Dr Charlie Andrews talks to Dr Jan Bornschein.

• (00:00:02) - Invent
• (00:00:32) - H. Pylori management
• (00:01:54) - H. Pylori and stomach cancer
• (00:07:47) - Diabetes dyspepsia: tests available for non-in
• (00:15:37) - H. Pylori test in peptic ulcer disease
• (00:21:58) - H. Pylori in gastroesophageal reflux
• (00:23:04) - Does helicobacter have a positive effect on reflux?
• (00:25:11) - H. Pylori disease 7, Parents and children
• (00:28:36) - H. Pylori management, first line treatment
• (00:37:25) - Bismuth based quadruple therapy
• (00:46:32) - Gastric cancer retesting

Based on a popular well known Christmas carol this episode reminds us about prescribing thoughtfully, recognising key red flags, and keeping often-missed diagnoses like bile acid diarrhoea, coeliac disease and liver disease on the radar. The episode also reinforces the importance of early-life microbiome influences and structured differential diagnosis for abdominal symptoms in primary care.

Prescribing and de-prescribing • Taper PPIs rather than stopping abruptly to avoid rebound acid hypersecretion, driven by upregulated gastrin during PPI therapy. • Always link NSAID use and H. pylori status to ulcer risk, and remember: gastric ulcers typically cause pain with meals, duodenal ulcers 2–3 hours after eating. Diagnosis, tests and red flags • Use three coeliac test “groups”: serology (tTG/EMA, with total IgA checked), genetics (HLA‑DQ2/DQ8) and duodenal biopsies; ensure patients eat gluten for at least six weeks pre‑testing and to endoscopy. • Actively screen for GI red flags: dysphagia and weight loss (upper GI), PR bleeding and unexplained iron‑deficiency anaemia (lower GI), and escalate for urgent investigation. Practical tools and endoscopy indications • Use the Bristol Stool Chart (types 1–7) routinely in consultations to standardise conversations about stool form and avoid ambiguous “food analogies.” • Remember the three main indications for endoscopy: diagnostic (e.g. dyspepsia, chronic diarrhoea), surveillance (Barrett’s, polyp follow‑up) and therapeutic (RFA/EMR in Barrett’s, polyp removal). Conditions to consider and not miss • Keep bile acid diarrhoea prominent in the differential for IBS‑D: up to ~40% of IBS‑D patients may have it, particularly with ileal disease/resection, Crohn’s, or post‑cholecystectomy. • Maintain a broad GI bleeding differential beyond cancer (e.g. gastritis, peptic ulcer, Mallory–Weiss tear, haemorrhoids/fissures, liver disease/coagulopathy, IBD, angiodysplasia, diverticular disease). Liver disease, microbiome and early life • Remember major causes of liver failure in primary care: excess alcohol, paracetamol overdose, DILI, autoimmune hepatitis, Wilson’s disease, haemochromatosis, viral hepatitis B/C and progressive MASLD. • Support breastfeeding where possible to promote a healthy infant microbiome (HMOs favouring bifidobacteria) and recognise how birth mode and early microbes shape immune development and later allergy/immune risk. Structuring abdominal symptom assessment • For undifferentiated abdominal symptoms, consciously work through a core list: IBS, lactose intolerance, coeliac disease, gastroenteritis, SIBO, IBD, diverticular disease, colorectal cancer, peptic ulcer disease, gallstones/biliary colic, pancreatic insufficiency and medication‑related causes (e.g. metformin, NSAIDs, antibiotics). • Use these categories to guide targeted history, examination, basic tests and thresholds for referral back to gastroenterology or specialist services.

• (00:00:04) - The 12 Days of Gutmas
• (00:01:04) - PPIs
• (00:02:19) - How to manage gastric and duodenal ulcers on
• (00:03:40) - Celiac disease tests 6, Interventions
• (00:05:33) - GI red flags on Christmas Day
• (00:07:48) - The main indications for endoscopy
• (00:09:07) - 7 causes of liver failure on Christmas Day
• (00:10:17) - Healthy gut microbiome 8 days after Christmas
• (00:12:03) - Bile acid diarrhea
• (00:13:52) - 10 causes of abnormal gastrointestinal bleeding
• (00:15:34) - The microbiome of the body
• (00:17:55) - 12 causes of abdominal dysrhythmia
• (00:19:59) - 12 Days of Gutmas

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:

1. What the Microbiome Is and Why It Matters

• Definition: 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 Life

• Early 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 System

• Immune 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 Diet

• Probiotics: 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 Testing

• Direct-to-Consumer Testing: Online microbiome tests are not currently recommended due to lack of stand...

• (00:00:00) - Ingest: The microbiome
• (00:01:06) - Dark Matter
• (00:03:45) - What exactly is the microbiome?
• (00:06:11) - What is the microbiome?
• (00:08:49) - The role of the microbiome in health
• (00:09:54) - Antimicrobial agents in the gut
• (00:13:20) - Probiotics and antibiotics
• (00:15:37) - How the microbiome affects the immune system
• (00:24:05) - The role of the microbiome in health
• (00:27:04) - Will we measure the microbiome 100%?
• (00:31:02) - Primary care: The microbiome challenge
• (00:32:22) - Probiotics and the future of gut health
• (00:36:02) - The microbiome of the human gut