1. 3.13 Digestive Health Session One: Lower GI Session Two: Upper GI Minor Topic: Screening Dr Richard de Ferrars Updated 1 st May 2016

2. ST1/2 Half Day Programme Programme Aims: 1. Curriculum coverage ◦ Cover key clinical guidelines & conditions over 2 years 2. Being a GP ◦ In a way that develops awareness of GP elements 3. Peer Group ◦ Meet the other GPSTs 4. Broadening Your Thinking ◦ Programme content, minor topics…

3. ST1/2 Half Day Programme Year 1Year 2 Major TopicMinor TopicMajor TopicMinor Topic AugustInduction & AKT SeptemberEye Problems Portfolio ENT & Facial Portfolio OctoberCardiovascular Ethics Cardiovascular Professionalism NovemberCommunication Skills Day DecemberDermatology ESR Preparation Drugs & Alcohol ESR Preparation JanuaryMental Health Professionalism Respiratory Changing behaviour FebruaryWomen’s & Sex Health Contraception Metabolic & Endocrine Investigations MarchMen’s Health Cancer Neurology Learning Disability AprilPaediatrics Statistics Paediatrics EBM/ Critical appraisal MayDigestive Screening Digestive Genetics JuneCommunication Skills Day JulyRheumatology & MSK Complementary Rx Elderly Care Driving & DVLA

4. Session Overview Digestive Health (3.13) – Lower GI Key Knowledge Key curriculum content Key guidelines & pathways AKT Topics Clinical Content Irritable bowel syndrome Colorectal cancer & perianal problems Nutrition – fibre (constipation) Food allergies Minor Topic -Screening

5. AKT Question 1 A 29 year old female presents with symptoms that fulfil the diagnostic criteria for irritable bowel syndrome Which ONE of the following tests is not recommended to confirm the diagnosis? A. CRP (C-reactive protein) B. FBC (Full blood count) C. TFT (Thyroid function tests) D. Total IgA E. tTG IgA (tissue transglutimase IgA)

6. AKT Question 2 A 53 year old male presents with a 5-week history of painless rectal bleeding each time that he opens his bowels. His stools are normal and his bowel habit is unchanged. Abdominal examination is normal. Digital rectal examination is normal. What is the next most appropriate management option? Select ONE answer only. A. FOB testing B. FBC (Full blood count) & Ferritin C. GP review of symptoms in 2 weeks D. Refer for a colorectal appointment within 2 weeks E. Abdominal CT scan

7. AKT Question 3 A new screening test has been developed to diagnose bladder cancer by machine analysis of urine for abnormal cells. These results are from a study where all patients had a urine sample tested and also diagnostic cystoscopy. Total number of patients in the study1000 Number of samples that tested positive28 Number of true positives (confirmed by cystoscopy)4 Number of samples that tested negative972 Number of false negatives (confirmed by cystoscopy)10 Which ONE of the following statements about this data is FALSE? A.The negative predictive value of the test is 962/972 (99%) B.The positive predictive value of the test is 4/28 (14%) C.The sensitivity of the test is 4/14 (29%) D.The specificity of the test is 24/986 (2.5%) E.There were 24 type 1 errors

8. AKT Question 4 You see a patient with advanced lung cancer. His pain control is poor and you consider starting him on an opioid-based analgesic. He is worried about becoming constipated as he has a previous history of severe constipation. What is the SINGLE MOST appropriate management to prevent constipation in this patient? Select ONE option only. A. Prescribe senna at the time of the first opioid prescription B. Prescribe macrogols at the time of the first opioid prescription C. Prescribe a phosphate enema in case he gets constipated D. Use only non-opioid analgesia E. Wait until constipation is established then treat

9. AKT Question 5 You are called to the treatment room to see a 17-year-old boy who has become unwell after receiving a vaccination. He has a generalised blotchy rash and is wheezing. You suspect anaphylaxis. His observations have been noted by the nurse: Temp 37.4°CBP 90/60 mmHgPulse 128 per minute Respiratory rate 28 breaths/minuteOxygen sats 95% (on air) What is the SINGLE MOST appropriate initial treatment? Select ONE option only. A. Adrenaline 0.5 ml 1:1000 intramuscularly B. Adrenaline 1 ml 1:1000 intramuscularly C. Chlorphenamine 10 mg intramuscularly D. Chlorphenamine 10 mg orally E. Hydrocortisone 200 mg intramuscularly

11. Key Knowledge Guidelines & Pathways NICE -Cancer referral (06/15) IBS (02/08) Coeliac disease (09/15) Constipation (05/10) GORD (09/14) SIGN -Hepatitis C Other -Rome criteria for IBS. AKT Exam Feedback Irritable Bowel Syndrome Coeliac disease Nutrition Key Curriculum Content Irritable Bowel Syndrome Dyspepsia & GORD Colorectal cancer & screening Viral hepatitis Being a GP? Holistic approach Targeted history examination, tests Appropriate use of resources Probability & prevalence Shared management

12. Key Knowledge - Learning Resources AKT Feedback Irritable Bowel SyndromeEKU 16NICE Coeliac diseaseEKU 12NICE NutritionThis programme? Curriculum Content Irritable Bowel SyndromeEKU 16NICE Dyspepsia & GORDEKU 15NICE Colorectal cancer & screeningNHS BCSPNHS BCSP Viral hepatitisEKU 15SIGNRCGP OLERCGP OLE

