Download Gastrointestinal Problems in Primary Care

Gastrointestinal Problems
November 2011
Nick Pendleton
What we are going to cover
• Dyspepsia
• Change in Bowel habit
• Rectal Bleeding
• Gastric Ulcers & Cancer, Barrett’s Oesophagus
• Irritable Bowel Syndrome
• Inflammatory Bowel Disease, Colon Cancer
Dyspepsia
What is it?
What does it feel like?
What is the cause?
Any investigations?
What is the treatment?
What are the Red Flags?
When do you refer for Endoscopy?
Dyspepsia is very common
Often related to lifestyle choices
When does it become a medical problem?
Definition
•
•
•
•
•
•
upper abdominal (epigastric) pain or discomfort
heartburn
acid reflux
nausea
vomiting
present for at least 4 weeks
Pooled prevalence from studies in
Europe, Australia and the USA is 34%
Beware!
Review Medications
• Non-steroidal anti-inflammatory drug (NSAIDs)
• Aspirin
• SSRIs
• Calcium antagonists
• Nitrates
• Theophyllines
• Bisphosphonates
• Steroids
Lifestyle Advice
• Smoking, Alcohol, Coffee
• Chocolate, Fatty foods
• Advise patient on weight reduction (being
overweight may cause dyspepsia)
• Raising the head of the bed and not eating close
to bedtime may reduce dyspepsia symptoms in
some people
• Consider antacid and/or alginate therapy for
immediate symptom relief
Endoscopy (to investigate for
malignancy) is indicated in:
Patients of any age with any of the following alarm signs:
• Significant acute gastrointestinal bleeding
• Chronic gastrointestinal bleeding
• progressive weight loss (unintentional and unexplained)
• progressive difficulty swallowing (dysphagia)
• persistent vomiting, iron deficiency anaemia
• mass in epigastrium
In patients > 55 years old
• any unexplained or persistent dyspepsia symptoms (of at
least 4 weeks duration) of recent-onset (<1 year) should be
referred
•
Helicobacter Pylori
• Infection with H. pylori is the cause of most
stomach and duodenal ulcers. H. pylori also
causes some cases of non-ulcer dyspepsia
• Blood testing for Helicobacter antibodies or
• With a carbon 13 urea breath test or a stool
antigen test
• NB: The patient must stop acid suppression 2 weeks prior to
H.pylori testing to avoid false results wherever possible.
H. Pylori Eradication
• As twice daily regimen for 7 days:
• Omeprazole 20mg + Clarithromycin 250mg +
Amoxicillin 1g
• For Penicillin-allergic patients:
• Omeprazole 20mg + Clarithromycin 250mg +
Metronidazole 400mg, all twice daily.
OTC Indigestion Remedies eg Gaviscon, Peptac
• These are based on a mixture of :
• Buffering agents and neutralisers: calcium carbonate
and sodium bicarbonate, magnesium carbonate
• & Gelling agents: alginic acid and aluminium
hydroxide.
• The combination of the alginic acid and bicarbonate
creates a barrier which prevents stomach acid from
refluxing up into the oesophagus.
• If reflux occurs, the protective barrier is the first to
contact the oesophageal mucosa, in lieu of gastric
contents
Proton Pump Inhibitors
• In Bolton PPIs make up 4% of the total drugs
budget!
• Therefore it is important to choose the most
cost effective preparation (this often changes)
but currently Omeprazole and Lansoprazole
are recommended by the PCT medicines
management team
ATP Powered proton pump
Takes in K+ in exchange for
H+ out
Stimulated by Ach, Gastrin,
Histamine
PPI Treatment Tips
• Address lifestyle, triggers, medications
• Trial of PPI for 1 month & then stop
• Step down to a maintenance dose after a
month if continuing
• If continuing consider checking H.Pylori
• If not responding to treatment try a higher
dose or alternative
• Consider referring those on longer term
treatment for endoscopy: Barretts? Ulcer?
PPI Treatment Tips
• If not responding to treatment then refer
endoscopy
• If any red flags eg new dyspepsia >55yrs > 1
month refer urgent endoscopy
• If patient develops diarrhoea after starting
lansoprazole – remember that there is an
association with C.Difficile.
Findings in patients referred for endoscopy:
• Normal or minor changes (60%)
• Oesophagitis (19%)
• Duodenal, gastric and/or peptic ulcer (13%)
• Gastric and/or oesophageal cancer (3%)
• Miscellaneous (5%)
Peptic ulcer disease
Peptic ulcer disease
• Erosion of gastric mucosa by acid & pepsin,
when mucin protection is overwhelmed
• H.pylori - 90% duodenal ulcers, 70% gastric
• NSAIDS, aspirin, stress, alcohol, nutrient
deficiencies, smoking
• Duodenal 4-5x more common, M > F
• Duodenal almost always benign
• 4% Gastric can be malignant (biopsies)
Peptic ulcer disease
• Epigastric Pain - Duodenal ulcers are classically
relieved by food, whilst gastric ulcers are
exacerbated by it
• Bloating and abdominal fullness, waterbrash
• Nausea, and vomiting, loss of appetite and
weight loss
• Complications – Bleeding, Anaemia, Melaena or
Haematemesis, Perforation, Scarring &
Obstruction, Malignancy, Acute Peritonitis, Death
v
Chronic reflux causes metaplastic change in the distal oesophageal lining
from the normal squamous epithelium to intestinalised columnar
epithelium. Diagnosis by endoscopy with biopsy. Patients with Barrett's
oesophagus have an 30 to 125 times higher risk of developing
oesophageal adenocarcinoma for which 5 year survival is 17%.
