GP Student Handbook GI Common Presentations Flashcards
Define dyspepsia and its presentation
Upper abdominal pain/discomfort
Described as: Burning sensation, heaviness, ache often related to eating.
Associated with nausea, abdominal fullness and belching
What is GORD?
Gastro-oesophageal reflex disease
Endoscopically determined oesophagitis or endoscopy-negative reflux disease
What is peptic ulcer disease
Occurrence of ulceration of either the mucosa of the stomach (gastric ulcer) or of the duodenum (duodenal ulcer)
3 most common causes of dyspepsia?
GORD
Peptic ulcer disease
Non-ulcer dyspepsia (dyspepsia with normal endoscopy)
Other: Hiatus herna, barrett’s oesophagus, gastric/oesophageal cancer, drugs, smoking, alcohol
Red flags associated with dyspepsia?
Haematemesis Weight loss Dysphagia Persistent vomiting Malaena On examination: Epigastric mass, low ferritin
Investigations prompted by presentation with dyspepsia
- Blood tests – FBC, Ferritin (Red flag: iron deficiency anaemia)
- Helicobacter Pylori – In Lothian this is a stool antigen test, other health boards use breath tests and/or serology
- Endoscopy (see below for indications)
What is an alginate?
Alginic acid derivatives, or alginates, treat GORD by creating a mechanical barrier that displaces the postprandial acid pocket. In the presence of gastric acid, they precipitate into a gel and form a raft that localizes to the acid pocket in the proximal stomach.
e.g. Peptac and Gaviscon
Management of dyspepsia with no red flags?
- Stop NSAIDs, consider other medications that may be contributing/causing symptoms
- Reduce alcohol/smoking
- Trial of medication if above measures not indicated/not working
- Alginates e.g. Peptac/Gaviscon
- Histamine 2 Receptor Antagonist (H2RA) e.g. Ranitidine
- Proton Pump Inhibitor (PPI) e.g. Lansoprazole
Indication for endoscopy in dypepsia presentation
- Red Flags present – urgent endoscopy
- If H. pylori negative and no response to medication, consider endoscopy/alternative diagnoses
- If >55 with persistent or recurrent dyspepsia with NO red flags, consider routine referral for endoscopy
H pylori test consideration
It is important to bear in mind that H Pylori testing is inaccurate if a patient has been taking a PPI, so this must be stopped at least 3 weeks prior to undergoing the test.
What are the limits of normal frequency of bowel movement?
3 movements per day-week
Clinical definition of diarrhoea
3+ loose stools per day
What is acute diarrhoea?
The abrupt onset of 3+ loose stools per day for less than 14 days
What are the infective causes of acute diarrhoea?
Often accompanied by fever, vomiting and abdo pain. Usually lasts about a week
- Rotavirus
- Norovirus (winter vomitng bug)
- Clostridium difficile
- Food poisoning
- Traveller’s diarrhoea
Presentation of acute diarrhoea due to rotavirus
Rotavirus is the commonest cause of diarrhoea in young children.
It presents with severe watery diarrhoea, vomiting, fever and abdominal pain, and typically lasts for about a week.
Routine vaccination gives partial protection.
Presentation of acute diarrhoea due to norovirus
Norovirus affects all ages and causes outbreaks in the winter months.
It presents with watery diarrhoea, vomiting, fever and abdominal pain.
It is very contagious and spreads quickly in residential settings such as hospitals and care homes.
Presentation of acute diarrhoea due to c. diff
Clostridium difficile is uncommon in general practice – it generally affects hospital patients, especially those taking antibiotics.
Presentation of acute diarrhoea due to food-poisoning
It can be caused by toxins produced by bacteria (such as Bacillus cereus which is associated with rice) or by the ingestion of viruses (norovirus) or bacteria (E coli, salmonella, campylobacter). The symptoms of toxin-mediated food poisoning occur within hours of ingesting contaminated food, whereas viral and bacterial food-poisoning take longer to present.
Presentation of acute diarrhoea due to travellers diarrhoea
Diarrhoea is common in patients returning from abroad and is mainly caused by ingestion of food or water contaminated by bacteria (E coli, salmonella, shigella); by viruses such as rotavirus; or by protozoa (giardia lamblia, entamoeba histolytica, cryptosporidium).
Non-infective causes of acute diarrhoea
Drugs e.g. antibiotics, metformin, ferrous sulphate and laxatives
Start of chronic diarrhoea
Acute diarrhoea management
- Decide whether the patient is at risk of dehydration. If the patient is well and not at risk, advise them to DRINK plenty and REST.
- If the patient is at risk of DEHYDRATION, they should be admitted to HOSPITAL.
- If a stool sample result shows pathogenic BACTERIA, treat with ANTIBIOTICS if recommended by microbiology.
- It may be appropriate to contact the local HEALTH PROTECTION UNIT if (i) there is a suspicion of a public health hazard (for example diarrhoea in food handlers or residents of a care home) or (ii) isolating the organism may help pinpoint the source of a community outbreak.
With chronic diarrhoea what other symptoms should be assessed for?
Pain Fatigue Unintended weight loss Blood in stoll FH of bowel condition
Exam:
- Abdo for Hepatomegaly and masses
- Rectal for masses and impacted faeces (overflow)
7 conditions in which chronic diarrhoea can occur?
Coeliac disease Inflammatory (Crohns or UC) Diverticulitis Chronic infection Anxiety Overflow diarrhoea Colonic carcinoma
Define impaction
I.e. faecal loading
Retention of faeces to the extent that spontaneous evacuation is unlikely
Usually palpable on abdo exam and maybe on rectal exam
