8: GASTROENTEROLOGY

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CHAPTER 8 GASTROENTEROLOGY

Dyspepsia
Gastro-oesophageal reflux disease (GORD)
Halitosis
Coeliac disease
Infective diarrhoea
Change in bowel habit
Diverticulitis
Inflammatory bowel disease
Irritable bowel syndrome
Constipation
Rectal bleeding
Pruritus ani
Anal fissure
Jaundice

DYSPEPSIA

Dyspepsia covers a range of symptoms, including epigastric/oesophageal pain, fullness, early satiety, bloating and nausea. It accounts for 3–4% of GP consultations. The main causes are:

• non-ulcer or functional dyspepsia (60–70%)
• peptic ulcer disease (15–20%)
• gastro-oesophageal reflux disease (GORD) (15–20%)
• upper GI cancers (<2%) (less than 1 in 1 000 000 under-55 year olds with dyspepsia have cancer).

Diagnosis

History.

Ask about:

• aspects of the epigastric pain, e.g. relationship to food, periodicity, waking at night
• associated features, e.g. nausea and vomiting, bloating, changes in appetite, dietary indiscretion, alcohol intake, weight loss.

Alarm symptoms

Patients with dyspepsia who fulfil these criteria require referral for urgent endoscopy:

• chronic gastrointestinal bleeding
• progressive unintentional weight loss
• dysphagia
• iron deficiency anaemia (excluding NSAIDs and menorrhagia)
• persistent vomiting
• epigastric mass
• suspicious barium meal.

Without alarm symptoms, patients of any age presenting with dyspepsia do not require an endoscopy. Exceptions to this are patients aged >55 who have persistent symptoms despite H. pylori eradication, if appropriate, and proton pump inhibitor therapy, continuing need for NSAIDs, previous gastric ulcer, gastric surgery or raised risk of gastric cancer.

Management

Advice

• Review medication (e.g. calcium antagonists, nitrates, theophyllines, bisphophonates, corticosteroids and NSAIDs).
• Stop smoking.
• Reduce coffee and alcohol intake.
• Lose weight, if appropriate.
• Consider stress factors.

Prescribing

For mild dyspepsia.

Antacids/alginates: e.g. magnesium trisilicate 10 ml after meals and at bedtime or prn, or Gaviscon 10–20 ml after meals and at bedtime or prn.

For more significant symptoms

• Prescribe a proton pump inhibitor at full dose for 1 month (e.g. lansoprazole 30 mg od or omeprazole 40 mg od) and test for H. pylori and treat, if appropriate (see below).
• If symptoms persist, add an H2 receptor antagonist (e.g. cimetidine 400 mg bd or ranitidine 150 mg bd) for 1 month or a prokinetic agent (e.g. metoclopramide or domperidone) for 1 month.
• Most patients who do not respond to these measures, and without alarm symptoms, have non-ulcer dyspepsia. Endoscopy does not alter management, but gastroenterology referral may be considered. In addition to H. pylori serology, investigations prior to referral should include FBC, LFTs and CRP, and consider endomysial antibody.

Ongoing treatment.

When PPIs have provided symptom control, then the PPI may be continued at the lowest effective dose on a prn basis. Annual review is appropriate for patients requiring long-term management.

HELICOBACTER PYLORI

H. pylori is associated with >90% of DUs, >80% of GUs and >60% of gastric cancers. It is not associated with GORD. Long-term healing of DUs and GUs can be achieved rapidly by eradicating H. pylori. Reinfection is rare.

Tip

The presence of H. pylori should be confirmed before starting eradication treatment.

Tests for H. pylori

• Serology or faecal antigen testing are recommended for initial testing.
• Urea breath testing is recommended for those patients where it is necessary to confirm eradication of H. pylori, e.g. for recurrent dyspepsia after eradication therapy or treatment of complicated peptic ulcer. This is usually arranged via referral, although urea breath tests are prescribable on FP10.

H. pylori eradication therapy regimens

• Full dose PPI (e.g. lansoprazole 30 mg) bd + amoxicillin 1 g bd + clarithromycin 500 mg bd for 7 days or
• Full dose PPI (e.g. lansoprazole 30 mg) bd + metronidazole 400 mg bd + clarithromycin 250 mg bd for 7 days.

GASTRO-OESOPHAGEAL REFLUX DISEASE (GORD)

This is common. It usually presents as retrosternal pain, which is worse on lying flat, together with an acidic taste in the mouth. It is usually secondary to a hiatus hernia.

Management

Advice

• As for dyspepsia (see p. 116).
• Elevate the head of the bed.
• Avoid eating late in the evening.
• Avoid large meals.
• Lose any excess weight.
• Avoid foods which aggravate symptoms, e.g. fatty foods, alcohol, coffee, citrus fruits.

Prescribing.

(Prescribe according to severity.)

• Antacids (as for dyspepsia).
• Prescribe a full dose PPI (e.g. lansoprazole 30 mg) daily for 1–2 months, followed, if necessary, by a double dose PPI for 1 month.
• If symptoms persist, add an H2 receptor antagonist (e.g. ranitidine 150 mg bd) or a prokinetic (e.g. metoclopramide or domperidone) to the PPI for 1 month.
• When symptom control is achieved, then the PPI may be continued at the lowest effective dose on a prn basis.

Referral.

Non-responders should be referred for a gastroenterological opinion. Patients with alarm symptoms should be referred for urgent endoscopy.

HALITOSIS

When persistent, this is a distressing complaint and is usually due to poor oral hygiene or dental or gum sepsis.

Diagnosis

History.

Ask about:

• chronic sinusitis, tonsillitis, respiratory infections and mouth-breathing in children (adenoids)
• smoking and drugs, e.g. alcohol, nitrates, disulfiram
• dry mouth due to e.g. drugs, Sjögren’s syndrome
• mood disorders which can present as halitosis.

Investigations.

These are rarely necessary, but it may be appropriate to exclude nasopharyngeal malignancy, upper GI tract pathology or metabolic disorders.

Management

• Refer to a dentist for oral assessment.
• Advise on oral hygiene.
• Use a mouth rinse, e.g. 0.2% aqueous chlorhexidine gluconate.

Antibiotic treatment is rarely necessary, but consider treatment with e.g. metronidazole or amoxicillin for 2 weeks to eradicate bacterial overgrowth

COELIAC DISEASE

The prevalence of coeliac disease in adults is 1 in 300. Diagnosis requires a high index of suspicion. It is often wrongly diagnosed as irritable bowel syndrome. In children it commonly presents as growth retardation or delayed puberty. In adults the common presentations are anaemia, chronic fatigue and variable abdominal symptoms (discomfort, bloating, excess wind, aphthous mouth ulcers, altered bowel habit).

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