Dr Charlie Andrews talks to Dr James Kinross, PhD, FRCS Dr. Kinross is a senior lecturer in surgery at Imperial College in London. He is also a practicing colorectal surgeon in the NHS with a clinical interest in the prevention and treatment of colon cancer. He leads a team of amazing researchers working to better define how the microbiome causes cancer and other chronic diseases of the gut. He is increasingly interested in how the gut microbiome develops in newborn babies and the implications on our long-term health. He is the author of the well know book DARK MATTER.Here are the key learnings for primary care on the microbiome from the attached transcript of the Ingest podcast with James Kinross:Key Learnings for Primary Care on the Microbiome1. What the Microbiome Is and Why It MattersDefinition: The microbiome is the collection of all microscopic organisms (bacteria, viruses, fungi, etc.) and the environment they inhabit within a specific niche in the body, such as the gut, skin, or lungs. Symbiosis: The microbiome has a symbiotic relationship with the host, evolved over millennia. It is not static but dynamic and changes throughout life. Personalization: Each person’s microbiome is unique, impacting how individuals respond to treatments and develop diseases[1].2. Microbiome Development and Early LifeEarly Colonization: The microbiome starts developing in utero, influenced by the mother’s microbiome, and is further shaped by birth route, breastfeeding, and early environmental exposures. Critical Window: Early life is a critical period for microbiome development. Disruption, especially through antibiotic use, can have long-term effects on immune system development and disease risk[1]. Antibiotics Impact: Repeated or broad-spectrum antibiotic use in early life can lead to persistent changes in the microbiome, increasing the risk of immune-mediated diseases (e.g., allergies, asthma, eczema), obesity, and other non-communicable diseases[1].3. Microbiome and the Immune SystemImmune Regulation: The microbiome plays a crucial role in shaping both the innate and adaptive immune systems. It influences how the body recognizes and responds to threats. Disease Risk: Early disruption of the microbiome can increase susceptibility to autoimmune diseases, allergies, and chronic conditions later in life. Gene-Environment-Microbiome Interaction: Disease risk is not just about genes and environment but also involves the microbiome (GEM interaction), which is highly personalized and dynamic[1].4. Probiotics, Prebiotics, and DietProbiotics: There is evidence supporting the use of probiotics, especially multi-strain, high-dose formulations, during and after antibiotic courses. However, probiotics must be taken consistently for weeks to have an effect. Prebiotics and Diet: Feeding the microbiome with a high-fiber, plant-based diet is crucial for maintaining a healthy gut ecosystem. Processed foods and sugary drinks should be minimized, especially during illness or antibiotic treatment[1]. Practical Advice: Clinicians should recommend probiotics and dietary changes as part of a holistic approach to gut health, but the evidence for specific strains is still evolving[1].5. Microbiome TestingDirect-to-Consumer Testing: Online microbiome tests are not currently recommended due to lack of stand...

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...

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...

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.

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

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

With significant waiting lists and growing demand for secondary care services, Advice and Guidance is being increasingly explored as one potential solution to this problem.    In this episode, Charlie Andrews discusses an innovative and extremely successful use of advice and guidance in Northumbria with gastroenterologists Matthew Warren and Richard Thomson.  Through the enhanced use of advice and guidance for all incoming referrals for secondary care input, they have demonstrated a significant reduction in waiting times for routine outpatient care.  They discuss their advice and guidance model, and what they have learned from developing this service and the impact it has been having on their waiting times, and how it has been received by primary care colleagues (3:30).  We go on to discuss some common advice and guidance queries that Matt and Richard see (19:30) and I ask the question - what makes a good advice and guidance query? (43.30).  

Key takeaways from the IBS Part 1 episode of the PCSG Ingest podcast:Diagnosis of IBSThe episode is focused on making a diagnosis of Irritable Bowel Syndrome (IBS)and features Dr. Anton Emmanuel, a consultant gastroenterologist and Professor of neuro-gastroenterology at University College Hospital London.Importance for Primary CareIBS is a common condition that primary care clinicians need to have a structured approach to diagnosing.Topics CoveredCauses of IBS Different subtypes of IBS Challenges in making a positive diagnosisClinical PearlsDr. Emmanuel shares several insights:Key questions to include in the patient history How to describe the condition to patients Practical tips for enhancing IBS diagnosis in primary careDiagnostic ApproachThe episode emphasises the importance of:Taking a structured approach to diagnosis Understanding the various presentations of IBS Recognizing the challenges in making a definitive diagnosisPatient CommunicationGuidance is provided on:Explaining IBS to patients effectively Addressing patient concerns and misconceptionsAdditional ResourcesThe episode mentions useful guidance from the British Society of Gastroenterology, which listeners were encouraged to reference for more detailed information. Part 2 focusing on the management of IBS to be released soon.bsg.org.uk/clinical-resource/british-society-of-gastroenterology-guidelinesThe 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

