is suspicion of complete obstruction. 
• Methotrimeprazine is an antipsychotic with analgesic properties that can be a useful adjuvant in the setting of pain complicated by agitation or delirium

Abdominal Pain

Key Feature 2: In a patient with diagnosed abdominal pain (ex: gastroesophageal reflux disease, peptic ulcer disease, ulcerative colitis, Crohn’s disease), manage specific pathology appropriately (ex: with. medication, lifestyle modifications). 
Skill: Clinical Reasoning
Phase: Treatment

Key Feature 8: Given a patient with a diagnosis of inflammatory bowel disease (IBD) recognize an extra intestinal manifestation. 
Skill: Clinical Reasoning
Phase: Hypothesis generation, Diagnosis

Chronic Disease

Key Feature 1: In a patient with a diagnosed chronic disease who presents with acute symptoms, diagnose:

1. Acute complications of the chronic disease (ex: diabetic ketoacidosis).
   
2. Acute exacerbations of the disease (ex: asthma exacerbation, acute arthritis).
   
3. A new, unrelated condition.

Skill: Clinical Reasoning
Phase: Diagnosis

​When I was on rotation on the Family Practice Teaching Service at St Paul's Hospital I was managing a 27 year old female inpatient admitted with abdominal pain NYD (not yet diagnosed). Her past medical history was significant for ulcerative colitis, intravenous drug use now on opioid agonist therapy, pelvic inflammatory disease, and a ruptured ovarian cyst. Prior to the onset of the pain that brought her into the emergency department, she had not been taking any medications for the ulcerative colitis (the disease had been in remission) and she was on opioid agonist therapy to help manage her opioid use disorder. When she presented to the ED with acute abdominal pain she did not have a clear etiology to blame, and she was certainly unwell, so she was admitted to our service so we could manage her pain and figure out what was going on to resolve the underlying issue. After a couple of days into her admission and many investigations later, the team surmised that her pain was likely secondary to a flare up of the ulcerative colitis compounded with the pain of acute opioid withdrawal - the opioid agonist therapy she was taking was in the form of ingested slow-release oral morphine, which was likely not getting absorbed in her gut given its disposition. She was started back up on her antiinflammatory medication, her pain was temporarily managed with hydromorphone, and soon she was feeling back to her baseline. 

The list of possible aetiologies for abdominal pain is - as I've highlighted in previous blog posts - extensive. I will outline here the general management of selected aetiologies of abdominal pain that I must be  familiar with as a family doctor.

My information was gathered from Bugs & Drugs and the following UpToDate articles:

• Medical management of gastroesophageal reflux disease in adults
• Antiulcer medications: Mechanism of action, pharmacology, and side effects
• Peptic ulcer disease: Management
• Treatment regimens for Helicobacter pylori
• Management of mild to moderate ulcerative colitis in adults
• Management of severe ulcerative colitis in adults
• Overview of the medical management of mild (low risk) Crohn disease in adults 
• Overview of the medical management of severe or refractory Crohn disease in adults

Overview of the management of gastroesophageal reflux disease (GERD)
For uncomplicated GERD without alarm features*

