A look at GI disorders and their associated tests.
By Jim Poggi, Principal, Tested Insights
The advice of the experts is becoming ever clearer: “take care of your core for better health.” Whether they are referring to exercises to improve the strength of your core, the emerging evidence that 70% of our immune system resides in our gastrointestinal tract (our core), or simply making sure we know the core diseases that comprise the majority of the leading causes of morbidity and mortality, this advice applies to our everyday lives and those of our customers.
This column will focus on gastrointestinal diseases and the tests we offer to our customers. As this information unfolds, I plan to remind you of the diseases and tests we commonly consult about, and I believe I have some new information to share as well. So, trust your gut and follow along.
What we are learning about GI disease and incidence trends
There is an emerging body of evidence that GI health is an important factor in overall health, and that the GI system contains and maintains the largest amount of immune tissue in the human body. What does this mean to us and our customers? Fundamentally a healthy gut promotes overall immune health and helps protect us from a variety of infections. At the same time, GI disorders including irritable bowel, diverticulitis, GI reflux and GI infections all reduce GI health, reducing immune strength and putting us at risk for other infections and a decline in general health.
Did you know that “nonfoodborne GI infections” occurred over 135 million times annually in recent years? Coupled with 76 million “foodborne GI infections,” they caused over 2.4 million physician office visits in recent years. What we often refer to as “stomach flu” is usually self-limiting and typically can be resolved with a prescription or simply palliative care, but these infections render short-term and sometimes long-term disruption of the patient’s immune system.
As we learn more about the importance of GI health in the overall scheme of things, it brings up some interesting conversation starters, such as:
- “How often do you encounter patients exhibiting ‘stomach flu’ in your practice?”
- “How do you typically treat the patient?”
- “Do you see any linkage between acute GI disorders and longer-term health issues?”
If they ask why you are posing these questions, I recommend you discuss the data on immune health and seek their opinion regarding how and whether they engage in specific follow up for patients with these symptoms. It is likely to be patient specific and related to age and other co-morbidities, but it takes opening a discussion on lab testing in a new direction.
CDC is an excellent resource for information confirming the importance of GI health. Any good internet search will uncover a number of other sources from leading universities and research institutions. If you plan to initiate this conversation, make sure to come prepared with facts and a sound, respectful way to present the information. Do not be surprised if some of your customers inform you that, if a patient presents with a series of GI complaints, the clinician looks to CBC,CRP, erythrocyte sedimentation rate (ESR) and other procedures to get to the root cause of the patient’s condition.
Working with your trusted lab manufacturer, you are well equipped to offer a wide range of lab tests to help get to the bottom of a variety of chronic or acute GI disorders. Needless to say, in many cases imaging and other studies will round out the follow-up treatment plan. In thinking along with your customers, as a trusted consultant, these sorts of discussions can lead you to know more about your customer than starting out with a lab product presentation. As your experience grows, you will see the respect of your customers increase as well.
Specific GI diseases and associated lab tests
Colorectal cancer
Colorectal cancer (CRC) is the third most common cancer in the U.S., accounting for approximately 10% of all U.S. cancer cases annually. About 107,000 new cases of CRC are diagnosed annually using a variety of lab and other diagnostic procedures. The two most prominent sources regarding providing information about colorectal cancer and diagnostic recommendations are the American Cancer Society and the United States Preventive Services Task Force (USPSTF).
Colorectal Cancer Screening recommendations
| Recommendations are for screening, not follow up after polyp discovery | ||||
| Organization | Age range for screening | Test type | Frequency | Notes |
| American Cancer Society | 50-75* | Fecal immunochemical test (FIT) | annually | *starting at 45 is a “qualified” recommendation |
| high sensitivity guiac test | annually | |||
| multitarget stool DNA test | every 3 years | |||
| Colonoscopy | every 10 years | |||
| CT colonography | every 5 years | |||
| flexible sigmoidoscopy | every 5 years | |||
| USPSTF | 50-75 years** | **starting at 45 based on patient considerations | ||
| high sensitivity guiac test | annually | |||
| Fecal immunochemical test (FIT) | annually | |||
| sDNA-FIT *** | every 1-3 years | ***different name for multitarget stool DNA test | ||
| Colonoscopy | every 10 years | |||
| CT colonography | every 5 years | |||
| flexible sigmoidoscopy | every 5 years | |||
| flexible sigmoidoscopy with FIT | flex sig every 10; FIT annually | |||
The good news about colorectal cancer is that early diagnosis, combined with public awareness campaigns and lifestyle changes, are reducing the incidence. According to the NIH, the incidence of CRC has declined by more than 30% from 1975 to 2013. The efforts of you and your trusted manufacturers in creating awareness of appropriate screening methods are a part of this reduction.