Dr Charlie Andrews speaks to Dr Jeremy Shearman about everything related to high iron levels (hyperferritinaemia).  We discuss how iron is regulated within the body, causes of raised iron levels, and then we dive into hereditary haemochromatosis - when to suspect, how to test, who to refer (and to whom!), and how the condition is managed.   Useful links to accompany this episode include: Welcome > Haemochromatosis: genetic iron overload disease (exeter.ac.uk) Haemochromatosis - British Liver Trust

In this episode, Charlie Andrews speaks to Melanie Orchard, a consultant surgeon, about diverticular disease and diverticulitis.  This is something that we encounter frequently in primary care, and understanding how to approach this condition is extremely important.  Melanie discusses a really pragmatic approach to patients with symptoms suggestive of diverticulitis.  We discuss risk factors, presenting features, and how to assess the patient with suspected diverticulitis.  We also discuss the difference between diverticulosis, diverticular disease and diverticulitis, and give you useful tips on what advice to give to patients who has just had a colonoscopy showing that they have diverticulosis.   For a useful visual summary of the management of patients with diverticulosis and diverticulitis, please follow this link: visual-summary-pdf-6968965213 (nice.org.uk)

Join Charlie Andrews as he discusses Hepatitis C with hepatologist Dr Kosh Agarwal and GP and clinical champion for Hepatitis C Dr Rik Fijten. They discuss the prevalence and presentation of Hepatitis C,  as well as how to test for the condition along with an overview of the treatment options available. Hepatitis C is a chronic liver disease which carries significant morbidity and mortality if left untreated.  Fortunately, it is both easy to test for and the treatments available offer a fantastic cure rate of in excess of 95% with simple and relatively short tablet regimens.   NHS England has set itself the target of eradicating the disease by 2025 through active case finding, simplifying the diagnostic process, and ensuring pathways are in place to provide rapid and effective treatments for the condition.   Resources:  For more information on Hepatitis C, the British Liver Trust offers useful patient-friendly leaflets and further information about the condition: Hepatitis C - British Liver Trust The self-testing portal mentioned by Rik during the episode can be found here: Home - HepC (hepctest.nhs.uk)

In this episode, Dr Charlie Andrews speaks to Professor Mark Pritchard about neuroendocrine tumours (NETs) of the gastrointestinal tract.  You may be asking yourself: 'Do I really need to know about NETs in primary care, aren't they extremely rare?'  The answer to that is a resounding yes, you do need to know about NETs and Mark will tell you why in this episode!   Neuroendocrine cancer is the 10th most prevalent cancer in England, and the second most prevalent cancer of the GI tract, with a rapidly rising incidence (371%) over the last 20 years.  NETs are commonly diagnosed at a more advanced stage due to late diagnosis as the signs and symptoms can be vague, or mimic other more common conditions such as IBS.  Mark provides lots of useful, practical advice about when to suspect this form of cancer in primary care, which patients may be a higher risk, and what to do if you are suspicious about this form of cancer in your patient.   Listen on to find out more.    

Dr Charlie Andrews, a committee member of the Primary Care Society for Gastroenterology (PCSG), introduces Ingest, the podcast for primary care that focuses on when to suspect, how to diagnose and how to manage common gastrointestinal presentations and conditions.

In this episode Dr Charlie Andrews looks back at 2023 and highlights some key takeaways from Ingest in 2023.

In this episode, Charlie Andrews speaks to Dr Andrew Moore about this condition, which affects up to 1.5% of the population, with a risk of progression to cancer of 3-13% over the patient's lifetime (Cancer Research UK).  They discuss the typical presenting features, who needs an endoscopy to look for Barrett's, and how the condition is managed both in primary and secondary care. The BSG guidelines mentioned by Dr Moore in the episode can be found here: https://www.bsg.org.uk/clinical-resource/bsg-guidelines-on-the-diagnosis-and-management-of-barretts-oesophagus/ For more episodes about the oesophagus, you may find the following episodes of Ingest useful: Dyspepsia, Eosinophilic oesophagitis, Dysphagia and Achalasia.  BSG guidelines on the diagnosis and management of Barrett's oesophagus - The British Society of GastroenterologyFitzgerald RC, di Pietro M, Ragunath K et al. Abstract These guidelines provide a practical and evidence-based resource for the management of patients with Barrett’s oesophagus and related early neoplasia. The Appraisal of Guidelines for Research and Evaluation (AGREE II) […]www.bsg.org.uk