•
Stomach cancer is the fourth most common cancer
worldwide. Second most common cause of cancer
death worldwide after lung cancer. Presents late. Can
be symptomatic or symptoms of dypepsia, anorexia,
weight loss, iron deficiency anaemia, abdominal pain,
bloating, fatigue.
Gastric Cancer
• H. pylori is the main risk factor in 65–80% of
gastric cancers, but in only small % of such
infections. 10% have a genetic component
• Smoking & high alcohol intake increase risk.
• 90% are adenocarcinomas. They aggressively
invade the gastric wall.
• 80-90% metastasise. 5 year survival overall is
20%.
• If localised with no spread & surgery can be
performed 80% live to 5 years and 2/3 will be
cured
Change in Bowel Habit,
Including Rectal Bleeding
How do you differentiate :
?
Irritable Bowel Syndrome
IBD (Crohn’s, Ulcerative Colitis)
Colonic Carcinoma
• FOBT screening
Faecal Occult Blood Screening
• Eg. Haemoccult test – Changes colour when
oxidised by peroxidases in Haemoglobin
Faecal Occult Blood Test
• A screening test for Colonic Carcinoma
• Bleeding from Lesions anywhere in
Gastrointestinal tract cause +ve test!
• Eg. Erosive oesophagitis, gastric cancer
• False +ve: rare red meat, fruit & veg
containing peroxidases – broccoli, turnips,
radishes, Aspirin & Nsaids. Avoid for 3/7
• False –ve: polyps & carcinomas do not bleed
all the time (false reassurance)
FOBT Population Screening
• Occurs in the UK now
• Ages 45-50 & older
• In some studies (eg. 1996 Nottingham trial,
150,000 patients) Decreased mortality from
Colo-rectal carcinoma by 15%
• A positive test requires investigation
• There are risks of having a colonoscopy eg
perforation
Screening tests should be:
• Cheap
• Safe
• Sensitive  1 test 50-60%, 3 tests 70%
• Specific 
• Acceptable to patients? (50%)
• Cost-effective 
The Symptom : Change in Bowel Habit
•
•
•
•
•
•
•
•
Diarrhoea, Constipation
Alternating diarrhoea & constipation
Mucus production
Painful defaecation
Frank blood loss
‘Tenesmus’
Associated symptoms –
Bloating, lethargy, wt loss
Johnny 17, College Student
• Looks very worried
• Very infrequent attender
• Noticed red blood on toilet paper this
morning, no pain
• Worried he’s got bowel cancer
• What’s the risk of bowel cancer?
• What do you do?
Stephanie 21, Admin Assistant
• Constipated sometimes, then diarrhoea
• Feels bloated, abdominal cramps & pain
• Made worse by eating, Relieved by
defaecation, Intermittent symptoms for years
• Weight stable, work is stressful, relationship
issues currently. Asks if she could have food
intolerance?
• What do you do? What is the differential
diagnosis? Treatment options?
Jenny 26, Solicitor
•
•
•
•
•
•
•
Tired all the time
Losing weight
Abdominal pain & diarrhoea
Passing mucus, stained with blood
History of joint pain & swelling
Last year went to eye clinic with a painful eye
What is the likely diagnosis?
Crohn’s Disease
• Presents at any age, although usually at age 1630 years
• Chronic, relapsing & remitting
• Transmural intestinal inflammation of any part
of GI tract (mouth to anus)
• Occasional extraintestinal features such as
arthropathy (seronegative)or dermopathy (eg.
erythema nodosum), eye involvement eg. uveitis
Uveitis
• Inflammation of the uvea: iris, lens muscles,
blood vessels supplying the retina
Crohn’s
• Genetics, autoimmune or immunodeficiency
• Associated with smoking
• Obstruction, fistulae, and abscesses. Obstruction
typically occurs from strictures or adhesions,
malnutrition malabsorption
• Increased risk of small & large bowel cancer
Ulcerative Colitis
• Affects colon & rectum
• Increased risk of colon cancer
• The cause is not known: genetic,
immunological, dietary, and psychological
factors have all been implicated.