13. RCGP - AKT Content Guide Symptoms and signs Abdominal masses and swellings including organ enlargement such as splenomegaly and hepatomegaly Abdominal pain including differential from non ‐ gastrointestinal causes e.g. gynaecological or urological Ascites, chest pain, constipation, diarrhoea, change in bowel habit, tenesmus, faecal incontinence, cough, disturbance of smell and taste, dyspepsia, heartburn, dysphagia, haematemesis, hiccups, jaundice, mouth ulceration, leukoplakia, salivary problems, nausea & vomiting including non ‐ gastrointestinal causes, obesity, weight gain, anorexia & weight loss, pruritus, rectal bleeding Investigations Endoscopy, ultrasound and other scans Interpretation of tests - Helicobacter pylori infection, coeliac disease, stool culture results, faecal calprotectin Tests of liver function including interpretation of immunological results, markers of malignancy e.g. CEA and AFP Screening programmes for colorectal cancer such as occult blood testing, sigmoidoscopy, colonoscopy Secondary care interventions - endoscopy, laparoscopic surgery, ERCP, contrast and CT scans Work through CKS (management), InnovAiT, Patientplus (patient.co.uk), GP Notebook

14. RCGP - AKT Content Guide Constipation - primary & secondary to other diseases such as hypothyroidism, drug ‐ induced, hypercalcaemia Diarrhoea - toxins (C. difficile and E coli), bacterial causes (salmonella, campylobacter, amoebic dysentery), viral causes (rotavirus, norovirus) and parasitic causes such as Giardia lamblia Inflammatory bowel disease such as Crohn’s disease, ulcerative colitis Malabsorption - coeliac disease, lactose intolerance, pancreatic insufficiency (chronic pancreatitis, cystic fibrosis, bacterial overgrowth) Rectal problems including anal fissure, haemorrhoids, prolapse, polyps, malignancy Gastrointestinal malignancies including oesophageal, gastric, pancreatic, colorectal, carcinoid, lymphoma Nutritional problems such as vitamin and mineral deficiencies, supplementary nutrition such as dietary, PEG and parenteral feeding Complications and management of stomas Disorders of weight; obesity and weight loss including non ‐ nutritional causes such as thyroid disease and other endocrine conditions Hernias – inguinal, femoral, diaphragmatic, hiatus, incisional Work through CKS (management), InnovAiT, Patientplus (patient.co.uk), GP Notebook

16. InnovAiT Learning Resources TopicInnovAiT Article Acute abdominal painIVT4;4:204 IVT6;6:355 GI bleeding, PR bleedingIVT2;5:300 IVT7;1:36 IVT7;7:398 Dysphagia & GORDIVT9;3:99 Dyspepsia & ulcer-diseaseIVT1;9:608 IVT2;8:486 IVT4;4:218 IVT7;7:389 IVT7;7:404 Jaundice, liver disease & gallstonesIVT3;3:137 IVT2;8:479 IVT2;3:140 IVT6;12:790 IVT8;12:752 IVT9;1:11 Pancreatic diseaseIVT2;11:662 IVT3;3:166 Gastroenteritis & diarrhoeaIVT2;2:80 IVT4;4:212 Coeliac diseaseIVT2;8:471 IVT9;1:5 Irritable bowel syndromeIVT1;9:611 Constipation & obstructionIVT3;5:290 IVT3;5:279 Faecal incontinenceIVT9;1:18 Inflammatory bowel diseaseIVT1;9:615 IVT7;1:43 Diverticular DiseaseIVT4;4:223 Colorectal cancerIVT7;11:675 Abdominal herniaIVT7;11:668 Perianal disease – piles, pain & bleeding

17. Case Study 1 – Jess West 29F I hope that you can help because I am getting so fed up with the way that my bowels are running my life for me… I get so much trouble with cramps & diarrhoea that I am always looking for the nearest toilet. Probability & Prevalence: What diagnoses are you considering? Holistic Approach (Impact): What other aspects of her problems spring to mind?

18. Case Study 1 – Jess West 29F I hope that you can help because I am getting so fed up with the way that my bowels are running my life for me… I get so much trouble with cramps & diarrhoea that I am always looking for the nearest toilet. Probability & Prevalence: What diagnoses are you considering? Irritable bowel syndrome Coeliac disease Inflammatory bowel disease.

19. Case Study 1 – Jess West 29F I hope that you can help because I am getting so fed up with the way that my bowels are running my life for me… I get so much trouble with cramps & diarrhoea that I am always looking for the nearest toilet. Holistic Approach (Impact): What other aspects of her problems spring to mind? Stress & anxietyAlcohol Work & impactFamily history Home & impact.

20. Case Study 1 – Jess West 29F She explains… Occasional for years. Several months, 2-3 loose stools most days, cramps, fear won’t make toilet. Cramp eases after passage of stool Office work 20h pw, children 7 and 5. Husband works long hours. Occasional alcohol Targeted history: What other areas spring to mind? Bleeding etcBlood once 2m ago after hard stool, no mucus or slime Diarrhoea at night (unlikely to be IBS) General healthTires easily but busy. Appetite & weight OK Family historyNo FH bowel disease Stress/ anxietyLifestyle stress but not enough to reach for GAD7.

