1. Common General Gastroenterological problems
Dr Laksh Ayaru
Consultant Gastroenterologist
Charing Cross and Hammersmith Hospitals
Hospital of St John and St Elizabeth
Highgate Hospital

2. Outline
5 clinical cases-common presentations to primary and secondary care
Discuss clinical approach
Discuss evidence/ guidelines

3. Case 1 30 yr old male recent cold and cough
Routine blood tests Hb 11.5, MCV 60 WCC 5.0, plt 250
Serum Iron low

4. Question 1
Treat with oral Iron
OGD
OGD and Colonoscopy
Other

5. Question 1 Treat with oral Iron OGD OGD and Colonoscopy
Other-haematinics

6. Anaemias
Normochromic
Microcytic
Macrocytic

7. Microcytic anaemia-differential
Haemoglobinopathy
Iron deficiency anaemia
Anaemia of chronic disease
Sideroblastic anaemia

8. Investigations
Repeat Iron studies normal (serum Iron, transferrin, ferrtitin)
Hb electrophoresis abnormal
Diagnosis-thalassaemia trait

9. Case 2 50 year old male Short of breath and lethargic
Hb 8.0 mcv 70 WCC 7.0 Plt 239

10. Question 2 Which single blood test do you want to order?
Ferritin

11. Iron absorption

12. Ferritin Most specific test for iron deficiency
Not 100% sensitive as can be raised to normal levels in inflammatory diseases and malignancy
Always check ferritin before starting oral iron as will cloud picture

13. Iron studies in hypochromic microcytic anaemias
Serum Fe
Transferrin Saturation
Ferritin
Iron deficiency
low
low (normal)
Anemia of chronic disease
normal
Thalassaemia trait

14. Iron deficiency anaemia
2-5% of adult men and post menopausal women

15. Investigations (BSG guidelines 2011)
Upper and lower GI investigations should be considered in all postmenopausal female and all male patients unless there is a history of significant overt non-GI blood loss
All patients should be screened for coeliac disease
Urine testing for blood is important in the examination of patients with IDA

16. If oesophagogastroduodenoscopy (OGD) is performed as the initial GI investigation, only the presence of advanced gastric cancer or coeliac disease should deter lower GI investigation
In patients aged >50 or with marked anaemia or
a significant family history of colorectal carcinoma, lower GI investigation should still be considered even if coeliac disease is found

17. Further direct visualisation of the small bowel is not necessary unless there are symptoms suggestive of small bowel disease, or if the haemoglobin cannot be
restored or maintained with iron therapy

18. Who not to refer for scope
Premenopausal woman, no gi symptoms and no FHx of colorectal cancer (check for coeliac
In patients <50 with iron deficiency without anaemia

19. Case 3 35 yr old female Type II diabetic on metformin Asymptomatic
Alcohol 14 u/week
Normal examination
LFT- alt 72, ast 53, GGT 65, ALP67, bil 7

20. Question 4-Diagnosis? Hepatitis C Hepatitis B Fatty liver disease
Drugs

21. Question 4-Diagnosis? Hepatitis C Hepatitis B Fatty liver disease
Drugs

22. Hepatocyte location of liver enzymes
Goessling et al 2005 Clin Gasto hepatol

23. Abnormal LFTs Increased liver tests in 1-4% of asymptomatic people
Mild AST/ALT rise < 5 x ULN

24. Transaminitis NAFLD Hepatitis B,C Haemochromatosis
drugs (over the counter, prescribed)
Autoimmune hepatitis
Wilsons (rare)
Alpha 1 antri-trypsin

25. Liver tests Hep B S Ag, Hep C antibody Anti Sm, ANA, immunoglobulins
Ferritin, transferrin saturation
Cu, Caerluoplasmin
Alpha 1 antitrypsin
Tissue transglutaminase
Liver ultrasound

26. Non alcoholic fatty liver disease (NAFLD)
Fatty infiltration, fat and inflammation (NASH), cirrhosis
Risk of liver cancer/liver related death and increased CVS risk
Hepatic manifestation of metabolic syndrome
94% of BMI>30 and 40-70% of Type 2 diabetics

