GEM - digestive problems educational module part one

Dyspepsia and gastro-oesophageal reflux disease (GORD) are common conditions, affecting around 28% of the population.They cause significant impairment of quality of life (1)

• dyspepsia
  • only 20% of those with dyspepsia or GORD consult a doctor, but this accounts for 2% to 8% of all primary care consultations
    • almost all of those who consult receive a prescribed medication, and 49% of all patients with dyspepsia take over the counter medications, with disease-modifying drugs now available without prescription

Colorectal cancer

• Scotland has one of the highest incidences of colorectal cancer in the world (41 per 100,000 in men, 29 per 100,000 in women) and, is the second most common cause of cancer death (1)

With reference to symptoms of digestive problems:

Dyspepsia:

• there has now been modification of the NICE dyspepsia suggesting that new onset dyspepsia in patients over 55 years old is appropriate for urgent endoscopy referral in certain circumstances. When is urgent referral appropriate in this case? GPN reference

Abdominal pain:

• which of the following can be a cause of left upper quadrant abdominal pain include?
  • gallbladder disease
  • pneumonia
  • acute pancreatitis
  • spontaneous splenic rupture
  • hepatic abscess
  • GPN reference
• apart from gastric ulceration, what other pathologies are associated with abdominal pain that is precipitated by food?
  • GPN reference

Vomiting:

Vomiting is a symptoms that may signify different pathologies based on the age of a patient. For example vomiting in a neonate may due to a cause such as feeding problems (including overfeeding) or systemic infection. If a mother has had a home delivery and requests a visit for her 3 day old baby then what other causes of the vomiting should be considered?

• GPN reference

In adult presenting to the GP surgery with persistent vomiting, what metabolic causes of vomting should be considered?

• GPN reference

In addition the GP should also consider possible neurological causes. Vomiting may occur with vestibular dysfunction such as benign positional vertigo and Meniere's disease. Vomiting may also be a feature of raised intracranial pressure. What other neurological causes might be considered?

• GPN reference

Haematemesis:

Haematemesis is the vomiting of blood. This condition occurs when there is bleeding in the oesophagus, stomach or duodenum, i.e. bleeding proximal to the duodenal-jejunal junction

Ehlers-Danlos syndrome is a rare syndrome that may initially present with an episode of haematemesis. What is Ehlers-Danlos syndrome?

• GPN reference

What mineral supplement taken in accidental overdose (e.g. by an infant) could result in an acute presentation with haemetemesis?

• GPN reference

Melaena:

Melaena is the passage of black, tarry stools. The stools have a characteristic and offensive smell due to the presence of blood that has been digested by intestinal enzymes and bacteria. The degradation of the blood also accounts for the dark colouration. It usually implies a bleed at some point early in the gastrointestinal system proximal to the splenic flexure of the colon (usually the oesophagus, stomach or duodenum).

Rectal Bleeding:

Causes of rectal bleeding include haemorrhoids, diverticular disease, colonic polyps and carcinoma. A review of the causes of rectal bleeding is available on GPN

• GPN reference

An unsual cause of rectal bleeding is a bleeding Meckel's diverticulum - what is this? GPN reference

Colonic angiodysplasia may be a cause of rectal bleeding in the elderly. What is colonic angiodysplasia and how may it be treated?

• GPN reference

Tenesmus:

Tenesmus is an intense, painful but fruitless desire to defaecate. It may be continuous or recurrent. The rectum feels full, but when the patient tries to pass a stool, nothing appears, or a little blood and mucus is passed.

In the context of a symptom of tenesmus, what is the likely diagnosis?

• a 35 year old woman with a has a history of alternate loose stools and constipation. She also complains of episodes of abdominal discomfort and bloating relieved by passing flatus
• brother diagnosed with familial polyposis coli
• an elderly man with a history of weight loss and anorexia. He has had previous episodes of bright red blood passed per rectum over the last 6 months
• a 25 year old man with a history of previous bleeding per rectum. He now complains of severe anal pain which is exacerbated when passing motion
• GPN reference

Jaundice:

A 35 year old man was noted to have yellow sclera by the practice nurse during his new patient medical. She tested his urine sample and the sample was negative for urine bilirubin.

Is the cause of this gentelman's jaundice prehepatic, hepatic or posthepatic?

• GPN reference

This gentleman has no history of ongoing medical problems and says that he is otherwise well. He notes that his father and brother also intermittently have episodes of "yellow eyes".

What is the likely diagnosis and how is this relevant to the family history ?

• GPN reference
• what exacerbates jaundice in this context?
  • GPN reference

This patient was seen by the GP the following week and was noted to have a mild splenomegaly. A set of screening blood tests revealed a normocytic anaemia. A blood smear was reported to have increased number of reticulocytes. This gentleman notes that his father has a history of "something wrong with his blood" and gallstones.

• in the context of the preceeding information, what condition might cause the clinical features noted?
  • GPN reference
• the blood smear also noted the presence of spherocytes.
  • what is now the most likely cause of the jaundice symptom?
  • how is this condition inherited?
    • GPN reference
  • what is the relevance of his father's history of gallstone disease?
    • GPN reference

Constipation:

A 62 year old man comes into the GP surgery with a history of a change in bowel habit in the last 2 months. He has now opens his bowels every other day when before he had opened his bowels once per day. He is otherwise well and has had no weight loss. He has no past history of bowel disease. Clinical examination was unremarkable.

• is a change in bowel habit to constipation over a two month period a criteria for urgent cancer referral?
  • GPN reference
• screening blood tests were undertaken including a FBC, LFTs, ESR and CRP. The results were unremarkable apart from an MCV of 102.5 fl  
  • what is the likely cause of this gentleman's constipation?
    • GPN reference
  • what other causes of macrocytosis should be considered?
    • GPN reference
  • can you name some other metabolic causes of constipation?
    • GPN reference

Diarrhoea:

A 62 year old man comes into the GP surgery with a history of a change in bowel habit in the last 2 months. He has now opens his bowels three to four times per day when before he had opened his bowels once per day. He is otherwise well and has had no weight loss. He has no past history of bowel disease. Clinical examination was unremarkable.

• what are some causes of persistent diarrhoea in an adult?
  • GPN reference
• is his change in bowel habit a criteria for urgent referral
  • GPN reference
• screening blood tests were undertaken including a FBC, LFTs, ESR and CRP. The results revealed a haemoglobin of 10.9 mg/dl and an MCV of 73.5 fl
  • what is the significant of his blood results?
    • GPN reference
• this gentleman was urgently referred for a colonoscopy and a sigmoid colon carcinoma was diagnosed. What is the most common site for a colorectal carcinoma?
  • GPN reference
• what proportion of colocrectal carcinomas occur in patients less than 40 years of age?
  • GPN reference

Dysphagia:

The causes of dysphagia should be considered in terms of oesophageal causes and systemic causes. Some systemic causes of dysphagia include:

• GPN reference

What lesions outside the oesophageal lumen might cause dysphagia?

• GPN reference

What is odynophagia?

• GPN reference

Dysphagia is a symptom that should prompt urgent referral. The urgent referral guidance for suspected upper GI cancer is GPN reference

Reference:

1. Royal College of General Practitioners. Curriculum Statement 15.2 Digestive Problems.