21. Case Study 1 – Jess West 29F Long history of episodes of abdominal discomfort eased after passage of loose stool. Single episode of bleeding a few months ago. Busy life & a bit stressed. Otherwise well, no FH of note. Targeted examination: What examination would you perform? Pulse, anaemia Abdomen – massesRectal examination? SIGN126 - GPs should perform an abdominal and rectal examination on all patients with symptoms indicative of colorectal cancer. A positive finding should expedite referral, but a negative rectal examination should not rule out the need to refer.

22. Case Study 1 – Jess West 29F Making a diagnosis - has she got IBS? NICE Definition Abdominal pain/ discomfort that is relieved by defaecation or associated with altered stool form or frequency AND… two from 1.Altered stool passage (straining, urgency, incomplete evacuation) 2.Abdominal bloating 3.Symptoms made worse by eating 4.Passage of mucus Rome III Criteria Recurrent abdominal pain or discomfort at least 3 days/month in the last 3 months associated with two or more of the following: 1.Improvement with defecation 2.Onset associated with a change in frequency of stool 3.Onset associated with a change in form (appearance) of stool.

23. Case Study 1 – Jess West 29F Targeted tests - does she need any more tests? She should have: FBCESRCRP Coeliac (Total IgA and tTG) She should NOT have: TFT Faecal mcs, faecal parasites Hydrogen breath tests USS, sigmoidoscopy, colonoscopy, barium enema What about faecal calprotectin? Possibly – but probably not.

24. AKT Question 1 A 29 year old female presents with symptoms that fulfil the diagnostic criteria for irritable bowel syndrome Which ONE of the following tests is not recommended to confirm the diagnosis? A. CRP (C-reactive protein) B. FBC (Full blood count) C. TFT (Thyroid function tests) D. Total IgA E. tTG IgA (tissue transglutimase IgA)

25. AKT Question 1 A 29 year old female presents with symptoms that fulfil the diagnostic criteria for irritable bowel syndrome Which ONE of the following tests is not recommended to confirm the diagnosis? A. CRP (C-reactive protein) B. FBC (Full blood count) C. TFT (Thyroid function tests) D. Total IgA E. tTG IgA (tissue transglutimase IgA)

26. Case Study 1 – Jess West 29F Shared management – what are the options? Reassure Advice & information Prescribe Refer Investigate Observe & review RAPRIORAPRIO Explain Exercise, fluids, diet A few options Dietitian? Gastro? As discussed Must follow-up.

27. Case Study 1 – Jess West 29F Shared management – what are the options? Dietary advice in IBS Old advice – just eats lots of fibre Newer advice – more complex: Target fibre intake 30g per day (Same as for all. More later) Reduce insoluble fibre (many grains) If needed, increase soluble fibre (ispaghula, oats) Limit fruit to 3 portions per day Avoid sorbitol FODMAP – probably via a dietitian.

28. Case Study 1 – Jess West 29F Shared management – what are the options? Prescribing options in IBS Antispasmodic (mebeveine, alverine, peppermint oil) Constipation – laxative (ispaghula) Diarrhoea - antimotility (loperamide) 2 nd line – amitriptyline 3 rd line – SSRI.

29. Case Study 2 – Jo West 49F I hope that you can help. I’ve had trouble with IBS for as long as I can remember, but for a few months it’s been worse and I’m just so bloated. Probability & Prevalence: What diagnoses are you considering? Holistic Approach (Impact): What other aspects of her problems spring to mind?

30. Case Study 2 – Jo West 49F I hope that you can help. I’ve had trouble with IBS for as long as I can remember, but for a few months it’s been worse and I’m just so bloated. Probability & Prevalence: What diagnoses are you considering? Irritable bowel syndrome Coeliac disease Ovarian cancer Colorectal cancer?

31. Case Study 2 – Jo West 49F I hope that you can help. I’ve had trouble with IBS for as long as I can remember, but for a few months it’s been worse and I’m just so bloated. Holistic Approach (Impact): What other aspects of her problems spring to mind? Stress & anxietyAlcohol Work & impactFamily history Home & impact.

32. Case Study 2 – Jo West 49F Targeted tests - does she need any more tests? She should have: FBCESRCRPCoeliac (Total IgA and tTG) CA125 She should NOT have: TFT Faecal mcs, faecal parasites Hydrogen breath tests USS, sigmoidoscopy, colonoscopy, barium enema What about faecal calprotectin? Probably yes.

33. Case Study 3 – Jane West 69F I hope that you can help. I’ve had trouble with IBS off an on, but for a few weeks it’s been worse. The diarrhoea is so much more unpredictable. On a couple of occasions I’ve seen some blood – but that has happened before. Probability & Prevalence: What diagnoses are you considering? Holistic Approach (Impact): What other aspects of her problems spring to mind?

34. Case Study 3 – Jane West 69F I hope that you can help. I’ve had trouble with IBS off an on, but for a few weeks it’s been worse. The diarrhoea is so much more unpredictable. On a couple of occasions I’ve seen some blood – but that has happened before. Probability & Prevalence: What diagnoses are you considering? Colorectal cancer Diverticular disease (Coeliac disease).

