Gastroenterology for GP Trainees November 2006. K TEAHON. Topics. GI Symptoms Endoscopy, Dyspepsia & Barrett’s oesophagus Iron deficiency anaemia Irritable bowel syndrome Constipation Nutrition New “things”. AIM. GI alarm symptoms The use of upper GI endoscopy referrals
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A 50 year old male patient attends for the results of his investigations. He presented 3 weeks ago with a 6 month history of intermittent epigastric pain, relieved easily with antacids and which he himself attributed to a combination of stress at work and a weight gain of 1 stone in the previous 2 years. His helicobacter serology is (+).
How would you manage this patient?
1. What test would you use to confirm erradication of helicobacter?
2. What is the commonest cause of failure of erradication therapy?
Occult NSAID use
Cigarette and alcohol co-use
3. Answer True or False
Early gastric cancer often presents with dyspepsia
Reflux is a frequent presenting complaint in oesophageal carcinoma
Dysphagia responding to PPIs does not require follow-up endoscopy
When endoscopy doesn’t reveal the answer
An oesophagus in which any portion of the normal squamous lining has been replaced by a metaplastic columnar epithelium which is visible macroscopically
Incidence is about 1%
12% in those with GORD
36% in those with oes’itis
There is no evidence that endoscopic screening of heartburn patients to detect cancer or Barrett’s is worthwhile and benefit is so unlikely that endoscopy with this intent cannot be recommended
A 35 year old female school teacher presents with persistent GI symptoms following an episode of salmonella enteritis 3 months ago. She has recurrent abdominal pain and bloating worse during episodes of frequent watery diarrhoea and she has a recurrent persistent urge to defecate although “there is nothing there”. Her symptoms are troublesome although she has not missed work. Physical examination is normal.
A 30 year old shop assistant has been attending for over a year with symptoms which you have diagnosed as those of irritable bowel. She says her recurrent abdominal pain is now intolerable and she has missed work three times in the past 4 months. Up until now you have managed her symptoms with life style and diet advice.
You review her history and examination and find no alarm symptoms / signs.
A 45 year old female ex-school teacher has been attending you and your colleagues for management of a diagnosis IBS. She had been diagnosed 5 years previously at which time she had multiple normal GI investigations at hospital consultations. She transferred to your practice one year ago. She has tried all of the usual remedies. Her symptoms continue unabated especially and are so severe that she has recently lost her job because of absence.
A functional gastrointestinal disorder is a variable combination of chronic or recurrent gastrointestinal symptoms not explained by structural or biochemical abnormalities (NCCP, NUD, IBS)
Continuous or recurrent symptoms for at least 3 months of
and a varying pattern of defecation with 3 or more of the following
Back ache 75%
Early satiety 73%
Irritable bladder 56%
Functional dyspepsia 51%
“It is concluded that not a single study offers convincing evidence that any therapy is effective in treating the IBS symptom complex”
Rome III diagnostic criteria* for IBS
Recurrent abdominal pain or discomfort at least 3 days per month in the last 3 months associated with 2 or more of the following
(1) Improvement with defecatation
(2) Onset associated with a change in frequency of stool
(3) Onset associated with a change in form (appearance) of stool
* Criteria fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis.Discomfort means an uncomfortable sensation not described as pain.
* The likelihood of IBS is proportional to the number of Manning's criteria that are present.
A full psychological, social and family history inquiry is necessary
Try to get an answer to the question “Why has this patient presented at this time”?
To which category does this patient belong?
USE THE APPROPRIATE COMBINATION OF DIET, PSYCHOTHERAPY & DRUGS IN THE CONTEXT OF A GRADED THERAPEUTIC RESPONSE & CONTINUING CARE
1.Review dietary history and consider limitation of caffeine and alcohol
Bloating and pain predominant: alter fiber
Constipation predominant: high fiber
Diarrhoea predominant: low residue diet
2. Consider the use antidiarrhoeals, laxatives, antispasmodics, anxiolytics & antidepressants
Supportive psychotherapy, stress management skills
Patients should be referred when:
A 35 year old lady attends for her review appointment.
She presented 3 months ago with a life long history of constipation--- bowel frequency of 1 per week but only if she used laxatives, nil else in history, normal physical examination. There was a small amount of soft stool in the rectum and some peri-anal soiling.
You suggested an increase in natural fibre to 30g/d, increased fluid intake and discontinuation of the laxatives.
She now reports no improvement in her symptoms.
How would you continue her management ?
Please list the following laxatives in order of cost
Please answer true or false
Natural bran is the best first choice laxative in frail elderly
Psychosexual problems are common in patients with simple constipation
Weight loss is common in severe simple constipation
Stools that are either too frequent and / or too liquid
Frequency 3 / day to once to 3 per weeks
formed or semiformed
Any departure from the patient’s own standard of frequency or fluidity (to include urgency or abdominal discomfort)
“ A stool weight of > 200g/24hours (or 10g/kg)”
Pseudo-diarrhoea (increased frequency of defaecation)
on at least 25% of occasions for 3 months
$400 million spent annually in US on laxatives
No physical obstruction Physical obstruction
Tumour IBD Ischaemia Diverticular D Congential
No gut dilatation Gut dilatation
Hirschsprungs Ideopathic megarectum / megacolon Chronic pseudo-obstruction
Simple Pregnancy Elderly IBS Severe Ideopathic Constipation
account for about 90% of patients presenting with constipation
Ideopathic slow transit Normal transit defecatory disorder Anismus Internal anal sphincter myopathy
A multimodality approach aimed at teaching patients to defecate effectively. Dietary manipulation, stool bulkers, biofeedback, baloon pull through and defecation stimulation are all used.
The biofeedback element involves providing the patient with a visual display of their pelvic floor pressure or electrical activity while being taught to coordinate appropriately
You are called for a first visit to your local nursing home to review the care of a recently discharged patient. The patient is female, 89 years of age, has recently suffered bilateral stroke, has global aphasia and no swallow reflex. She is being fed through a PEG tube. You are asked to review because of sepsis at the PEG site. During your visit the nurses express concern that the patients son is angry that “his mother is being kept alive in this way” and is asking to see you.
How would you deal with the sepsis?
How would you deal with the sons concern?
1. List your clinical indications for sip / supplemental feeds
3. What are your concerns in replacing a PEG?
4. What are your concerns in replacing a jejunostomy tube?
5. What is the MUST tool
Using the above three case histories please outline your management policy for IBS under the following headings:
1. First step in management
2. Your management classification of IBS subtypes
3. Most important interview skills
4. Your referral criteria