As with most cancers, early detection is the key to patient recovery and a return to health. According to the American Cancer Society, five-year survival for local CRC is 91%, for distant or metastatic cancer it drops dramatically to 13%. Clearly, early diagnosis is the key to the best patient outcomes. Annually CRC awareness month is observed in March. This article is a little late to help you prepare for CRC awareness activities this year, but should help you think about how and to what extent you want to be involved in coming years.
Peptic Ulcer
I have not written about peptic ulcer before, but it has an interesting diagnostic history. For years it was thought to be a result of stress and lesions to the stomach and GI tract. It was not until the early 1980s that H. pylori was determined to be the cause of peptic ulcer.
While establishment of the cause and diagnosis is relatively recent, the second factor in dealing with peptic ulcer is treatment. H. pylori is a very stubborn bacterium and quite difficult to treat successfully. It typically involves a lengthy regimen of multiple antibiotics coupled with acid reduction therapy. However, complete healing is possible. Peptic ulcer is quite common in the U.S., affecting over 15 million Americans annually, causing 360,000 hospitalizations and over 5 million prescriptions a year.
The first step in dealing with peptic ulcer is effective diagnosis. Today there are three well recognized diagnostic methods. The first is the H. pylori breath test. The patient receives a liquid containing radioactive hydrogen and urea. After administration the patient blows into a balloon which is then presented to the instrument that reads the result. The amount of carbon dioxide exhaled by the patient indicates the presence of H. pylori. The CPT code for this test is 83009 with reimbursement of $67.36. Drug administration for the test is CPT code is 83014 with reimbursement of $7.86.
A second common test is the H. pylori antigen test, CPT code 87339 with reimbursement of $16. There is also an H. pylori stool test with CPT code of 87338 and reimbursement of $14.38. A waived version of this test is available. While there are a wide range of reasons for patients to present with GI pain and discomfort, peptic ulcer is a common reason and you in cooperation with your trusted lab manufacturer have several diagnostic options.
Other common GI tests
The GI system is a complex one and subject to infection, structural damage and even organ failure. Some of the other more common GI tests (even some we do not think about as GI tests) include:
- Amylase and lipase: tests for pancreatic enzymes. Typically done on moderate complexity chemistry systems. These tests are typically not done in large panels. Elevated levels may indicate pancreatitis or other serious organ conditions. Patients typically present with acute abdominal pain and show up in the ER or urgent care center. Rapid diagnosis is critical.
- Liver function tests (AST, ALT). Elevated levels are indicative of acute or chronic liver damage. Acute damage is often reversible, as is chronic damage if caught early and the source of the damage (alcohol or exposure to airborne toxins) is removed. ALT and AST are part of the comprehensive metabolic panel, and both waived and non-waived solutions are available. Alkaline phosphatase is also an enzyme associated with severe liver disease and other conditions and is part of the CMP.
- Kidney function tests: BUN and creatinine. Critical to assuring proper overall health. Available in both the BMP and CMP.
- CBC. Any time an infection or an injury that could be associated with internal bleeding is suspected, the CBC is a first line of defense diagnostically. I do not usually think of CBC as a GI test, but there are many reasons to test for CBC when a GI disorder is suspected.
So often working with our trusted lab manufacturers, we present solutions around annual physicals, screening tests and respiratory panels. Every bit of this information is important and helps us to effectively consult with our customers and build credibility and relationships. Hopefully, this information on GI disorders and their associated tests will add more useful information to establish sound conversations with your customers. Be in the conversation to be part of the solution.