35. Case Study 3 – Jane West 69F I hope that you can help. I’ve had trouble with IBS off an on, but for a few weeks it’s been worse. The diarrhoea is so much more unpredictable. On a couple of occasions I’ve seen some blood – but that has happened before. Holistic Approach (Impact): What other aspects of her problems spring to mind? Family & support network Faecal incontinence.

36. Case Study 3 – Jane West 69F Past history of IBS 6 week history of unpredictable diarrhoea and blood with stool. Targeted history: What other areas spring to mind? General healthAppetite & weight OK Family historyFather had CRC aged 72y BCSPNot participated in BCSP.

37. Case Study 3 – Jane West 69F Past history of IBS 6 week history of unpredictable diarrhoea and blood with stool. Has not participated in BCSP. Targeted examination: What examination would you perform? Pulse, anaemia Abdomen – massesRectal examination? SIGN126 - GPs should perform an abdominal and rectal examination on all patients with symptoms indicative of colorectal cancer. A positive finding should expedite referral, but a negative rectal examination should not rule out the need to refer.

38. Case Study 3 – Jane West 69F Targeted tests - does she need any more tests? She should have: FBCESRCRPeGFR Coeliac (Total IgA and tTG)CA125 She should NOT have: TFT Faecal mcs, faecal parasites Hydrogen breath tests What about faecal calprotectin? No What about other imaging? No.

39. Case Study 3 – Jane West 69F Past history of IBS 6 week history of unpredictable diarrhoea and blood with stool. Appropriate referral: 1.‘Routine’ colorectal clinic referral 2.‘Urgent’ colorectal clinic referral 3.Refer colorectal clinic for appointment within 2 weeks.

40. UK’s 3 rd most common cancer (after breast & lung) – 40,000 cases annually 2 nd most common cause of cancer death 75% present in people over 65y It takes ~10years for a small adenomatous polyp to develop into a colorectal cancer Right-side present later ◦ Weight-loss, anaemia, mass, metastases Left-side present earlier ◦ Rectal bleeding, change in bowel habit, pain, tenesmus Why may sigmoidoscopy screening at age 55 years reduce mortality from right-sided cancer? Wiki 23.3.16 Colorectal Cancer

41. NICE cancer referral guidelines 2015

42. Unexplained= Diagnosis not made after history, examination, any primary care investigations Persistent= Continuation beyond period normally associated with self-limiting

43. NICE cancer referral guidelines 2015 Cancer referral guidelines are complex… 1. Rectal bleeding (unexplained) 2. Change in bowel habit 3. Other - abdominal masses, pain, weight loss, anaemia Aged over 40 with unexplained weight loss & abdominal pain Aged over 50 with unexplained rectal bleeding Aged over 60 with unexplained change in bowel habit (including new unexplained constipation) Others – check!

44. AKT Question 2 A 53 year old male presents with a 5-week history of painless rectal bleeding each time that he opens his bowels. His stools are normal and his bowel habit is unchanged. Abdominal examination is normal. Digital rectal examination is normal. What is the next most appropriate management option? Select ONE answer only. A. FOB testing B. FBC (Full blood count) & Ferritin C. GP review of symptoms in 2 weeks D. Refer for a colorectal appointment within 2 weeks E. Abdominal CT scan

45. AKT Question 2 A 53 year old male presents with a 5-week history of painless rectal bleeding each time that he opens his bowels. His stools are normal and his bowel habit is unchanged. Abdominal examination is normal. Digital rectal examination is normal. What is the next most appropriate management option? Select ONE answer only. A. FOB testing B. FBC (Full blood count) & Ferritin C. GP review of symptoms in 2 weeks D. Refer for a colorectal appointment within 2 weeks E. Abdominal CT scan

46. Bowels, lumps & bleeding Examination of perianal problems All consultations for anal problems should result in DRE & proctoscopy with a chaperone present, unless you can justify otherwise… Response? Unnecessary waste of time Intrusive & upsetting for patient Hard to get chaperone I am going to refer anyway.

47. Bowels, lumps & bleeding Examination of perianal problems All consultations for anal problems should result in DRE & proctoscopy with a chaperone present, unless you can justify otherwise… Response? Unnecessary waste of time Intrusive & upsetting for patient Hard to get chaperone I am going to refer anyway DRE or not? Age sensitive – never in under 18s, rarely in under 25s Pain sensitive – don’t when acute pain (fissure etc) Proctoscopy or not? As above… plus… If you want to blame it on piles… NICE CKS Management of haemorrhoids: Refer for non-urgent assessment and treatment: People who need assessment where the facilities for proctoscopy do not exist in primary care. Chaperone or not? Always offer, always record the offer Opposite sex and young – just get one, don’t offer. SIGN126 : GPs should perform an abdominal and rectal examination on all patients with symptoms indicative of colorectal cancer. A positive finding should expedite referral, but a negative rectal examination should not rule out the need to refer. SIGN 105 : All patients with rectal bleeding should have a full history taken, abdominal examination and should undergo digital rectal examination and proctoscopy.

48. Bowels, lumps & bleeding Examination of perianal problems All consultations for anal problems should result in DRE & proctoscopy with a chaperone present, unless you can justify otherwise… Probably not ALL Painful bleeding, younger patient – probably no Young (under 25), painless bleeding – possibly no All other painless bleeding – yes.