1. Lifestyle/dietary modifications
   1. Weight loss: if overweight or recent weight gain
   2. Positional interventions: Elevation of the head of the bed if symptoms occur at night or if there are laryngeal symptoms (ex: cough, hoarseness, throat clearing). In the same vein, not eating 2-3 hours before bedtime or laying down after eating would be advisable.
   3. Dietary modifications: To selectively eliminate individualised triggers. Common triggers include fatty foods, caffeine, chocolate, spicy food, carbonated beverages, and peppermint. Alcohol can also be a trigger. Patients need not eliminate anything that is not a trigger for them, but these are common culprits to counsel about that may be worth a trial of elimination. 
2. Acid-suppressing medication
   1. Antacid therapy: With only intermittent episodes of bothersome heartburn occurring less than once weekly, starting with an over-the-counter antacid medication is a good first-line strategy
   2. H2RA therapy: If there are recurrent episodes happening no more than about once weekly, then a low-dose histamine 2 receptor antagonist (H2RA), taken only as needed, would suffice. My go to H2RA is ranitidine, which can be prescribed or purchased over-the-counter. And if there is an extra occasional episode of heartburn, perhaps because of a dietary indiscretion, then supplementing with an additional dose of over-the-counter antacid therapy would be totally appropriate. If the pain is not alleviated with a low-dose of H2RA used as needed, then stepping up to taking it regularly two times daily for a minimum of 2 weeks is warranted.
   3. PPI therapy: If the symptoms of heartburn continue to occur despite this continuous treatment, then it is time to discontinue the H2RA and initiate a once-daily proton pump inhibitor (PPI), starting at a low dose, and increasing this if the pain is still not controlled. Alternatively, if the patient first presented complaining of heartburning happening at least twice weekly from the get-go, starting a once-daily PPI at a low-dose without first trying antacids or an H2RA is warranted. My go-to PPI for GERD is omeprazole. The increase in the dose of the PPI, if needed, should be gradual, occurring after a 2 to 4 week interval at the trialed dose. Then, once the discomfort is controlled, the treatment (be it the H2RA or the PPI) should be continued at the first effective dose for at least 8 weeks. 
   4. Gastroenterology referral: Patients who fail to respond to once-daily PPI therapy are considered to have refractory GERD and should be referred to a gastroenterologist for further evaluation. They should also be referred to a gastroenterologist if they exhibit any alarm features* as part of their presentation. 
   5. Trial of cessation: If symptoms resolve completely with acid-suppressing medication, after a minimum of 8 weeks on this therapy, a trial of cessation is in order (unless there is another complicating factor to their acid reflux such as known esophagitis or Barrett's esophagus). If, after stopping the acid-suppressing therapy, the symptoms of acid reflux recur within three months, then the patient may need to be on the medication indefinitely. If it's been more than 3 months since stopping when the symptoms recur, then simply repeated a course of the above approach would be warranted.

*If any of the following alarm features are present, a referral to a gastroenterologist is indicated:

1. New onset epigastric discomfort in patients ≥60 years
2. Dysphagia or odynophagia
3. Anorexia, persistent vomiting, or unexplained weight loss
4. Evidence of gastrointestinal bleeding (hematemesis, melena, hematochezia, or occult blood in stool) or iron deficiency anaemia
5. Gastrointestinal cancer in a first-degree relative

Overview of the management of peptic ulcer disease (PUD)
The patient will have already been seen by a gastroenterologist, as endoscopy would've been done to detect the presence of ulceration. Although this means the gastroenterologist almost certainly will have developed a treatment plan for the patient to follow, it is important for family doctors to understand what needs to be done so they can ensure patient compliance.

1. Stop NSAID use: The patient should abstain from taking any NSAIDs. Avoiding tobacco is also recommended.
2. H. pylori eradication: If the patient was diagnosed as being infected with H. pylori, current standard of therapy specific to this part of the world, unless there are patient-specific reasons for prescribing an alternative regimen, is concomitant quadruple therapy for 2 weeks. This consists of a PPI twice daily, along with 3 antibiotics once daily: amoxicillin 1 g twice daily, clarithromycin 500 mg twice daily, and metronidazole 500 mg twice daily.
3. PPI therapy: The patient will need to be on daily PPI therapy for a total of 12 weeks, regardless of whether or not it was used as part of an H. pylori eradication regimen 
4. Test for cure: After 12 weeks of treatment and resolution of symptoms, if the patient was treated for H. pylori, a test for cure is warranted. This can be in the form of a urea breath test, fecal antigen test, or upper endoscopy. PPI therapy must be stopped at least 2 weeks before testing as the acid suppression reduces H. pylori bacterial load and so makes the testing for H. pylori less sensitive. If eradication was successful, awesome! No more treatment is indicated. But if eradication was not successful, a second alternative antibiotic regimen should be tried, and patient compliance with the antibiotic regimen should be assessed. If the second eradication regimen fails, gastroenterology followup should definitely be arranged if not already being done so as to get samples of the organism to determine its microbial sensitivity. 
5. Possible indefinite acid suppression: There may be some individuals who will have risk factors that may warrant ongoing acid-suppressing treatment.  These may include having a peptic ulcer that cannot be attributed to H. pylori infection or NSAID use, having a "giant" ulcer (>2 cm), or having comorbidities that warrant continued PPI use, among others. 

