Gastroenterology for GP Trainees November 2006

Gastroenterology for GP TraineesNovember 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 • An approach to IBS • Poor referrals in anaemia • An approach to constipation • Artificial nutrition awareness

GI Symptoms • Appetite • Acid reflux • Heartburn • Food regurgitation • Dysphagia • Odonophagia • Chest pain • Early satiety • Dyspepsia/indigestion • Bloating • Pain

GI Symptoms contd…… • Rectal bleeding • Change in bowel habit • Diarrhoea • Constipation • Soiling & Incontinence

Upper GI alarm symptoms • Dysphagia • Dyspepsia with • weight loss • anorexia (Early satiety) • < than one year duration and patient  55 • continuous symptoms since onset and patient  55 • FH of upper GI cancer in  2 first degree relatives • surgery for peptic ulcer disease  20 years ago • PA • Anaemia

Lower GI alarm symptoms • Change in bowel habit to looser stool or to increased frequency of defecation persistent for more than six weeks • Rectal bleeding and a persistent change in bowel habit for at least six weeks • Rectal bleeding persistently without anal symptoms in patients  65 who have no external evidence of benign anal disease • Iron deficiency anaemia without an obvious cause and with a Hb of  10g/dl • Palpable abdominal mass • Palpable rectal mass

Dyspepsia & Reflux 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? Metronidazole resistance Occult NSAID use Poor compliance 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

Who to refer for upper GI endoscopy • Urgent: patient of any age presenting with dyspepsia and evidence of chronic GI bleeding, progressive unintentional weight loss, dysphagia, vomiting, IDA (amended Guideline 17) • Urgent: patients > 55 with unexplained and persistent recent onset dyspepsia • No others When endoscopy doesn’t reveal the answer

Barrett’s oesophagus 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

Barrett’s contd.. • Malignant risk (transformation is about 1% per year) • Males • Age > 45 • Segment longer than 8cm • Duration / severity of reflux history (< 1 : 1000) • Duodeno-gastro-oesophageal reflux • Ulcers & strictures • Surveillance every 2 years with quadrantic biopsies every 2cm

Barrett’s contd…. 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

IBS 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.

IBS A functional gastrointestinal disorder is a variable combination of chronic or recurrent gastrointestinal symptoms not explained by structural or biochemical abnormalities (NCCP, NUD, IBS) • 20% of population • 20 - 50% of referrals • 25% of patients post enteric infections and 7% go onto to develop true IBS • not a diagnosis of exclusion, a (+) diagnosis must be made

Characteristic symptoms Continuous or recurrent symptoms for at least 3 months of • abdominal pain or discomfort • pain relieved by defecation • pain with a change in frequency or form of stools

Characteristic symptoms contd. and a varying pattern of defecation with 3 or more of the following • Altered stool frequency • Altered stool form • Altered stool passage (straining, urgency, incomplete evacuation/ sensation of rectal fullness) • Abdominal distension and bloating • Passage of mucus

Alarm symptoms • Constant abdominal pain • Constant diarrhoea • Constant abdominal distension • Nocturnal disturbance • Passage of blood with stool • Weight loss

Associated symptoms Fatigue 96% Back ache 75% Early satiety 73% Nausea 62% Headache 61% Irritable bladder 56% Functional dyspepsia 51%

Differentiation from organic disease • Typical history • No alarm symptoms • FBC & ESR

Management of IBS “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.

Manning criteria for the diagnosis of irritable bowel syndrome* • Pain relieved with defecation • More frequent stools at the onset of pain • Looser stools at the onset of pain • Visible abdominal distention • Passage of mucus • Sensation of incomplete evacuation * The likelihood of IBS is proportional to the number of Manning's criteria that are present.

1. Make a positive diagnosis • This is usually possible form the history alone • A full physical examination is necessary to exclude organic disease • In younger patients a normal haemaglobin and ESR may help to reassure • In patients > 45 with a long history and no recent change a sigmoidoscopy and Barium enema may help to reassure / be necessary

2. Consider the patient’s agenda 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”?

3. Make a management classification To which category does this patient belong? • Bloating and pain predominant • Constipation predominant • Diarrhoea predominant • Anxiety associated • Depression associated

3. Make a management classificationTo which category does this patient belong? • Bloating & pain predominant • Constipation predominant • Diarrhoea predominant • Anxiety associated • Depression associated • Mild • Moderate • Severe

4. Plan a management strategy USE THE APPROPRIATE COMBINATION OF DIET, PSYCHOTHERAPY & DRUGS IN THE CONTEXT OF A GRADED THERAPEUTIC RESPONSE & CONTINUING CARE