49. Bowels, lumps & bleeding Younger people with perianal problems: Need to pick out the atypical cases: Atypical diagnoses? Inflammatory bowel disease Colorectal cancer Need to know the presentations for common perianal problems Need to know what common perianal problems look like o Common diagnoses? ◦ Piles & haemorrhoids ◦ Fissures ◦ Skin tags.

50. Common perianal problems A.I occasionally get constipated and strain. It really hurts when I open my bowels, often there is blood on the paper. It aches for hours afterwards. B.I occasionally get constipated and strain. This was bad yesterday and I have had this really painful lump since then. C.I occasionally get constipated and strain. I am worried as for the last few days I have noticed blood on the paper when I wipe myself. It does not hurt at all. D.I occasionally get constipated and strain. Off and on I notice blood on the paper, occasionally there were lumps that I could feel after I’ve opened my bowels. But now the lumps are there all the time E.I’m getting more annoyed with lumps on my bottom. It is getting harder & harder to clean after I have opened my bowels. All pictures CC BY 3.0 http://www.intechopen.com/books/screening-for-colorectal-cancer-with- colonoscopy/basic-endoscopic-findings-normal-and-pathological-findings Accessed 31.4.16 1 2 3 4 5

51. https://en.wikipedia.org/wiki/ Hemorrhoid#/media/File:Piles _Grade_3.svg Common perianal problems 1 2 3 4 5 A5 Anal fissure I occasionally get constipated and strain. It really hurts when I open my bowels, often there is blood on the paper. It aches for hours afterwards. B1(Thrombosed) External pile/ haemorrhoid I occasionally get constipated and strain. This was bad yesterday and I have had this really painful lump since then. C2First degree (internal) pile/ haemorrhoid I occasionally get constipated and strain. I am worried as for the last few days I have noticed blood on the paper when I wipe myself. It does not hurt at all. D4 Third (from second) degree (internal) pile/ haemorrhoid I occasionally get constipated and strain. Off and on I notice blood on the paper, occasionally there were lumps that I could feel after I’ve opened my bowels. But now the lumps are there all the time E3Skin tags I’m getting more annoyed with lumps on my bottom. It is getting harder & harder to clean after I have opened my bowels. A5 Anal fissure D4 Third degree piles B1 Thrombosed external piles C2 First degree piles CC BY 3.0 All pictures CC BY 3.0 http://www.intechopen.com/books/screening-for-colorectal-cancer-with- colonoscopy/basic-endoscopic-findings-normal-and-pathological-findings Accessed 31.4.16

52. Common perianal problems Anal fissure Tear in anal canal skin Pain/ blood with defaecation and pain afterwards Sentinel pile – may see skin tag at external end of fissure Inspection only – don’t DRE/ proctoscopy! Ensure soft stools (dietary fibre, laxatives - more later) Consider GTN ointment (if slow to heal) Refer if chronic/persistent. 5 All pictures CC BY 3.0 http://www.intechopen.com/books/screening-for-colorectal-cancer-with- colonoscopy/basic-endoscopic-findings-normal-and-pathological-findings Accessed 31.4.16

53. Common perianal problems External pile/ haemorrhoid Rupture of a subcutaneous vein at anal margin Pain usually resolves within 2-3d, lump within 2-3w Inspection only – don’t DRE/ proctoscopy! Ensure soft stools (dietary fibre, laxatives - more later) Topical haemorrhoid preparations for short-term relief (NOT GTN) Very rare referral – very large, very painful, onset < 72hrs. 1 All pictures CC BY 3.0 http://www.intechopen.com/books/screening-for-colorectal-cancer-with- colonoscopy/basic-endoscopic-findings-normal-and-pathological-findings Accessed 31.4.16

54. Common perianal problems Internal pile/ haemorrhoid Expansion of vascular cushions in the anal canal 1’- Stay internal (bleeding only, usually painless) 2’- Reach anal opening (intermittent lumps with bleeding + pain) 3’- Stay outside (permenant bleeding + pain) 1’ and 2’ can only be diagnosed with proctoscope Ensure soft stools (dietary fibre, laxatives - more later) Use moistened wipes to avoid rubbing Topical haemorrhoid preparations for short-term relief (NOT GTN) Refer if:- third degree haemorrhoids - diagnostic doubt (CKS – if no proctoscopy) - do not respond to conservative treatments. 2 4 All pictures CC BY 3.0 http://www.intechopen.com/books/screening-for-colorectal-cancer-with- colonoscopy/basic-endoscopic-findings-normal-and-pathological-findings Accessed 31.4.16

55. Common perianal problems Skin tags May be spontaneous May remain after resolution of external pile Not usually painful (if painful, consider fissure & ‘sentinel pile’) Use moistened wipes to avoid rubbing Consider surgery if very symptomatic/ troublesome.. 3 All pictures CC BY 3.0 http://www.intechopen.com/books/screening-for-colorectal-cancer-with- colonoscopy/basic-endoscopic-findings-normal-and-pathological-findings Accessed 31.4.16

56. And now for something completely different… Screening

57. Screening

58. Screening Wilson’s Criteria (WHO 1968) 1. The condition should be an important health problem. 2. There should be a treatment for the condition. 3. Facilities for diagnosis and treatment should be available. 4. There should be a latent stage of the disease. 5. There should be a test or examination for the condition. 6. The test should be acceptable to the population. 7. The natural history of the disease should be adequately understood. 8. There should be an agreed policy on whom to treat. 9. The cost of case-finding should be economically balanced. 10. Case-finding should be a continuous process, not just a "once and for all".