Overview of the management of inflammatory bowel disease [IBD] (ulcerative colitis [UC] or Crohn's disease [CD])
As with patients diagnosed with PUD, patients diagnosed with IBD will be seen and likely will continue to be seen by a gastroenterologist. It is important for family doctors to understand the management of IBD because they will be actively involved in helping patients manage the disease as well as their overall health, which can be impacted in numerous ways by IBD.

1. Vaccinations: Patients who have IBD are more immunocompromised, and the antiinflammatory medication needed to treat the disease compounds this. It is important to ensure patients are up to date on their vaccinations, of which more are indicated after being diagnosed with IBD. I list this management item first simply because patients are at increased risk of contracting infection once they start antiinflammatory medications, so this should be one of the first interventions that is addressed.
2. Antiinflammatory therapy: First line medication therapy will depend on severity and location, and patients with inflammatory bowel disease will almost certainly have a gastroenterologist whom they follow up with to manage treatment. The mainstay of therapy will be antiinflammatory medications. Common first-line ones include 5-aminosalicylic acid, budesonide, or sulfasalazine, among others. Corticosteroids and big guns like cyclosporine may be needed for refractory and severe symptoms (these medications being more potent but also with more negative side effects). And there are also newer and often highly effective but expensive monoclonal antibody therapies that may be used.
3. Management of complications: Patients with severe enough disease may need to be referred to the emergency department for more urgent management, hospital admission, and possibly even surgery. They may have a secondary gastrointestinal infection warranting antibiotics, they may be hypovolemic from having significant bloody diarrhea, and they made need intravenous strength medications. 
4. Management of extraintestinal manifestations: UC and CD have extraintestinal manifestations involving a number of other body systems, most commonly affecting the skin*, the eyes, or even the lungs. They will need to have management of all of these comorbidities, along with the underlying disease process (as treated with antiinflammatory medications).
5. Monitoring overall health: Routine monitoring of global health status is indicated in these patients, and there is lots to think of. In children and adolescents who are diagnosed with inflammatory bowel disease in particular, monitoring growth and nutritional status are major priorities, as the bowel disease wrecks havoc in the gut that leads to decreased absorption of nutrients, compounded by bouts of sickness that can lead to inability to ingest as many nutrients, along with increased expenditure of nutrients secondary to the inflammation and greater cell turnover. Because of this excess degree of inflammation, risk of bowel cancer is elevated in patients with IBD, and in particular UC, so it is also important to ensure that patients are being screened for colorectal cancer in keeping with recommendations.
6. Patient-centred care: With my family doctor hat on here specifically, it is important to also monitor how patients are coping with management of their disease. There is such variability in how active or quiescent inflammatory bowel disease may be, and it tends to have a relapsing-remitting course, so it is important to inquire as to how patients are coping. If patients are better able to cope, they will likely also have better health outcomes, promoting a positive feedback loop. The negative corollary is also likely true.

*Interestingly, the patient I was managing who had ulcerative colitis had an outbreak of lesions on her arms and legs, which she said started only a few days before she went in to the ED with abdominal pain. The two common types of extraintestinal  skin manifestations associated with IBD are erythema nodosum and pyoderma gangrenosum. According to the UpToDate article, Dermatologic and ocular manifestations of inflammatory bowel disease, "Erythema nodosum typically appears as raised, tender, red or violet subcutaneous nodules on the extensor surfaces of extremities. As erythema nodosum usually parallels intestinal disease activity, treatment is directed at the underlying IBD. If skin nodules precede any bowel symptoms or occur during quiescent phases of IBD, therapy with other medications, including prednisone, may be required." I looked up pictures of erythema nodosum, and the lesions the patient had certainly fit the look, along with the fact that they were nodular and tender to palpation, and were located on the extensor surfaces of her arms and legs. How interesting that they erupted at the same time or possibly right before the concomitant flare-up in her bowel disease! 

