GEM - digestive problems educational module part two

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)

Helicobacter pylori (H. pylori) testing:

Helicobacter pylori (formerly named Campylobacter pylori) is a gram negative S shaped or spiral bacillus, described as a Unipolar flagellate, 1 by 3 micrometres in size. It is a microaerophilic, and produces urease and other toxins. Infection with Helicobacter pylori is common in patients with peptic ulceration

• if the criteria for referral for dyspepsia are not met then a test and treat strategy for H. pylori might be employed in the primary care setting
  • "...there is currently inadequate evidence to guide whether fulldose PPI for one month or H. pylori test and treat should be offered first. Either treatment may be tried first with the other being offered where symptoms persist or return.." NICE (2014)
  • testing for H. pylori
    • which tests can be used both pre- and post-eradication treatment to determine presence of H. pylori
    • can serological testing be employed post-eradication treatment
      • GPN reference
  • what are the triple therapy regimes recommended by NICE
    • GPN reference
  • if H. pylori diagnosis via an OGD, then what implication does the type of ulcer found (duodenal versus gastric) have for management following eradication therapy?
    • GPN reference
  • what is the role of H. pylori in gastric cancer?
  • GPN reference
  • some information concerning the evidence base for test and treat?
    • GPN reference

Coeliac Disease:

Coeliac disease is clinically very variable and so is defined pathologically as a permanent gluten-sensitive enteropathy. The mucosal lesions seen on upper GI biopsy are the result of an abnormal, genetically determined, cell-mediated immune response to gliadin, a constituent of the gluten found in wheat. A similar response occurs to comparable proteins found in rye and barley. Gluten is not found in oats, rice and maize

In what age group does coeliac disease most commonly present?

• GPN reference

There is an association between development of coeliac disease and insulin dependent diabetes. Can you think of any other associations?

• GPN reference

How can coeliac disease present to the primary care clinicians in adults?

• GPN reference

Dermatitis herpetiformis is a rash that is classically associated with coeliac disease. What are the clinical features of this condition?

• GPN reference

Investigation for Coeliac Disease

Three different antibodies are often used in the diagnostic work-up for possible coeliac disease (antigliadin antibody, anti-endomysial, anti-transglutaminase antibody)

• which two antibody tests are the most specific?
• which antibody test is the most sensitive?
• is immunological testing sufficient to make the diagnosis of coeliac disease?
  • GPN reference
• what other blood test findings might be present if a patient has possible coeliac disease?
  • GPN reference

Treatment of this conditon includes dietary advice and a gluten-free diet. What factors should be considered if there was a failure to respond to the dietary changes?

• GPN reference

Faecal occult blood testing

• there is trial evidence that faecal occult blood testing can lead to a reduction in mortality of colorectal cancer. If a two-yearly screening programme is employed in adults aged 50 years or over will lead to:
  • a) 20% reduction in mortality
  • b) 50% reduction in mortality
  • c) 70% reduction in mortality
    • GPN reference

Liver Function Tests

Scenario: 35 year old man was seen by the health care assistant at his new patient medical and had some "routine blood tests" done. Of note in the results was a raised ALT at 90 IU/l (reference range 10-50 IU/l) with the rest of his liver function tests within the normal range. He had a fasting blood glucose of 5.8 mmol/l and a total cholesterol of 6.2 mmol/l and triglycerides of 3 mmol/l. His blood pressure was 135/80 mmHg. This gentleman had a BMI of 32.1. Abdominal examination revealed nil of note.

• what causes of the asymptomatic raised ALT should be considered?
  • GPN reference

This gentleman had an alcohol consumption of 30 units per week. A repeat ALT and a GGT were requested after a period of reduction/abstinence from consumption of alcohol. The GGT was raised at 80 IU/l.

• what other causes of a raised GGT should be considered (in addition to secondary to excessive alcohol consumption)?
  • GPN reference
• a raised GGT in a obese individual is a risk factor for the development of what chronic disease?
  • GPN reference

This gentleman's repeat ALT was 85 IU/l. How should this be managed?

• GPN reference

After referral and further investigation, it was concluded that this gentleman had non-alcoholic fatty liver disease (NAFLD). What options are there for management of this condition?

• GPN reference

Futher references on GPN:

• Coeliac disease section
• H. pylori section
• ALT section

Reference:

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