59. The Screening Grid True Diagnosis PositiveNegative True Result Positive Negative a TP (True Positive) b FP (False Positive) Type 1 error c FN (False Negative) Type 2 error d TN (True Negative) Sensitivity a/a+c SNOUT Avoid false negative Specificity d/b+d SPIN Avoid false positive Negative Predictive Value NPV = d/c+d Positive Predictive Value PPV = a/a+b

60. AKT Question 3 A new screening test has been developed to diagnose bladder cancer by machine analysis of urine for abnormal cells. These results are from a study where all patients had a urine sample tested and also diagnostic cystoscopy. Total number of patients in the study1000 Number of samples that tested positive28 Number of true positives (confirmed by cystoscopy)4 Number of samples that tested negative972 Number of false negatives (confirmed by cystoscopy)10 Which ONE of the following statements about this data is FALSE? 1.The negative predictive value of the test is 962/972 (99%) 2.The positive predictive value of the test is 4/28 (14%) 3.The sensitivity of the test is 4/14 (29%) 4.The specificity of the test is 24/986 (2.5%) 5.There were 24 type 1 errors Diagnosis PosNeg Test PosTPFPPPV NegFNTNNPV SensSpec

61. AKT Question 3 A new screening test has been developed to diagnose bladder cancer by machine analysis of urine for abnormal cells. These results are from a study where all patients had a urine sample tested and also diagnostic cystoscopy. Total number of patients in the study1000 Number of samples that tested positive28 Number of true positives (confirmed by cystoscopy)4 Number of samples that tested negative972 Number of false negatives (confirmed by cystoscopy)10 Which ONE of the following statements about this data is FALSE? 1.The negative predictive value of the test is 962/972 (99%) 2.The positive predictive value of the test is 4/28 (14%) 3.The sensitivity of the test is 4/14 (29%) 4.The specificity of the test is 24/986 (2.5%) 5.There were 24 type 1 errors Diagnosis PosNeg Test PosTP 4FP 24PPV 4/28 NegFN 10TN 962NPV 962/972 Sens 4/14Spec 962/986

62. Sensitivity & Specificity Consider sensitivity and specificity for common tests Verbalise these in terms of FP/ TP and FN/ TN PSA in prostate cancer ◦ Specificity  33% ◦ Sensitivity  66% Urine dip – Leuc & nitrite ◦ Specificity  60% ◦ Sensitivity  95% Sigmoidoscopy in CRC ◦ Specificity  98% ◦ Sensitivity  50%

63. Find it early? Where is the harm? Harm from false positive? Tests to prove FP Over treatment Harm from false negative? Delay in diagnosis Harm from true positive? Over diagnosis Over treatment Harm from true negative? Post-screen complacency Delayed presentations Joe Public’s perception: Finding it early must be good Give me as much of this as I can get….

64. What screening is offered by NHS? Cervical cancer Women 25-643-yearly 25-495-yearly 50-64 Breast screening Women 50-70 3-yearlyWomen over 70 can self-refer Colorectal cancer Men/ women FOB every 2 years 60-74, over 75 can self-refer Men/ women single flexi-sig age 55 (by end 2016) Aortic aneurysm Men in 65 th year Mid-life MOT (more next) 5-yearly CV risk assessment aged 40-74 Diabetes retinopathy screening Annual retinal photograph Pregnancy Viral infections, Haemoglobinopathies, Downs, anomaly scans Newborn Blood spot - CF, thyroid, sickle, six metabolic [PKU, MCADD] Hearing test, physical exam.

65. What do you think about screening? 1. What other screening programmes have you heard of? 2. Do other countries do more (or less)? Front half: ◦ Discuss in 2-3s Back half: ◦ Read this BMJ article Overall opinion?

66. Mid-life MOTs Organised via Public Health – may be GP or otherwise (Pharmacy) ◦ 5-yearly CV risk assessment for those aged 40-74 ◦ Measure BP, BMI, lipids & HbA1c (PoC) ◦ Looking for those with Q-risk >10% Uptake is low (21%) Only 40% of high-risk were prescribed statins (needed to be 85%) 2016 Review Compared 10y CV-risk in screened and non-screened groups ◦ Reduced by 0.21% (absolute risk) If 10yr ARR is 0.21%, what is the NNT? ◦ 10y NNT of nearly 500, annual NNT of 5,000 Cost estimate of £450,000 per life saved.

68. Session Overview Digestive Health (3.13) – Lower GI Key Knowledge Key curriculum content Key guidelines & pathways AKT Topics Clinical Content Irritable Bowel Syndrome Colorectal Cancer Nutrition – fibre (constipation) Food allergies Minor Topic -Screening

69. Nutrition - fibre

70. Building up diet advice in stages through the 2-years. Benefits of good fibre intake? Colorectal cancer T2DM IHD, CVA Recommended target = 30g Average intake = 18g.

