8: GASTROENTEROLOGY

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CHAPTER 8 GASTROENTEROLOGY

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.

• 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.

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

• chronic gastrointestinal bleeding

• progressive unintentional weight loss

• 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.

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

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.

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).

It should be considered especially if the patient also has:

• a family history of coeliac disease

• an autoimmune disease

• osteoporosis

• infertility

• an undefined neurological disorder.

Coeliac disease doubles the risk of GI tumours.

Diagnosis

Investigations

• Take blood for endomysial antibodies (positive predictive value Δ95%), FBC, B₁₂, folate, Fe, albumin, calcium and IgA antibodies (patients with IgA deficiency have a false-negative endomysial antibody result). Antigliadin antibodies are also useful. Refer to a gastroenterologist if results are positive.

• The definitive test is a distal duodenal biopsy.

Bone density scans are recommended at diagnosis, at the menopause for women, at age 55 for men, or if a fragility fracture occurs at any age (coeliac disease increases the risk of osteoporosis).

Management

Refer to a dietician

A strict lifelong gluten-free diet (resolves symptoms and eliminates the extra risk of osteoporosis and malignancy).

Prescription charge exemption.

Patients receiving gluten-free products on prescription are exempt from prescription charges.

INFECTIVE DIARRHOEA

Acute diarrhoea is usually due to food poisoning or a viral infection. Most patients recover spontaneously. Always consider alternative diagnoses, e.g. inflammatory bowel disease, drugs or ischaemic colitis.

Management

Advice

• Fluid intake should be copious.

• Food should not be withheld.

• Rehydration solutions may be helpful, especially in children (e.g. Dioralyte).

• On the whole antidiarrhoeal agents should be avoided, especially in children and the elderly.

• If necessary, diarrhoea in adults can be treated with e.g. loperamide two capsules stat. then one capsule after each loose stool.

Prescribing.

Indications for antibiotics are few, as they usually fail to influence the course of the illness and they can prolong and increase the frequency of the carrier state. Ciprofloxacin 500 mg bd for 5 days is occasionally used for prophylaxis against traveller’s diarrhoea, but routine use is not recommended. Antibiotics are, however, indicated for:

• Salmonella, if severe (ciprofloxacin 500 mg bd for 5 days or trimethoprim 200 mg bd for 5 days).

• Campylobacter (erythromycin 500 mg qds for 5 days).

• Giardiasis (metronidazole 2 g daily for 3 days). Prompt response to antibiotic treatment is, in fact, a more reliable diagnostic test than stool examination in giardiasis, which is suspected with a >2-week incubation period, watery stools and excessive flatus without fever.

• Shigella (ciprofloxacin 500 mg bd for 5 days or trimethoprim 200 mg bd for 5 days).

Referral.

• there is dehydration

• there is toxaemia, abdominal pain or abdominal distension

• the diagnosis is unclear.

Administration

Notify, if appropriate (see appendix, p. 347).

CHANGE IN BOWEL HABIT

• Remember to perform a rectal examination.

• Check for anaemia and perform faecal occult bloods.

• Refer if the cause is unclear.

Suspect colonic carcinoma when a patient presents with unexplained, persistent change of bowel habit, either constipation or diarrhoea.

DIVERTICULITIS

Ninety-five per cent of diverticula are in the sigmoid colon.

Acute diverticulitis usually presents with:

• lower abdominal pain (usually left iliac fossa)

• altered bowel habit

There may also be:

• nausea and vomiting

• dysuria and urgency (if the affected area lies close to the bladder)

• rectal bleeding.

Chronic diverticulitis (diverticular disease) presents with abdominal pain (usually left iliac fossa) and altered bowel habit. Symptoms are often improved by defaecation.

INFLAMMATORY BOWEL DISEASE

Diagnosis, treatment and management of exacerbations fall to the specialist. The GP’s role is in the management of established disease only.

The inflammation of Crohn’s disease affects any part of the GI tract, frequently in discontinuity (skip lesions). Ulcerative colitis is a chronic disease of the colon which always affects the rectum and extends proximally. Drug therapies include oral prednisolone, rectal corticosteroids, aminosalicylates (e.g. mesalazine), azathioprine and methotrexate. Antibiotics may be used in Crohn’s disease for small intestinal overgrowth, perianal sepsis and abscesses associated with fistulae. Patients with Crohn’s disease are more likely to require surgery at some stage.