Severity based management Mild • Educate • Reassure • Life style • Moderate • symptom monitoring • symptom modification (as detailed in symptom based) • Severe • physician based behavioral techniques • to provide psychosocial support, prevent doctor shopping, reduce maladaptive illness behaviour

Severe contd. • perform diagnostic and therapeutic measures based on objective findings or observation of clinical features over time rather than in response to patient demand • set realistic goals rather than cure • shift responsibility for treatment decisions to the patient by providing therapeutic options • demonstrate a commitment to the patient well being rather than to the treatment of the disease

Symptom based management 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

Symptom based management 2. Consider the use antidiarrhoeals, laxatives, antispasmodics, anxiolytics & antidepressants • Bloating and pain predominant: bulking agents regularly & antispasmodics during episodes of bloating/pain • Constipation predominant: bulking agents • Diarrhoea predominant: low residue diet & anti-diarrhoeals • Anxiety associated: supportive psychotherapy ? anxiolytics • Depression associated: supportive psychotherapy ?anti-D

Symptom based management Supportive psychotherapy, stress management skills Behavioral • Relaxation response training, meditation and autogenic training • Hypnosis • Biofeedback Psychotherapy • insight oriented therapy • cognitive behavioral therapy • group therapy

When & how should referrals be made? Patients should be referred when: • there is concern about the certainty of the diagnosis • when symptoms change to include sinister symptoms (nocturnal disturbance, weight loss, blood pr) • when standard treatment regimens are not helping AND symptoms are interfering with life style

The interview technique • Obtain the history through a nondirective, nonjudgemental, patient centered interview • Conduct a careful examination and cost efficient investigation • Determine the patients understanding of the illness and his/hers concerns (“What do you think is causing your symptoms?”) • Provide a thorough explanation of the disorder • Identify and respond realistically to the patients expectations for improvement (“How do you feel I can be helpful to you?”) • Set consistent limits (“I appreciate how bad the pain is but narcotic medication is not indicated”) • Involve the patient in the treatment (“Let me suggest some treatments you might consider”)

Iron deficiency anaemia • Story

Anaemia, IDA • Iron • TIBC • Ferritin

The issues • All anaemias • No iron studies • Inflammatory conditions (infection & inflammation) • Anaemia of chronic disease

The issues • Anaemia & GI symptoms +/- elevated inflammatory markers • IDA & no GI symptoms in the absence of blood loss elsewhere • N N anaemia & elevated inflammatory markers • NN anaemia & no evidence of iron defficiency & no GI symptoms

Constipation 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 Movicol Fybogel Lactulose Senna Sodium Doccusate 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

DIARRHOEA---Definition Clinical Stools that are either too frequent and / or too liquid The reference Frequency 3 / day to once to 3 per weeks Consistency formed or semiformed Any departure from the patient’s own standard of frequency or fluidity (to include urgency or abdominal discomfort)

Diarrhoea ---------- Definiton Scientific “ A stool weight of > 200g/24hours (or 10g/kg)” Pseudo-diarrhoea (increased frequency of defaecation) Incontinence

Constipation • 2 or fewer bowel movements per week • Straining • Hard lumpy stool • Sensation of incomplete evacuation on at least 25% of occasions for 3 months $400 million spent annually in US on laxatives

CONSTIPATION 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

Constipation --- Define symptoms • Frequency • Character of stool • Straining on defecation (more accurate than frequency) • Abdominal bloating • Incomplete rectal evacuation • Assisted defecation • Faecal soiling • Incontinence of urine or faeces • Relationship of abdominal or rectal pain to defectaion • History of hemorrhoids or other anorectal disease • History of laxative use prior and current • Diet

Constipation -- Examination • Psychological / Psychiatric • Systemic disease (Ca; Thyroid) • Perianal & rectal

Constipation --- who to refer • Weight loss • Alternating symptoms in patients > 45 • Unexplained new onset symptoms in patients > 45 • Metabolic • Rectal bleeding • Clear evidence on history and examination of pelvic floor dysfunction • Anaemia • Fail to respond to usual programme for simple constipation (if compliant <1% will fail)

Constipation ------Those who are referred • History • Contrast studies • Transit studies • Luminal studies

Anorectal and pelvic floor studies • Baloon expulsion tests • Defecation proctography • Anorectal manometry • Perineometry • Pudendal nerve terminal motor latencies • Sphincter puborectalis electromyogram • Measurement of rectoanal angle • Ultrasonagraphy • Scintigraphic epulsion of artificial stool • Rectal sensation (mechanical & electrical) • Spinal evoked potentials by rectal stimulation • Cerebral evoked potentials by rectal stimulation

Gastroenterology for GP Trainees November 2006