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Common General Gastroenterological problems

Common General Gastroenterological problems. Dr Laksh Ayaru Consultant Gastroenterologist Charing Cross and Hammersmith Hospitals Hospital of St John and St Elizabeth Highgate Hospital. Outline. 5 clinical cases-common presentations to primary and secondary care Discuss clinical approach

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Common General Gastroenterological problems

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  1. Common General Gastroenterological problems Dr Laksh Ayaru Consultant Gastroenterologist Charing Cross and Hammersmith Hospitals Hospital of St John and St Elizabeth Highgate Hospital

  2. Outline 5 clinical cases-common presentations to primary and secondary care Discuss clinical approach Discuss evidence/ guidelines

  3. Case 1 • 30 yr old male • recent cold and cough • Routine blood tests Hb 11.5, MCV 60 WCC 5.0, plt 250 • Serum Iron low

  4. Question 1 • Treat with oral Iron • OGD • OGD and Colonoscopy • Other

  5. Question 1 • Treat with oral Iron • OGD • OGD and Colonoscopy • Other-haematinics

  6. Anaemias • Normochromic • Microcytic • Macrocytic

  7. Microcytic anaemia-differential • Haemoglobinopathy • Iron deficiency anaemia • Anaemia of chronic disease • Sideroblastic anaemia

  8. Investigations • Repeat Iron studies normal (serum Iron, transferrin, ferrtitin) • Hb electrophoresis abnormal • Diagnosis-thalassaemia trait

  9. Case 2 • 50 year old male • Short of breath and lethargic • Hb 8.0 mcv 70 WCC 7.0 Plt 239

  10. Question 2 Which single blood test do you want to order? • Ferritin

  11. Iron absorption

  12. Ferritin • Most specific test for iron deficiency • Not 100% sensitive as can be raised to normal levels in inflammatory diseases and malignancy • Always check ferritin before starting oral iron as will cloud picture

  13. Iron studies in hypochromic microcytic anaemias

  14. Iron deficiency anaemia • 2-5% of adult men and post menopausal women

  15. Investigations (BSG guidelines 2011) • Upper and lower GI investigations should be considered in all postmenopausal female and all male patients unless there is a history of significant overt non-GI blood loss • All patients should be screened for coeliac disease • Urine testing for blood is important in the examination of patients with IDA

  16. If oesophagogastroduodenoscopy (OGD) is performed as the initial GI investigation, only the presence of advanced gastric cancer or coeliac disease should deter lower GI investigation • In patients aged >50 or with marked anaemia or a significant family history of colorectal carcinoma, lower GI investigation should still be considered even if coeliac disease is found

  17. Further direct visualisation of the small bowel is not necessary unless there are symptoms suggestive of small bowel disease, or if the haemoglobin cannot be restored or maintained with iron therapy

  18. Who not to refer for scope • Premenopausal woman, no gi symptoms and no FHx of colorectal cancer (check for coeliac • In patients <50 with iron deficiency without anaemia

  19. Case 3 • 35 yr old female • Type II diabetic on metformin • Asymptomatic • Alcohol 14 u/week • Normal examination • LFT- alt 72, ast 53, GGT 65, ALP67, bil 7

  20. Question 4-Diagnosis? • Hepatitis C • Hepatitis B • Fatty liver disease • Drugs

  21. Question 4-Diagnosis? • Hepatitis C • Hepatitis B • Fatty liver disease • Drugs

  22. Hepatocyte location of liver enzymes Goessling et al 2005 Clin Gasto hepatol

  23. Abnormal LFTs • Increased liver tests in 1-4% of asymptomatic people • Mild AST/ALT rise < 5 x ULN

  24. Transaminitis • NAFLD • Hepatitis B,C • Haemochromatosis • drugs (over the counter, prescribed) • Autoimmune hepatitis • Wilsons (rare) • Alpha 1 antri-trypsin

  25. Liver tests • Hep B S Ag, Hep C antibody • Anti Sm, ANA, immunoglobulins • Ferritin, transferrin saturation • Cu, Caerluoplasmin • Alpha 1 antitrypsin • Tissue transglutaminase • Liver ultrasound

