GP Gastroenterology

Question 1

What are diverticula?

Answer 1

abnormal sacs or pockets in the GI tract thought to form due to increased luminal pressure and a low fibre diet

Question 2

Explain the difference between diverticulosis, diverticular disease and diverticulitis?

Answer 2

• Diverticulosis = presence of diverticula in the colon without symptoms
• Diverticular disease = the presence of diverticula with mild abdominal pain or tenderness and no systemic symptoms
• Diverticulitis = inflammation of diverticula

Question 3

What part of the colon are diverticula most common?

Answer 3

sigmoid colon

Question 4

What group does diverticula tend to most commonly occur in?

Answer 4

the elderly

Question 5

Presentation of diverticulosis, diverticulitis and diverticular disease?

Answer 5

• Diverticulosis is asymptomatic
• Diverticular disease presents with mild and intermittent left lower quadrant pain with constipation, diarrhoea or occasional rectal bleeds
• Diverticulitis presents with constant abdominal pain, usually severe and localising to the left quadrant, fever, sudden change in bowel habit, significant rectal bleeding, a palpable abdo mass or distension may be felt

Question 6

Investigations for diverticulosis, diverticulitis and diverticular disease?

Answer 6

• Those with diverticular disease do not need referred unless they have not been able to have routine endoscopic or radiological investigations in primary care, or they have cancer red flags or colitis
• Those with complicated acute diverticulitis suspected need referred to hospital for FBC, U and Es, CRP and a contrast CT

Question 7

Management for diverticulosis, diverticulitis and diverticular disease?

Answer 7

• Those with diverticulosis just need reassurance and advice on a high fibre diet
• Those with diverticular disease do not need antibiotics, they should be advised to stop smoking, weight loss, high fibre diet, can consider bulk forming laxatives, simple analgesia and/ or antispasmodics if needed
• Those with uncomplicated acute diverticulitis likely need antibiotics but in some cases can be sent home with simple analgesia to see if resolves
• Those with complicated will be given IV antibiotics (amoxicillin, metronidazole and gentamicin)

Question 8

What causes GORD?

Answer 8

• Most people have a degree of reflux but if acidic stomach contacts stay in contact with oesophagus for longer than normal, people may complain of symptoms of GORD
• GORD is caused by combination of incompetent LOS, poor oesophageal clearance and visceral sensitivity (someone may be very sensitive to reflux and complain of severe symptoms but actually very little oesophagitis present)

Question 9

What are some risk factors for GORD?

Answer 9

• Increased intra-abdominal pressure e.g. obesity or pregnancy
• High fat diet
• Caffeine
• Alcohol
• Smoking (nicotine relaxes sphincter)
• Certain drugs can cause reflux such as antihistamines, steroid, CCBs, benzodiazepines and antidepressants
• Some medical conditions increase risk: hiatal hernia (part of stomach has squeezed up into diaphragm), scleroderma, Zollinger-ellison syndrome (gastrin secreting tumours cause your stomach to secrete too much acid))

Question 10

List some drugs that cause GORD?

Answer 10

antihistamines, steroid, CCBs, benzodiazepines and antidepressants

Question 11

List some medical conditions that increase risk of GORD?

Answer 11

Hiatus hernia - part of stomach goes up into diaphragm
Scleroderma - causes problems with sphincter
Zollinger ellison syndrome - gastrin secreting tumours cause stomach to secrete too much acid

Question 12

Symptoms of GORD?

Answer 12

• Main symptom is heartburn (burning pain behind sternum), may also complain of regurgitation and odynophagia (due to oesophagitis)
• If there is severe oesophagitis there can be scarring of the oesophagus which causes oesophageal stenosis and then patient may complain of dysphagia
• If reflux is severe, it can cause chronic coughing and hoarseness

Question 13

Diagnosis of GORD?

Answer 13

• Clinical diagnosis can be made without investigation but if red flag symptoms or uncertainty can do endoscopy
• 24hr pH monitoring can be helpful to confirm diagnosis if not responding to treatment
• Therapeutic trial – try PPIs – if they work it’s GORD

Question 14

Management of GORD?

Answer 14

• PPIs (omeprazole) are best drug treatment as they both eliminate symptoms and heal oesophagitis
• Take for 8 weeks, see if symptoms come back or if settles, if symptoms come back can start taking again
• Patients should also be encouraged to make lifestyle changes e.g., lose weight and diet changes
• Antacids and H2 antagonists can provide symptomatic relief
• Those who are young and suitable can have surgery to help with GORD (Nissen fundoplication – wrap part of the gastric fundus around the LOS)

Question 15

What is Barretts oesophagus?

Answer 15

complication of GORD where there is intestinal metaplasia- change from the normal squamous epithelium to columnar epithelium

Question 16

Management of Barrett’s oesophagus?

