Gastro

Question 1

What is the prevalence of coeliac disease in the UK? What about in first degree relatives of sufferers?

Answer 1

General population - 0.8-1.9%If first degree relative - 4.5-12%

Question 2

What are complications of coeliac disease?

Answer 2

Anaemia, osteoporosis; in children, growth failure and delayed puberty,

Question 3

What symptoms, according to NICE, should prompt Ix for coeliac disease?

Answer 3

Chronic or intermittent diarrhoeaFailure to thrive (children)Persistent or unexplained GI symptoms, e.g. nausea/vomitingRecurrent abdominal painProlonged fatigueUnexpected weight lossUnexplained iron deficiency anaemia

Question 4

What conditions should prompt a screen for coeliac disease, due to their association?

Answer 4

Autoimmune thyroid diseaseDermatitis herpetiformisIrritable bowel syndromeType 1 diabetesFirst degree relative with coeliac……But there are loads more!

Question 5

What is the first line test for coeliac disease? What information should patients be given when considering a test for coeliac?

Answer 5

First line Ix is anti tissue transglutanimase Ab (tTGA) or antiendomysial antibody.Patients must be eating more than one gluten-containing meal each day for 6w prior to the test.You should discuss with patients that the serology test will identify a group of patients who require further investigations and that these are an endoscopy and biopsy.It is important to know the IgA status of patients in interpreting the serology results (in practice most labs now check IgA levels at the same time as initial serology and perform an IgG-based test if IgA levels are found to be low.

Question 6

Are patients with coeliac disease entitled to free prescriptions?

Answer 6

At present, no.

Question 7

What is gluten found in?

Answer 7

Gluten is found in wheat, rye and barley. In those with severe sensitivity to gluten, a similar protein to gluten is found in oats and may cause a problem.Compliance with a gluten-free diet is often poor – ranging from 45 to 87%.

Question 8

What radiological Ix might be considered for someone with coeliac disease? Why?

Answer 8

Those with coeliac disease are at increased risk of osteoporosis. The Primary Care Society for Gastroenterology recommends: DEXA scan at diagnosis repeat DEXA at menopause for women and 55y for men at any age if fragility fracture occurs.

Question 9

Patients with coeliac disease should be reviewed annually, and checked for…?

Answer 9

Annual review in primary care should include:-BMI-bowel function and symptoms-nutritional status bloods including: FBC, folate, ferritin, ALP, albumin, calcium, B12, vit D-immunisations: 25% have splenic atrophy sufficient to cause peripheral blood changes: consider vaccination for influenza, pneumococcus and H. influenzae.

Question 10

What criteria is used for defining constipation? What are those criteria?

Answer 10

The Rome criteria (it makes constipation glamorous!)
The criteria are the presence of 2 or more symptoms from the following list during bowel movements (BM’s):
-Straining for >25% of BM
-Lumpy or hard stools for more than 25% of BM
-Sensation of incomplete evacuation for >25% BM
-Sensation of anorectal obstruction or blockage for more that 25% of BM
-Manual manoeuvours to facilitate at least 25% of BM’s (e.g., digital evacuation)
-Fewer than 3 BM’s per week.

Question 11

How common is IBS? Who are mainly affected?

Answer 11

Common - prevalence 10-20%, mainly people aged 20-30, twice as many women as men.

Question 12

What three main symptoms should prompt assessment for IBS? And for how long should they have been present?

Answer 12

If any of the following have been present for 6 months or more:

1) Bloating.
2) Change in bowel habit.
3) Abdominal pain or discomfort.

Question 13

If a patient presents with possible IBS symptoms, what red flag symptoms should be specifically asked about? If any are positive, what should be done?

Answer 13

1) Family Hx of bowel or ovarian cancer.
2) PR blood.
3) Unintentional and unexplained weight loss.
4) Bowel habit changed to looser/more frequent stool in someone >60.
If ANY present, refer to secondary care.

Question 14

If a patient presents with possible IBS symptoms, what red flag features should be checked fort? If any are positive, what should be done?

Answer 14

1) Anaemia.
2) Rectal mass.
3) Abdominal mass.
4) Marker of IBD.

Question 15

What blood test should be performed in patients whose symptom could represent ovarian cancer?

Answer 15

CA125.

Question 16

When should IBS be considered (sort of in terms of major and minor criteria; also supporting criteria)?

Answer 16

Major criteria: Only if there is abdominal pain/discomfort that is either relieved by defecation or accompanied by change in bowel habit/stool form + 2 minor criteria.
Minor criteria: a) altered stool passage (straining etc), b) mucous, c) bloating, d) symptoms worse on eating.
Supporting criteria: lethargy, nausea, backache, bladder symptoms.

Question 17

What tests should be performed if IBS is suspected, and why are they performed?

Answer 17

These tests are to exclude other conditions, not to confirm IBS:

1) Coeliac screen (trans-glutanimase or endomysial Ab).
2) FBC, ESR, CRP.

Question 18

What tests are NOT required when IBS diagnostic criteria is met?

Answer 18

1) OGD
2) Rigid/flexible sigmoidoscopy
3) Barium enema
4) USS
5) FOB
6) Colonoscopy
7) H-breath test.
8) TFT
9) Faecal ova and parasite screen

Question 19

What general dietary advice could be given to people with IBS?

Answer 19

1) No more than 3 caffeinated drinks/day.
2) 8 cups of fluid a day.
3) No more than 3 fruit portions.
4) Limit fibre - e.g., wholemeal bread, brown rice, bran).
5) Regular meals with enough time to eat.
6) Avoid long gaps between meals.
7) Moderate alcohol and fizzy drinks.
8) If diarrhoea, avoid sorbitol (artificial sweeter in e.g., chewing gum).
9) Reduce intake of resistant starches.
10) If wind and bloating, oats and linseeds may help.

Question 20

What general advice for IBS?

Answer 20

1) Dietary advice (see other card)
2) Regular exercise
3) Encourage people to make use of leisure time/create relaxation time.
4) Bran is important - usually needs reducing. If required, advice soluble (e.g., ispaghula husk, oats) rather than insoluble (bran).
5) If probiotics used, try for at least 4/52.
6) Discourage aloe vera.
7) Do not encourage acupuncture or reflexology for IBS.

Question 21

What is a low FODMAP diet (often used for IBS)? Why?

Answer 21

Low fermentable oligosaccharides, disaccharides, monosaccharides, and polyols. These aren’t well absorbed in small intestine, and ferment in large intestine, worsening symptoms in IBS.
Could refer patient to a dietician for this if general advice fails.