  26. Non alcoholic fatty liver disease (NAFLD) • Fatty infiltration, fat and inflammation (NASH), cirrhosis • Risk of liver cancer/liver related death and increased CVS risk • Hepatic manifestation of metabolic syndrome • 94% of BMI>30 and 40-70% of Type 2 diabetics

  27. Diagnosis • Typical patient • raised LFT (alt>ast) • Liver u/s-sensitivity is limited if <33% of hepatocytessteatotic • Liver biopsy gold standard way to differentiate steatosis from NASH

  28. NAFLD score (http://nafldscore. com) • Age • BMI • Hyperglycemia • Platelets • Albumin • AST/ALT ratio • Metanalysis13 studies AUROC 0.85 advanced fibrosis (AF) • <-1.455 90% sensitivity and 60% specificity to exclude AF • >0.676 sensitivity and 97% specificity to detect AF

  29. Prognosis • Steatosis –no increased risk of end sage liver disease • 25-33% NASH have advanced fibrosis at diagnosis • 5% NASH progress to end stage liver disease Risk factors; >45, diabetic, obesity, hypertension

  30. Treatment • No drugs specifically licensed for NASH • RCTs support specific insulin sensitisers in selected patient groups • Mainstay –lifestyle interventions to support weight loss >7% weight reduction sustained over 48 weeks assoc with significant improvement in histological severity in NASH

  31. Case 4 • 30 year old female • Asymptomatic • Recent UTI • Routine bloods-ALP 200, alt 34 bilirubin 15

  32. Question 5- Next management step • Request hepatitis serology • Ultrasound abdomen • Request other LFTs • Repeat ALP at later date

  33. Question 5- Next management step • Request hepatitis serology • Ultrasound abdomen • Request other LFTs • Repeat ALP at later date

  34. ALP • Repeat blood tests when clear of infection • Raised ALP liver bone placenta • Check GGT to determine if liver in origin

  35. Differential of cholestatic LFTs • PBC • PSC • drugs • gallstones • malignancy (older age groups) • heart failure (older age groups)

  36. Diagnosis • Positive AMA • PBC • Treatment with URSO

  37. Case 5 • 38 year old lady • 1 yr history of epigastric pain and bloating • Intermittent on most days • No radiation or relation to food • No nsaids • No alarm symptoms

  38. Diagnosis? • dyspepsia

  39. Question 6 • Test and treat for H Pylori • PPI • Direct for OGD • Other tests

  40. Question 6 • Test and treat for H Pylori • PPI • Direct for OGD • Other tests

  41. Nice guidelines 2004 • Recommended test and treat • Remember improvement could be 1) PPI 2) placebo 3) spontaneous resolution Gastric ulcer Oesophagitis H Pylori gastritis Normal

  42. Test and Treat may not be most cost effective Speigel et al 2002 Gastroenterology

  43. Upper GI endoscopy • Normal • Antral biopsies negative for H Pylori

  44. Diagnosis? • Non-ulcer dyspepsia-most likely • Gastro-oesophageal reflux disease-less likely • Other pathology-eg pancreatic disease, gallstones-less common

  45. What is non-ulcer dyspepsia? • Heterogenous disorder • 40 % of population • Epigastric pain syndrome (EPS) • Post prandial distress syndrome (PPD) • Dysregulation of brain gut axis Tack et al 2004 Gastroenterology

  46. Treatment of non-ulcer dyspepsia • Often results disappointing in contrast to ulcer disease • Explanation, ‘not imagining symptoms’

  47. PPIs • Meta-analysis of 7 studies (n=3725) • PPIs were more effective than placebo for reducing symptoms of dyspepsia (RR10.3%, NNT =14) • Better only in ulcer or reflux like symptoms not dysmotility like Hong Wang et al 2007 Clin Gastro Hep

  48. H Pylori eradication • Possible small benefit • NNT 17 Cochrane review 2003 and 2006

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