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Difficult GI scenarios

Gastroenterologist Dr Ajay Verma offers management advice on four tricky GI problems in primary care

1. Persistent diarrhoea in the recently returned traveller

Traveller's diarrhoea is common and occurs in up to 50% of visitors to Latin America, Africa, the Middle East and Asia. The illness is usually self-limiting or mild, starting during or just after the trip.

If a patient presents with diarrhoeal symptoms, check if they have significantly bloody diarrhoea, high fever, abdominal guarding, severe dehydration or shock. Patients should be admitted to hospital if any of these signs are present. Outcomes are variable. Most hospitalised patients just require intravenous fluids for a day or two. But in extreme and rare cases they have to undergo colectomy due to fulminant colitis.

Patients with mild symptoms should be encouraged to rest. Ensure adequate hydration and reassure them that symptoms usually settle within three to four days. Consider sending stool cultures. Also consider stool analysis for Clostridium difficile toxin, particularly if there is a history of recent antibiotic use.

Avoid anti-diarrhoeal therapy in the acute phase of illness. The diarrhoea is serving a function to remove toxins. Taking loperamide can cause crampy abdominal pain.

If patients return to surgery or present in the chronic phase of illness, re-assess the situation by:

• Checking for alarm symptoms such as bloody stools, weight loss or nocturnal diarrhoea. This suggests inflammatory bowel disease as acute infection can reveal or trigger underlying IBD.

• Reviewing the medication and consider stopping or switching drugs that are known to make diarrhoea worse – for example, PPIs or metformin.

• Performing routine blood investigations (FBC, U&Es, LFTs, TFTs and CRP). Ensure stool cultures are sent off (ideally more than one set), request for microscopy, culture and sensitivity, ova, cysts and parasites and Clostridium difficile toxin.

• Requesting a coeliac serology.

• Referring to gastroenterology if you suspect IBD or coeliac disease.

Patients with persistent diarrhoea without alarm symptoms suggestive of IBD, with normal blood investigations and negative stool cultures, should be reassured. They probably have post-infective IBS. Symptoms can last for many months after the initial infection.

Explain that the bowel is essentially normal but after the initial illness it doesn't work in a normal way. Give patients the tools to cope with the symptoms – loperamide or similar for diarrhoea, buscopan for crampy pains. Advise them to avoid any triggers that might exacerbate symptoms – typically spicy foods or stress.

Written in conjunction with Dr Peter Wurm, consultant gastroenterologist at University Hospitals Leicester.

2. The patient with apparent GORD still getting symptoms despite good doses of PPI

The diagnosis of GORD is often made from taking a history in patients under 55 without alarm symptoms, or post-endoscopy in older patients or patients with alarm symptoms. The three cardinal symptoms are;

• retrosternal pain worse on bending

• discomfort starting at the lower

sternum and rising upwards, which

can be aggravated by lying down

• alleviation of these symptoms by a trial of proton pump inhibitors (PPIs).

Patients with predominantly non-GORD dyspepsia (satiety, bloating and sharp epigastric pain) should be tested and treated for Helicobactor pylori.

The difficulty arises when patients have breakthrough symptoms despite PPI therapy. In this situation taking a thorough history may save you and your patient from a frustrating ordeal. Ensure that the initial diagnosis is correct as misdiagnosis can occur in cases of biliary colic, ischaemic heart disease, musculoskeletal pain and anxiety.

Drugs such as aspirin, NSAIDs, bisphosphonates and steroids may be the culprit. Lifestyle issues such as large meal portions, late-evening eating, smoking, wine consumption, chocolate-eating, coffee-drinking and too much spicy food can also contribute to breakthrough symptoms. Losing weight is good advice if relevant, as is reducing stress and avoiding eating meals quickly. Finally, sleeping propped up and drinking plenty of water after a moderate-sized early evening meal often helps.

Therapeutic options include ensuring patients are on full-dose PPI therapy and are taking their medication at least 30 minutes before eating.

Switching PPI can be helpful. If the patient is on omeprazole or esomeprazole, temporarily doubling their dose can be effective, but this does not work for lansoprazole. Adding domperidone 10-20mg tds/qds or metoclopramide 10mg tds can have a synergistic effect.

Another strategy is the use of thicker alginate solutions (such as Gaviscon Advance) for use with breakthrough symptoms. Both these steps can make this condition manageable.

The advice above is in the NICE guidance1, but if all of the above strategies have failed refer to secondary care. If alarm symptoms develop (dysphagia, persistent vomiting, weight loss, malaena, iron-deficiency anaemia) an urgent referral to secondary care is a must. In secondary care we use endoscopy and pH manometry studies to diagnose severe reflux. In the absence of oesphageal dysmotility, fundoplication could be considered – a big step as the risks are significant but outcomes are good in large-volume centres.

Written in conjunction with Professor Janusz Jankowski, consultant gastroenterologist at Leicester and Queen Mary, University of London.