Answer 16

patient preference
but lifelong PPIs, endoscopic surveillance if patient consents, if dysplastic might ablate it

Question 17

What is IBS and what is it characterised by?

Answer 17

• Functional GI disorder
• Characterised by abdominal discomfort, bloating or pain associated with defaecation or a change in bowel habit

Question 18

Risk factors for IBS?

Answer 18

• It is not fully understood but thought to be some motor/ sensory dysfunction in the GI tract or changes in gut reactivity
• IBS is more common in middle aged women and is thought to be associated with emotional stimuli such as stress or abuse and is also linked to trauma
• Sometimes has initial trigger of gastroenteritis
• Related to other functional disorders e.g. fibromyalgia

Question 19

Presentation of IBS?

Answer 19

• Abdominal pain and cramping
• Generally pain is relieved by defaecating
• Diarrhoea
• Constipation
• Food intolerance
• Can be classified as IBS with diarrhoea, IBS with constipation or mixed IBS
• Might get worse with stress

Question 20

Explain what tests and questions you need to ask so you can diagnose IBS?

Answer 20

it is a diagnosis of exclusion

rule out cancer red flags
test for IBD and coeliacs

tests:
• QFit to check for blood in stool (sign of IBD or cancer)
• FBC (checking for anaemia and signs of a systemic disease)
• ESR AND CRP (for IBD)
• TTG (for coeliacs)

Question 21

What are the red flag referral symptoms for bowel cancer that you need to exclude to diagnose IBS?

Answer 21

• Bleeding – repeated rectal bleeding without an obvious anal cause or any blood mixed with stool
• Bowel habit – persistent (more than 4 weeks) change in bowel habit especially to looser stools (not so interested in constipation)
• Pain – abdominal pain with weight loss
• Iron deficiency anaemia – unexplained iron deficiency anaemia

Question 22

Management of IBS?

Answer 22

• Education and information on lifestyle, physical activity, diet and relaxation
• Diet and nutritional advice – general advice such as reducing caffeine and sugary drinks, reducing high fibre foods and resistant starch (recooked foods have this), if going to recommend the FODMAP diet should refer to a dietician
• Antispasmodic agents e.g. mebeverine hydrochloride, alverine citrate and peppermint oil
• Laxatives can be used and titrated to effect for those with constipation
• Loperamide can be used for acute diarrhoea
• Tricyclics and SSRIs can be used for pain

Question 23

Explain what is meant by a hiatus hernia?

Answer 23

• Hiatus hernia refers to herniation of the abdominal viscera through the oesophageal aperture of the diaphragm
• The vast majority of hiatus hernias involve only the herniation of a part of the gastric cardia through the muscular hiatal aperture of the diaphragm
• Rarely large defects allow other organs through e.g. spleen and pancreas

Question 24

What are the 2 types of hiatus hernia? What is more common?

Answer 24

Most cases are a sliding hiatus hernia where the gastro-oesophageal junction slides up into the thoracic cavity (this is 85-95% of cases)

Para-oesophageal (rolling) hiatus hernia- the junction remains in place but a part of the stomach herniates into the chest next to the oesophagus (5-15% of cases), many are mixed with a sliding component also

Question 25

Presentation and clinical significance of hiatus hernias?

Answer 25

• Clinical significance of a sliding hiatus hernia is increased risk of GORD
• [the concern of para-oesophageal hernias is the potential for obstruction, volvulus or ischaemia]
• Many individuals with sliding hiatus hernia will be totally asymptomatic, others may present with:
- Retrosternal burning sensation ‘heartburn’ especially on bending or lying
- Gastro-oesophageal reflux
- Difficulty in swallowing

Question 26

Diagnosis of hiatus hernia?

Answer 26

• Hiatus hernias are often intermittent so investigations can be unreliable
• CXR – may be seen
• Barium study
• Endoscopy
• Oesophageal manometry when considering surgery

Often found as an incidental finding when you have a CXR for something else

Question 27

Management of hiatus hernia?

Answer 27

• Treatment is not needed in the absence of symptoms except in para-oesophageal hiatus hernia where the potential risks are greater and surgery may even be considered in absence of symptoms
• Lifestyle factors are similar to those with GORD: avoid tight clothing and things that increase abdominal pressure, weight loss, elevate head of bed when sleeping, avoidance of foods that trigger symptoms (fatty foods, spicy foods, caffeine, citrus juices)
• PPIs can help relieve symptoms
• Asymptomatic sliding hernias do not need surgery but surgery is considered in those with very bad symptoms or complications of the condition and also in para-oesophageal hernias as these have greater risk of complications

Question 28

What are haemorrhoids?

Answer 28

• Haemorrhoids are abnormally enlarged vascular mucosal cushions on the anal canal
• These mucosal cushions are normal findings and help to maintain continence but when they become enlarged and start to cause symptoms they are haemorrhoids

Question 29

Explain the difference between internal and external haemorrhoids?

