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 Discuss evidence/ guidelines

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

Question 1 Treat with oral Iron OGD OGD and Colonoscopy Other

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

Anaemias Normochromic Microcytic Macrocytic

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

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

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

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

Iron absorption

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

Iron studies in hypochromic microcytic anaemias Serum Fe Transferrin Saturation Ferritin Iron deficiency low low (normal) Anemia of chronic disease normal Thalassaemia trait

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

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

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

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

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

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

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

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

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

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

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

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

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

Diagnosis Typical patient 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

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

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

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

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

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

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

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

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

Diagnosis Positive AMA PBC Treatment with URSO

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

Diagnosis? dyspepsia

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

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

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

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

Upper GI endoscopy Normal Antral biopsies negative for H Pylori

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

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

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

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

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

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

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

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