71. Know your fibre content: Arrange in fibre-content order (range is 0.5g to 9g): 1. Bowl of porridge 2. Bowl of cornflakes 3. Slice white bread 4. Slice wholemeal bread 5. Weetabix biscuit 6. Tin of tomatoes 7. Tin of baked beans 8. Apple 9. Jacket potato 10. Broccoli serving

72. Know your fibre content: Arrange in fibre-content order (range is 0.5g to 9g): 1. Bowl of cornflakes 0.5g 2. Slice white bread 0.75g 3. Weetabix biscuit 2g 4. Apple 3g 5. Jacket potato 3g 6. Slice wholemeal bread 3g 7. Bowl of porridge 4g 8. Tin of tomatoes 4g 9. Broccoli serving 5g 10. Tin of baked beans 9g 5-a-day is not enough! Now talk about 10-a-day…

73. Soluble & insoluble fibre Soluble: Full feeling, slows digestion Fruit Oats (porridge) Pulses Root vegetables Greens (30:70) Insoluble: Constipation & bowels Wheat Brown rice Greens (30:70)

74. Harm from fibre? Insoluble fibre can worsen IBS More than 2-3 portions of fruit per day can lead to excess sugar intake (diabetics – limit to 2 pieces) Smoothies – large glass may contain 50% of recommended daily sugar intake (12 teaspoons, 4g per spoon).

75. Constipation & Laxatives Constipation definition: Passing fewer than 3 stools per week with straining, discomfort or feeling of incomplete defaecation Younger (<40) – very low liklihood of CRC cancer Older – beware CRC. Is now included in cancer referral guidelines Laxatives: Bulk-forming: Osmotic: Stimulant: Mixed: Rectal: Bran, Ispaghula husk (Fybogel) Macrogol (Movicol), Lactulose Bisacodyl, Senna Docusate – mix of stimulant & softener Glycerol suppository, phosphate enemas.

76. Constipation & Laxatives Acute constipation Rectal examination? 1. Diet & lifestyle ◦ Fibre, fluids, mobility ◦ Stop constipating medication if appropriate 2. Bulk-forming (Fybogel) 3. Osmotic (Macrogol) – switch or add 4. Stimulant if soft stool but unable to expel Opiate-induced? Do not use bulk-forming Use stimulant then osmotic or mixed SIGN126 - GPs should perform an abdominal and rectal examination on all patients with symptoms indicative of colorectal cancer. Children: Macrogol 1 st Line Pregnancy: Macrogol NOT recommended.

77. AKT Question 4 You see a patient with advanced lung cancer. His pain control is poor and you consider starting him on an opioid-based analgesic. He is worried about becoming constipated as he has a previous history of severe constipation. What is the SINGLE MOST appropriate management to prevent constipation in this patient? Select ONE option only. A. Prescribe senna at the time of the first opioid prescription B. Prescribe macrogols at the time of the first opioid prescription C. Prescribe a phosphate enema in case he gets constipated D. Use only non-opioid analgesia E. Wait until constipation is established then treat

78. AKT Question 4 You see a patient with advanced lung cancer. His pain control is poor and you consider starting him on an opioid-based analgesic. He is worried about becoming constipated as he has a previous history of severe constipation. What is the SINGLE MOST appropriate management to prevent constipation in this patient? Select ONE option only. A. Prescribe senna at the time of the first opioid prescription B. Prescribe macrogols at the time of the first opioid prescription C. Prescribe a phosphate enema in case he gets constipated D. Use only non-opioid analgesia E. Wait until constipation is established then treat

79. Constipation & Laxatives Chronic constipation Impaction? I.Glycerol suppository II.Phosphate enema III.Macrogol – high dose Not impacted 1.Diet & lifestyle  Fibre, fluids, mobility  Stop constipating medication if appropriate 2.Bulk-forming (Fybogel) 3.Osmotic (Macrogol) – switch or add 4.Stimulant if soft stool but unable to expel 5.Other therapies (Prucalopride) only if failed with 2 laxatives for 6 months. Children: Macrogol 1 st Line Do not use rectal Rx

81. Food allergy and intolerance

82. I think that I am allergic to something that I am eating. I want a blood test to find out what foods I need to avoid to get rid of the problem…. Allergy UK Website 1.IgE mediated food allergy 2.Non-IgE mediated food allergy 3.Food intolerance 4.Oral allergy syndrome Beware: Many sites, including Allergy UK & NICE, mix 2) and 3) It is clearer NOT to mix

83. Food allergy and intolerance IgE mediated food allergy Last night I ended up at A&E when my face & mouth went swollen and I got an itchy lumpy rash all over my body… Oro-facial angio-oedema, urticarial, wheeze, vomiting, anaphyalaxis http://medpic.org/p/anaphylaxis_pictures 23.3.16 All of the images used on this website are found in various places throughout the internet and are believed to be within the public domain