In summary, this has been another long but not even very detailed post that provides an overview of  important elements in the management of common and occasionally serious causes of abdominal pain.

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Use a patient-centred approach to care of patients and families through exploration of both the disease and illness experience, understanding the whole person, and negotiating informed shared decision making regarding management
• Act in a caring and compassionate manner
• Initiate screening for mental health disorders in high-risk situations (ex: patients with cancer, chronic pain, war veterans, refugees, victims of domestic violence, etc.)
• Obtain a structured medication review including identification of potential drug-drug and drug-disease interactions (if appropriate, in consultation with a pharmacist)
  

Chronic Disease

​Key Feature 4: In patients with chronic disease, actively inquire about:

• The psychological impact of diagnosis and treatment
• Functional impairment
• Underlying depression or risk of suicide
• Underlying substance abuse

Skill: Patient Centered, Clinical Reasoning
Phase: History

Difficult Patient

Key Feature 3: In a patient with chronic illness, expect difficult interactions from time to time. Be especially compassionate and sensitive at those times.
Skill: Patient Centered, Professionalism
Phase: Treatment, Follow-up

Key Feature 4: With difficult patients remain vigilant for new symptoms and physical findings to be sure they receive adequate attention (ex: psychiatric patients, patients with chronic pain).
Skill: Selectivity
Phase: Hypothesis generation, Diagnosis

Disability

Key Feature 3: In patients with chronic physical problems (ex: arthritis, multiple sclerosis) or mental problems (ex: depression), assess for and diagnose disability when it is present.
Skill: Clinical Reasoning, Patient Centered
Phase: Diagnosis, Hypothesis generation

Key Feature 4: In a disabled patient, assess all spheres of function (emotional, physical, and social, the last of which includes finances, employment, and family).
Skill: Patient Centered
Phase: History

Key Feature 5: For disabled patients, offer a multi-faceted approach (ex: orthotics, lifestyle modification, time off work, community support) to minimize the impact of the disability and prevent further functional deterioration.
Skill: Patient Centered, Professionalism
Phase: Treatment

Multiple Medical Problems

Key Feature 4: Given a patient with multiple defined medical conditions, periodically assess for secondary depression, as they are particularly at risk for it.
Skill: Clinical Reasoning
Phase: Hypothesis generation, History

Key Feature 5: Periodically re-address and re-evaluate the management of patients with multiple medical problems in order to:

• Simplify their management (pharmacologic and other)
• Limit polypharmacy
• Minimize possible drug interactions
• Update therapeutic choices (ex because of changing guidelines or the patient’s situation)

Skill: Clinical Reasoning
Phase: Treatment, Follow-up

​Stress

Key Feature 1: In a patient presenting with a symptom that could be attributed to stress (ex: headache, fatigue, pain) consider and ask about stress as a cause or contributing factor.
Skill: Clinical Reasoning, Communication
Phase: Hypothesis generation, History

Key Feature 2:  In a patient in whom stress is identified, assess the impact of the stress on their function (i.e., coping vs. not coping, stress vs. distress).
Skill: Patient Centered
Phase: History, Diagnosis

Key Feature 3: In patients not coping with stress, look for and diagnose, if present, mental illness (ex: depression, anxiety disorder).
Skill: Clinical Reasoning
Phase: Hypothesis generation, Diagnosis

Key Feature 4a: In patients not coping with the stress in their lives: Clarify and acknowledge the factors contributing to the stress.
Skill: Patient Centered, Clinical Reasoning
Phase: History

The first patient I saw in clinic today was the first patient I saw in clinic at the same time last week, a 47 year old female who had an extensive relationship with chronic pain. Over the years, she had trialed a significant number of medications and alternative therapies to alleviate her pain, but her pain was tenacious. During my first visit with her last week, after confirming that her pain was indeed unchanged over the last many years, and after confirming for myself there weren't any "red flags" in her presentation suggestive of more ominous disease, I reviewed her current pain management strategies, including whether or not she was using any non-prescribed substances to cope. Her approach was as chaotic as the shopping bag she brought with the countless concoctions of over-the-counter supplements and herbal remedies, including some that appeared to not be sold on Canadian pharmaceutical shelves. She was speaking very quickly, wanting to tell me so very much about everything, and I think she was probably in anxious distress and having a hard time trying to cope. 