Answer 29

• External haemorrhoids originate below the dentate line and are covered by modified squamous epithelium, which is richly innervated in pain fibres so external haemorrhoids can be painful and itchy, they may be visible on examination
• Internal haemorrhoids arise above the dentate line and are covered by columnar epithelium which have no pain fibres so are therefore not sensitive to touch, temperature or pain (unless they become strangulated)
• Internal and external haemorrhoids can co-exist
• Internal haemorrhoids are classified on their degree of prolapse

Question 30

Risk factors for haemorrhoids?

Answer 30

Pretty common
Proposed risk factors include:
• Constipation
• Prolonged straining and time spent on the toilet
• Chronic diarrhoea
• Increased abdominal pressure e.g. ascites or pregnancy and childbirth
• Obesity
• Heavy lifting
• Chronic cough
• Injury to spinal cord or rectum
• IBD
• Ageing and hereditary factors

Question 31

Presentation of haemorrhoids?

Answer 31

• Can be asymptomatic
• Bright red painless rectal bleeding with defecation – streaks on toilet paper or dripping into toilet – blood may coat stools but should not be mixed with it
• Anal itching and irritation
• Feeling of rectal fullness, discomfort or incomplete evacuation
• Lump at anal verge (if haemorrhoids have prolapsed)
• Soiling due to mucus discharge or impaired continence may be experienced
• Thrombosed haemorrhoids are painful
• On examination internal haemorrhoids are not evident on inspection and difficult to feel on PR
• Asking patient to strain may allow haemorrhoids to become visible
• Although internal haemorrhoids are not palpable on PR it is essential to do one to rule out other pathology

Question 32

Would you expect to be able to see internal haemorrhoids and feel them on PR exam?

Answer 32

no
but you should still do one to rule out other pathology

Question 33

What is the most common symptom of haemorrhoids?

Answer 33

• Bright red painless rectal bleeding with defecation – streaks on toilet paper or dripping into toilet – blood may coat stools but should not be mixed with it

Question 34

Investigations for haemorrhoids?

Answer 34

• A rigid anoscope, protoscope or rectoscope can be used to make diagnose of haemorrhoids, classify their severity and exclude sinister pathology, where the facilities or expertise are not available the person may need referred for assessment

Question 35

Management of haemorrhoids?

Answer 35

• Consider admitting if extremely painful, acutely thrombosed external haemorrhoids or internal haemorrhoids which have prolapsed and become swollen, incarcerate and thrombosed
• Others may need referred for assessment if suspect other pathology or if haemorrhoids and complications too complicated to manage in primary care
• Secondary care treatments involves rubber band ligation, injection sclerotherapy, infrared coagulation, haemorrhoidectomy

General management:
• Ensure stools are easy to pass
• Lifestyle advice on anal hygiene – clean and dry, pat dry – advise against stool withholding and straining
• Manage any other symptoms e.g. simple analgesia, topic haemorrhoid preparations

Question 36

What is an anal fissure? What is the difference between primary and secondary?

Answer 36

• A tear in the sensitive skin-lined lower anal canal, distal to the dentate/pectinate line
• They can be primary or secondary
• Primary: no apparent cause
• Secondary: constipation, inflammatory bowel disease, STI, rectal malignancy
• In primary the exact aetiology is not understood

Question 37

Presentation of an anal fissure?

Answer 37

• Severe pain on defaecation “like passing shards of glass”
• There may be bleeding on passing stools, if present it is seen as bright red blood on the stool or toilet paper
• The fissure can be seen on external examination of the anus
• Usually, it is in the form of a linear split of the mucosa
• Should not attempt DRE in acute as will be very painful but if think there is a need can get patient to return

Question 38

Investigations for anal fissure?

Answer 38

• Diagnosis can usually be made on history and physical examination
• Further investigations only required if there are features of an underlying pathology

Question 39

Primary care management of anal fissure?

Answer 39

• Advise children and adults to take measures to keep stools regular and soft: adequate fluid intake, increase fibre content, consider use of laxative
• Pain relief e.g. paracetamol or ibuprofen, consider GTN ointment which relaxes smooth muscle and reduces anal tone, consider topical anaesthetic e.g. lidocaine for extreme pain
• Refer children with anal fissure that has not healed within 2 weeks, refer adults with ongoing pain which has not resolved within 6-8 weeks, refer adults who do not have symptoms but still have fissure after 12-16 weeks
• Consider earlier referral in elderly as it is less common in this group and there is a higher chance of malignancy

Question 40

Secondary care management of anal fissure?

Answer 40

• Topical diltiazem a CCB may be used
• Nifedipine another CCB may be used
• Botox may be used as a last resort
• Surgery might be done