3. Abnormal LFTs in a well patient

This is a common problem in primary care. Knowing if and when to refer is challenging and the calculations are changing as mild or benign liver disease is increasingly managed in primary care.

Remember LFTs don't necessarily measure liver function. Better markers for this are INR and albumin. If both become abnormal in conjunction with deranged LFTs then refer promptly to secondary care.

Transient abnormalities in LFTs are common and can occur because of intercurrent illness or newly prescribed drugs such as co-amoxiclav or flucloxacillin.

41270061Abnormal results – up to two times the upper limit of normal (ULN) – in well patients should just be repeated after a few days. If the patient remains well but LFTs fail to normalise, a liver screen (virology, biochemistry and immunology) and a liver ultrasound should be arranged.

Persistently raised ALT levels are commonly caused by non-alcoholic fatty liver disease (NAFLD), viral hepatitis, alcohol excess and occasionally other liver diseases. A good history, an ultrasound screen and liver screen will often reveal the diagnosis. If ALT levels are persistently raised at >2xULN then consider referring to secondary care.

Viral hepatitis due to hepatitis B and hepatitis C is increasingly common in the UK, especially in non-indigenous populations. Patients from Eastern Europe have an increased risk. High-risk groups include patients from the Far East, Africa and South Asia – for example 10-15% of the Pakistani population have hepatitis B or C infection. These patients often remain well for many years but all patients with positive virology must be referred to secondary care.

Alcohol excess can cause a minor rise in ALT and ALP, although patients can be quite well. Addressing alcohol consumption is recommended and abstinence is key. Referral to community alcohol teams may be required.

If the diagnosis is thought to be NAFLD (the most common cause of abnormal LFTs), the strategies implemented in primary care for prevention of ischaemic heart disease have a similar impact for NAFLD. Weight loss, tight control of diabetes and blood pressure, lipid-lowering therapy (statins are safe) and lifestyle modification are the mainstays of treatment and do not need secondary care input unless the LFTs deteriorate further.

In a well patient with persistently raised bilirubin in isolation, without obstructive symptoms such as pale stools and dark urine, the most common cause is Gilbert's syndrome (5-10% of the population). This is easily diagnosed by checking unconjugated bilirubin levels and its only main differential diagnosis is haemolysis. Gilbert's syndrome is a benign condition and patients should be reassured. Bilirubin levels can rise during illness or fasting – warn patients that jaundice can occur.

Written in conjunction with Dr Allister Grant, consultant hepatologist at University Hospitals Leicester.

4. The elderly patient with known diverticular disease presenting with bowel symptoms

Diverticular disease is common and occurs mainly in the west. Fewer than one person in 20 has the condition before age 40, rising to a quarter by 60 and two-thirds by 85. It is thought that our fibre-poor diets in the West reduce bowel transit, causing muscle hypertrophy and an increase in pressure in the bowel. Over time diverticulae form, predominantly in the sigmoid colon.2 These diverticulae can be troublesome. They can become blocked and inflamed (diverticulitis), resulting in pain, bleeding, diarrhoea or constipation. Most patients with diverticular disease are asymptomatic or the symptoms are mild – this condition is more of a nuisance than a significant problem. In the worst case, diverticulae can perforate, causing peritonitis. Avoiding constipation is key and is usually achieved with a high-fibre diet, laxatives, good hydration and exercise.

The dilemma for GPs is that the symptoms can mimic those of colorectal or other pelvic or abdominal malignancy. Both conditions are increasingly prevalent with age but the prognoses are very different.

If an elderly patient with diverticular disease presents with abdominal pain, bleeding or a change in bowel habit, they should be assessed with a high index of suspicion. Ask about the duration of symptoms, presence of rectal bleeding and pain. Examine the abdomen for a mass, check vital observations and perform a rectal examination. Check routine blood tests – FBC, U&Es, LFTs. If anaemic, check a serum ferritin – not serum iron.

Urgently refer patients with and of the following:

• alarm symptoms (change in bowel habit for more than six weeks, rectal bleeding, tenesmus, weight loss)

• evidence of abdominal guarding, fever, tachycardia and hypotension or mass palpable on rectal examination

• iron-deficiency anaemia (low Hb and low MCV or

low Hb and low ferritin), renal failure or abnormal LFTs.

If the patient is well but has mild bowel symptoms, encourage increased fluid intake and exercise, and prescribe laxatives. Ask patient to return urgently if not settling within a month or if they worsen with symptoms described above and refer urgently.

Written in conjunction with Dr Barrie Rathbone, consultant gastroenterologist at University Hospitals Leicester.

Dr Ajay Verma is a specialist registrar (ST6) in gastroenterology at University Hospitals Leicester.

Liver Test for Clostridium difficile is the patient has recently taken antibiotics Test for Clostridium difficile is the patient has recently taken antibiotics


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