At the first visit, we reviewed the past history of her chronic pain - all of the previous investigations that were done and all of the specialists she had seen - and what the conclusions were. We then proceeded to clean up her pain medications and reduce them to the ones she felt confident were making a real difference in her pain. And then our time was well up. We ended this visit with an organized regimen of pain medications and a followup appointment to reassess how things were going in one week. And now here we were. She sat down in front of me and after a polite exchange of hellos she gently asked what we should do this week to modify her pain medications.

There is so much about chronic pain we have yet to understand. The pathophysiology is still highly theoretical. We are aware of its association with mood disorders and psychosocial stressors, but we do not understand at a level of utilitarian specificity as to why this is the case. Chicken, egg, or both? In any case, no matter how we arrive at chronic pain, we do know that it worsens mood and aggravates social stress, just as mood and psychosocial stress negatively modulate perception of pain. By extension, if I can do anything to improve mood and psychosocial stress, I may alleviate suffering, and the corollary argument also holds that if I alleviate pain I may improve mood and attenuate psychosocial stress, thereby enhancing quality of life. 

Knowing the connection between chronic pain, mood, and stress, and now that I had the medical facts straight, during this follow-up appointment I decided to explore what was going on in this patient's personal life. As for mood, although she did not think she was clinically depressed and denied active suicidal ideation, it was certainly suboptimal, compounded not only by her pain but by her debt of sleep secondary to her pain. As it turned out, she attributed her low mood to the stresses in her life: her father living overseas was currently admitted to hospital for life-threatening cardiac disease, and her husband was riddled with aneurysms from his aorta to his renal arteries and was awaiting urgent surgery to prevent sudden rupture and possible death. Wow. Suddenly her pain had context, and was only a part of what I felt was infringing on her quality of life. The focus of our conversation shifted entirely away from her pain at this point, and she opened up about her fears of living life without her most significant others as well as her concerns regarding return to work as she felt she needed to prepare for a future with less financial stability, which was already troublesome. I did not have any advice for her anymore, and instead I just sat there listening to her experience with ache in my heart. 

After she shared the most salient aspects of her personal life stressors and the impact they were having on her ability to function or create disability, we rerouted the conversation to some practical takeaways to manage things for now, with planned follow-up again in one week. We decided that what was best right now was probably not to make any significant changes to medications, and rather to first have follow-up counselling later this week with her psychologist whom she endorsed having a strong relationship with. At this time she was not interested in any support groups or other community supports, but she said she would consider it in the future depending on how things progressed. She had come to the clinic today asking what we should do to modify her pain medications, and she left saying she was happy we weren't making changes to her current medications and that we were instead focusing on other ways of modulating her pain (I think this must have been partly because she had so many futile experiences with inconsequential medication changes over the years and didn't have much faith that yet another medication change would be her solution). As she was getting up to leave the examining room she said, "I'm now leaving here with more hope, and it's what I really need right now." 

When I first encounter patients with very complicated medical histories, either because of the number or significance (ex: cancer) of the comorbidities, I find myself feeling stunned by the complexity, oftentimes not knowing where to begin or to what depth I should delve under the pressure of time constraints. Indeed, this is how I felt when I first met this patient.  In vain, I have felt personally overwhelmed by patients with multiple somatic complaints, serving only to increase my stress without making any difference in quality of patient care. Instead, these feelings ought to serve as internal cues to the fact that if I am feeling overwhelmed, it almost certainly means the patient is feeling this too, and likely with greater whelm. In that midst of overwhelming complexity, taking time to move beyond exploration of the disease process to exploring the illness experience, can, as this patient taught me, be the basis for a restoration of hope, alleviation of suffering, and improved quality of life.