IRRITABLE BOWEL SYNDROME

Irritable bowel syndrome (IBS) is a functional disorder which may involve any part of the GI tract. It is characterised by abdominal pain (colonic or dyspeptic) and disordered bowel habit (diarrhoea and constipation occurring alone or in combination). The patient is likely to be young and female, and there is often a variety of non-bowel complaints, e.g. general malaise, headache and backache. Many patients associate an exacerbation of symptoms with stress.

Management

CONSTIPATION

Constipation is the passage of hard stools less frequently than the patient’s own normal pattern. Ensure that the patient has no misconceptions about normal bowel habits and that the constipation requires treatment. Laxatives should generally be avoided, but if they are used, prolonged treatment is seldom necessary.

In children, a high-fibre/high-fluid diet is often sufficient treatment (see p. 88).

CHRONIC CONSTIPATION

Diagnosis

History.

A good history is not always easy to obtain, as faecal build up is often very gradual.

Examination.

Perform an abdominal and a rectal examination.

Management

Advice

• Encourage exercise.

• Encourage a high fluid intake.

• Allow sufficient time for defaecation, e.g. after meals (especially after breakfast, when colonic activity is at its highest).

• Encourage a high-fibre diet, e.g. fruit, vegetables, wholemeal bread, pasta, wheat bran, cereals, pulses.

Prescribing

• Stimulants, e.g. senna 2–8 tablets nocte, according to response, are useful for ‘getting things going’ on an intermittent basis.

• Bulk-forming agents, e.g. ispaghula husk, are rarely necessary if the diet is high in fibre. They are useful for patients with colostomies, ileostomies, haemorrhoids, anal fissure, IBS, etc.

• Osmotic agents, e.g. lactulose 15 ml bd or Movicol 1–3 sachets daily, retain fluid in the bowel, and are commonly used.

• Stool softeners, e.g. liquid paraffin and magnesium hydroxide emulsion 20 ml prn, may be used.

Referral.

Refer for exclusion of a more serious underlying pathology if the history suggests it, e.g. constipation developing suddenly in a middle-aged person for no clear reason (see p. 121).

RECTAL BLEEDING

FRESH BLOOD

Fresh blood is usually the result of pathology between the anal margin and the lower sigmoid colon, e.g. haemorrhoids, anal fissure, diverticulitis, anorectal carcinoma.

• If the bleeding is minor in a patient aged <40 where the cause is clearly benign, e.g. haemorrhoids, it is reasonable to monitor symptoms over a period of time, and advise on avoiding constipation, etc.

• Remember to perform a rectal examination.

• Check Hb, if appropriate.

All patients aged >40, with new symptoms or where the bleeding is significant, or where there are associated symptoms, e.g. weight loss, change in bowel habit, should be referred for proctoscopy/sigmoidoscopy/barium enema, etc.

See also haemorrhoids (p. 268).

MELAENA OR ALTERED BLOOD

This suggests bleeding from the upper GI tract. Melaena is usually secondary to stomach pathology.

• Current symptoms: admit immediately.

• If the symptoms have settled: arrange urgent endoscopy.

• Stop NSAIDs.

OCCULT BLEEDING

This is suggested by anaemia with positive faecal occult bloods.

• Refer routinely.

• Stop NSAIDs.

• Treat with oral iron if iron deficiency anaemia is confirmed.

PRURITUS ANI

A clear cause for pruritus ani is not always found. Itch tends to occur if the anus is moist or soiled. In children, the usual diagnosis is threadworms, especially if the history is short.

Management

Threadworms.

Pruritus is due to perianal egg deposition. Examination is usually unnecessary. It is reasonable to treat only the affected child as long as the rest of the family are scrupulously attentive to hygiene. Alternatively, the whole family can be treated.

• Wash perianal skin each morning.

• Wash hands and nails after each visit to the lavatory.

• Treat with mebendazole 100 mg sachet stat. and repeat 2 weeks later if reinfection occurs, or piperazine powder one sachet stat. and repeat after 2 weeks.

General.

If no treatable cause is found:

• Consider treating empirically for threadworms.

• Advise careful perianal hygiene after defaecation with thorough drying.

• Avoid use of allergenic substances.

• Hydrocortisone ointment is useful, especially at night, or topical antifungal/steroid mixtures.

ANAL FISSURE

Related

Churchills Pocketbook of General Practice