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

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Presentation on theme: "Common General Gastroenterological problems Dr Laksh Ayaru Consultant Gastroenterologist Charing Cross and Hammersmith Hospitals Hospital of St John and."— Presentation transcript:

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 recent cold and cough Routine blood tests Hb 11.5, MCV 60 WCC 5.0, plt 250 Serum Iron low

4 Question Treat with oral Iron OGD OGD and Colonoscopy Other

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

6 Anaemias NormochromicMicrocyticMacrocytic

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 Serum FeTransferrin Saturation Ferritin Iron deficiencylow low (normal) Anemia of chronic diseaselow normal Thalassaemia traitnormal

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 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 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 NAFLD Hepatitis B,C Hepatitis B,CHaemochromatosis drugs (over the counter, prescribed) drugs (over the counter, prescribed) Autoimmune hepatitis 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

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

30 NAFLD score (http://nafldscore. com) AgeBMIHyperglycemiaPlateletsAlbumin AST/ALT ratio Metanalysis13 studies AUROC 0.85 advanced fibrosis (AF) < % sensitivity and 60% specificity to exclude AF >0.676 sensitivity and 97% specificity to detect AF

31 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

32 Treatment No drugs specifically licensed for NASH RCTs support specific insulin sensitisers in selected patient groups 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

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

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

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

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

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

38 Diagnosis Positive AMA PBC Treatment with URSO

39 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

40 Diagnosis? dyspepsia

41 Question Test and treat for H Pylori PPI Direct for OGD Other tests

42 Question Test and treat for H Pylori PPI Direct for OGD Other tests

43 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

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

45 Upper GI endoscopy Normal Antral biopsies negative for H Pylori

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

47 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

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

49 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

50 H Pylori eradication Possible small benefit NNT 17 Cochrane review 2003 and 2006

51 Domperidone Chinese study n=85 Double blind placebo controlled RCT Improvement in nocturnal bile reflux and symptoms

52 Tegaserod Two RCTs Inconsistent benefit Enhanced gastric accomodation Improvement in post prandial pain No serious adverse events Cardiovascular side effects in chronic constipation studies Vakil et al 2008 American Journal of Gastroenterology

53 Summary Fe def anemia check ferritin Abnormal LFT NAFLD common cause Non-ulcer dyspepsia explanation that one can offer a diagnosis and prognosis explanation that one can offer a diagnosis and prognosis


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