In this episode, Charlie Andrews speaks to Professor Julian Walters about bile acid malabsorption and diarrhoea. With up to a third of patients with diarrhoea-predominant IBS having underlying bile acid diarrhoea, and with diagnosis rates for this condition being low, this episode is an important one for anyone working in primary care. We explore the role and physiology of bile acids, the causes and symptoms of bile acid malabsorption, the diagnostic tests used to make the diagnosis and the treatment of this common but underdiagnosed condition. Should we use 'trial of treatment' in primary care to support the diagnosis? Are people who have had their gall bladder removed at greater risk of bile acid diarrhoea? Can bile acid sequestrants impact the absorption of other medications? These questions, and lots more, will be discussed in this episode!

In this episode, Charlie Andrews speaks to Dr James Turvill about faecal calprotectin use in primary care. Dr Turvill is a gastroenterologist based in York, who was instrumental in developing the NICE-approved and widely adopted York Faecal Calprotectin Care Pathway. What is calprotectin? When should we use it in primary care? How should we interpret the result? Can any medications or conditions affect the result? Listen on to find the answers to these questions! The care pathway can be found here: https://www.yorkhospitals.nhs.uk/seecmsfile/?id=941. It is recommended that you have a look at this either before, after or during this episode to enhance your learning. Enjoy!

Marianne Williams is an extremely experienced dietician, innovator, digital technology advocate and winner of the NHS England Allied Health Professional of the Year prize for 2018.   In this episode, Marianne shares her wealth of knowledge around all things IBS to discuss initial dietary management, the low FODMAPs diet, the role of probiotics, and gives us some great advice about how we can maximise our (often short) patient consultations with newly diagnosed IBS patients.  Marianne also discusses her innovative dietetic-led gastroenterology clinic for IBS patients with us.   There is so much food for thought here, and so many useful nuggets of information throughout this episode.  Sit back and tuck into this feast of information!  Useful links/websites discussed in the episode: Patient Webinars website: https://patientwebinars.co.uk/ Monash university IBS grand tour: https://www.youtube.com/watch?v=Z_1Hzl9o5ic Monash university app: https://www.monashfodmap.com/ibs-central/i-have-ibs/get-the-app/ IBS symptoms, the low FODMAP diet and the Monash app that can help See updated video for Irritable Bowel Syndrome (IBS) relief: Take the Monash University Low FODMAP grand tour down under! at https://www.youtube.com/watch?v=stdYoA4G9Dg See more: IBS patient course: https://www.monashfodmap.com/online-training/patients-course/  Website: https://www.monashfodmap.com/  Monash FODMAP blog: https://www.monashfodmap ...www.youtube.com BSG guidelines on the management of IBS: https://gut.bmj.com/content/gutjnl/early/2021/04/27/gutjnl-2021-324598.full.pdf

In this episode Charlie Andrews speaks to Dr Kevin Barrett about IBD flare management.  On average, 50% of patients will flare annually, and often the GP surgery is the first port of call.  We therefore need to know how to assess and manage patients presenting with symptomatic IBD.  Kevin Barrett, IBD clinical champion for IBD for the RCGP and Crohns and Colitis UK (2017-2021) shares his wealth of knowledge about IBD flare management.  We discuss how if can affect patient's quality of life, common symptoms of IBD flare, calprotectin testing and the management of IBD flare. 

In this episode, Charlie Andrews speaks to Dr Kevin Monahan, lead author for the joint guidelines published by the BSG and ACPGBI in July 2022 outlining the role of FIT testing in patients with symptoms suggestive of colorectal cancer.  These guidelines have informed how we use FIT in primary care, and in this episode he asks Dr Monahan how this guideline has changed clinical practice, they discuss when it should be used and what to do if you have ongoing concerns about your patient's symptoms.  In addition, they discuss specific situations such as iron deficient anaemia, rectal bleeding, whether we can use it in younger age groups, and whether there is a role for repeat FIT testing.   A link to the full guideline can be found here: https://www.bsg.org.uk/clinical-resource/faecal-immunochemical-testing-fit-in-patients-with-signs-or-symptoms-of-suspected-colorectal-cancer-crc-a-joint-guideline-from-the-acpgbi-and-the-bsg/