• Any age group
• About 1 in 5 have a close relative with UC
• Extraintestinal symptoms – seronegative
arthropathy eg Ankylosing spondylitis,
sacroilitis episcleritis & uveitis
Ulcerative Colitis
• usually starts in the rectum and extends proximally in
a symmetrical, circumferential, and uninterrupted
pattern
• may affect parts of the colon, or its entire mucosal
surface
• characterised by exacerbations and remissions
IBD treatments
• Aminosalicylates: Sulfasalazine – oral or PR
• Corticosteroids: orally, IV, PR
• Immunomodulators: Eg. Azathioprine or 6mercapto-purine (6-MP)
• Surgery – emergency & elective +/- stoma
Carol 40, Hairdresser
• Abdominal pain, abdominal distension, pelvic
pain, increased urinary frequency,
constipation or diarrhoea, abnormal vaginal
bleeding, weight loss, abdominal bloating, and
fatigue
Carol 40, Hairdresser
• Abdominal pain, abdominal distension, pelvic
pain, increased urinary frequency,
constipation or diarrhoea, abnormal vaginal
bleeding, weight loss, abdominal bloating, and
fatigue
• OVARIAN CANCER
Ca-125
•
•
•
•
•
Is this a useful test?
Not raised in early Ovarian Cancer
Not very sensitive
Not very specific
Mainly used as a marker of recurrence of
Ovarian Cancer
• Not useful as a screening test
• Could be useful as part of investigations to
build clinical picture
Gavin 45, Musician
•
•
•
•
•
•
•
•
1-2 months history
Diarrhoea (loose, greasy, malodorous stools)
Excessive wind
Nausea, vomiting
Bloating
Weight loss
Tiredness
Skin rash
Coeliac disease
Frank 53, Butcher
• New onset constipation -3 months
• Feels like he’s not finished after going
• Now noticed bright red blood on paper
Frank 53, Butcher
• New onset constipation, 3 months
• Feels like he’s not finished after going
• Now noticed bright red blood on paper
Colonic Carcinoma
•
•
•
•
Pre-existing colonic polyps
Familial polyposis coli, Ulcerative colitis
Crohn's disease
Family history – 1st degree relatives of
patients with colorectal cancer have 2-3 fold
increased risk, esp if diagnosed < 50
Colonic Carcinoma
• Environment - exposure to radiation; asbestos
• Diet - high fat, high calories, low dietary
calcium, low fermentable fibre
• Genetic markers, e.g. a chromosome 2 locus
may define a subset of colorectal cancer
patients - hereditary non-polyposis colon
cancer - that constitute about 5% of all
colorectal carcinomas.
Prognosis of Colonic Carcinoma
• Staging of colonic carcinoma is the most
important determinant of survival rate
• Dukes classification
• Overall 5 year survival rate is 35%
• Large differences according to the stage of
disease
• The 5-year survival rate for advanced colorectal
cancer is less than 5%
• Without treatment, the approximate survival
period after diagnosis of metastatic disease is 6–9 months
Dukes Classification (old)
A: tumour confined to the bowel wall
– 97% 5 year survival
B: tumour extends across the bowel wall
– 80% 5 year survival
– if locally-invasive, dramatically worse prognosis
C: involvement of regional nodes
– C1: only a few nodes are involved near the primary growth
and the proximal nodes are free from metastases
• approximately 60% 5 year survival
– C2: proximal nodes are involved
• approximately 30% 5 year survival
D: distant metastases
– less than 5% 5 year survival
Prognosis depends on staging
2 Week Wait referral for suspected malignancy is indicated
for:
A. Iron Deficiency anaemia with no obvious cause
B. 6 w history of diarrhoea in a 60 year old man
C. 6 w history of constipation 40 year old women, with
rectal bleeding
D. Painful rectal bleeding in 25 year old
E. A mass in the right lower quadrant
2 Week Wait referral for suspected malignancy is indicated
for:
A. Iron Deficiency anaemia with no obvious cause
B. 6 w history of diarrhoea in a 60 year old man
C. 6 w history of constipation 40 year old women, with
rectal bleeding
D. Painful rectal bleeding in 25 year old
E. A mass in the right lower quadrant
T,T,T,F,T
Coeliac Disease:
A.
B.
C.
D.
E.
Carries an increased risk of small bowel lymphoma
Can be diagnosed by Upper GI Endoscopy
There is malabsorption of B vitamins
Anti-gliadin antibodies are present in serum
Can be prescribed gluten free food on prescription
Coeliac Disease:
A.
B.
C.
D.
Carries an increased risk of small bowel lymphoma
Can be diagnosed by Upper GI Endoscopy
There is malabsorption of B vitamins (A,D,E & K)
Anti-gliadin antibodies are present in serum (and antiendomysial & transglutaminase antibody)
E. Can be prescribed gluten free food on prescription
T,T,F,T,T
Alarm symptoms or signs in dyspepsia:
A.
B.
C.
D.
E.
Gastrointestinal bleeding
Bloating
Progressive unintentional weight loss
Excessive flatus
Persistent vomiting
Alarm symptoms or signs in dyspepsia:
A.
B.
C.
D.
E.
Gastrointestinal bleeding
Bloating
Progressive unintentional weight loss
Excessive flatus
Persistent vomiting
T,F,T,F,T
Common side effects of Proton Pump Inhibitors:
A.
B.
C.
D.
E.
Nausea
Vomiting
Abdominal pain
Diarrhoea
Depression
Common side effects of Proton Pump Inhibitors:
A.
B.
C.
D.
E.
Nausea
Vomiting
Abdominal pain
Diarrhoea
Depression
T,T,T,T,F