84. AKT favourite! Main causes in UK: Foods Venom Drugs Management: 1. A B C D E Oxygen 2. Adrenaline  IM injection anterolateral mid-third thigh  Repeated at 5 minute intervals if needed  Adult (over 12y)0.5mg500mcg0.5ml of 1:1000  6 – 12y0.3mg300mcg0.3ml of 1:1000  < 6y0.15mg150mcg0.15ml of 1:1000 3. IM/ IV Chlorphenamine (10mg) / Hydrocortisone (200mg) afterwards. Anaphylaxis - nuts, fish & shellfish, eggs, milk, wheat, kiwi, soya - wasp & bee - antibiotic, nsaid, opioids, IV contrast http://medpic.org/p/anaphylaxis_pictures 23.3.16 All of the images used on this website are found in various places throughout the internet and are believed to be within the public domain

85. AKT Question 5 You are called to the treatment room to see a 17-year-old boy who has become unwell after receiving a vaccination. He has a generalised blotchy rash and is wheezing. You suspect anaphylaxis. His observations have been noted by the nurse: Temp 37.4°CBP 90/60 mmHgPulse 128 per minute Respiratory rate 28 breaths/minuteOxygen sats 95% (on air) What is the SINGLE MOST appropriate initial treatment? Select ONE option only. A. Adrenaline 0.5 ml 1:1000 intramuscularly B. Adrenaline 1 ml 1:1000 intramuscularly C. Chlorphenamine 10 mg intramuscularly D. Chlorphenamine 10 mg orally E. Hydrocortisone 200 mg intramuscularly

86. AKT Question 5 You are called to the treatment room to see a 17-year-old boy who has become unwell after receiving a vaccination. He has a generalised blotchy rash and is wheezing. You suspect anaphylaxis. His observations have been noted by the nurse: Temp 37.4°CBP 90/60 mmHgPulse 128 per minute Respiratory rate 28 breaths/minuteOxygen sats 95% (on air) What is the SINGLE MOST appropriate initial treatment? Select ONE option only. A. Adrenaline 0.5 ml 1:1000 intramuscularly B. Adrenaline 1 ml 1:1000 intramuscularly C. Chlorphenamine 10 mg intramuscularly D. Chlorphenamine 10 mg orally E. Hydrocortisone 200 mg intramuscularly

87. Food allergy and intolerance IgE mediated food allergy Last night I ended up at A&E when my face & mouth went swollen and I got an itchy lumpy rash all over my body… Oro-facial angio-oedema, urticarial, wheeze, vomiting, anaphyalaxis Commonest - nuts, seafood, milk, eggs, wheat, kiwi, soya Skin test vs. blood test (for specific IgE) Refer to allergy clinic? Adrenaline pen (awaiting referral) if: - Asthmatic - Severe (anaphylaxis) reaction. Refer to allergy clinic if: Acute systemic reaction Not responded to single allergen avoidance IgE-allergy in asthmatic

88. Food allergy and intolerance Non-IgE mediated food allergy My friend told me that I should take my (4m) baby off cow’s milk. He still has bad reflux, his poo is always runny and his eczema is getting worse and worse… Cow’s milk protein allergy T-cell mediated (response rate is days) No blood test Usually refer Hydrolysed vs amino-acid milks.

89. Food allergy and intolerance Food intolerance Wheat really upsets my IBS. I am sure that I have coeliac disease It’s not fair – if we go for a curry, anything more than a Korma, the next morning I can’t get off the toilet. But my partner is fine… I love milk – I can take a dash in my tea but drink a pint of milk….. It’s not fair – I love Herring roll-mops but they give awful stomach cramps Several mechanisms: - Irritant effect of food ‘chemicals’ - Enzyme-system activity (lactase deficiency) - Histamines & salicylates in foods Food diary & elimination are the only Rx (eliminate for 2-6w).

90. Food allergy and intolerance Oral Allergy Syndrome I was eating an apple last night and my lips started to swell up. My mouth felt funny and when I looked in the mirror, the dangly bit was almost like a grape. I took one of the tablets I take for my hayfever and over the next 20- 30 minutes it settled. IgE-mediated cross reaction between pollen IgE and other immunogenically similar botanical allergens Commonest: fruits (apple, kiwi) in birch pollen allergy Exceedingly rare for it to progress to systemic/ anaphylaxis Cooking the food usually eliminates cross-reaction (not always).

91. Food allergy and intolerance Non-IgE mediated food allergy Doctor, I feel tired all the time. And my stomach always feels bloated. And I get lots of stomach cramps and loose stools. And I often get these mouth ulcers. And I have this itchy blister rash on my arms…. Coeliac disease IgA response to wheat gluten & related proteins Measure total IgA and tTG IgA (EMA if weak pos) Must NOT be on GFD at time of testing Refer if positive serology – still need biopsy.

92. Food allergy and intolerance I think that I am allergic to something that I am eating. I want a blood test to find out what foods I need to avoid to get rid of the problem…. Allergy UK Website 1.IgE mediated food allergyAnaphylaxis 2.Non-IgE mediated food allergyCoeliac, Cow’s milk protein 3.Food intoleranceLactase deficiency, curries 4.Oral allergy syndromeAtopic - tingly mouth with fruit Beware: Many sites, including Allergy UK & NICE, mix 2) and 3) It is clearer NOT to mix

93. Session Overview Digestive Health (3.13) – Lower GI Key Knowledge Key curriculum content Key guidelines & pathways AKT Topics Clinical Content Irritable bowel syndrome Colorectal cancer & perianal problems Nutrition – fibre (constipation) Food allergies Minor Topic -Screening