29. Diagnosis Typical patient raised LFT (alt>ast)
Liver u/s-sensitivity is limited if <33% of hepatocytes steatotic
Liver biopsy gold standard way to differentiate steatosis from NASH

30. NAFLD score (http://nafldscore. com)
Age
BMI
Hyperglycemia
Platelets
Albumin
AST/ALT ratio
Metanalysis13 studies AUROC advanced fibrosis (AF)
< % sensitivity and 60% specificity to exclude AF
>0.676 sensitivity and 97% specificity to detect AF

31. Prognosis Steatosis –no increased risk of end sage liver disease
25-33% NASH have advanced fibrosis at diagnosis
5% NASH progress to end stage liver disease
Risk factors; >45, diabetic, obesity, hypertension

32. Treatment No drugs specifically licensed for NASH
RCTs support specific insulin sensitisers in selected patient groups
Mainstay –lifestyle interventions to support weight loss
>7% weight reduction sustained over 48 weeks assoc with significant improvement in histological severity in NASH

33. Case 4 30 year old female Asymptomatic Recent UTI
Routine bloods-ALP 200, alt 34 bilirubin 15

34. Question 5- Next management step
Request hepatitis serology
Ultrasound abdomen
Request other LFTs
Repeat ALP at later date

35. Question 5- Next management step
Request hepatitis serology
Ultrasound abdomen
Request other LFTs
Repeat ALP at later date

36. ALP Repeat blood tests when clear of infection Raised ALP liver bone
placenta
Check GGT to determine if liver in origin

37. Differential of cholestatic LFTs
PBC
PSC
drugs
gallstones
malignancy (older age groups)
heart failure (older age groups)

38. Diagnosis
Positive AMA
PBC
Treatment with URSO

39. Case 5 38 year old lady 1 yr history of epigastric pain and bloating
Intermittent on most days
No radiation or relation to food
No nsaids
No alarm symptoms

40. Diagnosis?
dyspepsia

41. Question 6
Test and treat for H Pylori
PPI
Direct for OGD
Other tests

42. Question 6
Test and treat for H Pylori
PPI
Direct for OGD
Other tests

43. Nice guidelines 2004 Recommended test and treat
Remember improvement could be
1) PPI
2) placebo
3) spontaneous resolution
Gastric ulcer Oesophagitis
H Pylori gastritis Normal

44. Test and Treat may not be most cost effective
Speigel et al 2002 Gastroenterology

45. Upper GI endoscopy
Normal
Antral biopsies negative for H Pylori

46. Diagnosis? Non-ulcer dyspepsia-most likely
Gastro-oesophageal reflux disease-less likely
Other pathology-eg pancreatic disease, gallstones-less common

47. What is non-ulcer dyspepsia?
Heterogenous disorder
40 % of population
Epigastric pain syndrome (EPS)
Post prandial distress syndrome (PPD)
Dysregulation of brain gut axis
Tack et al 2004 Gastroenterology

48. Treatment of non-ulcer dyspepsia
Often results disappointing in contrast to ulcer disease
Explanation, ‘not imagining symptoms’

49. PPIs Meta-analysis of 7 studies (n=3725)
PPIs were more effective than placebo for reducing symptoms of dyspepsia (RR10.3%, NNT =14)
Better only in ulcer or reflux like symptoms not dysmotility like
Hong Wang et al 2007 Clin Gastro Hep

50. H Pylori eradication Possible small benefit NNT 17
Cochrane review 2003 and 2006

51. Domperidone Chinese study n=85 Double blind placebo controlled RCT
Improvement in nocturnal bile reflux and symptoms

52. Tegaserod Two RCTs Inconsistent benefit Enhanced gastric accomodation
Improvement in post prandial pain
No serious adverse events
Cardiovascular side effects in chronic constipation studies
Vakil et al 2008 American Journal of Gastroenterology

53. Summary Fe def anemia check ferritin Abnormal LFT NAFLD common cause
Non-ulcer dyspepsia
explanation that one can offer a diagnosis and prognosis