GASTROINTESTINAL PROBLEMS

BOWEL CANCER (cancer of the colon or rectum [CRC])

Third most common cancer in the UK. Treatable if diagnosed early. Main symptoms and signs are rectal bleeding, persisting change in bowel habit and anaemia. Tumours are usually diagnosed by colonoscopy. Eight out of 10 diagnosed are aged over 60. 

Screening for bowel cancer, using a faecal immunochemical test (FIT), is offered to people over the age of 60 in England, Wales and Northern Ireland but from this year, the NHS will gradually reduce the age range. In Scotland, screening starts at age 50. Screening improves the outcomes and mortality of CRC by earlier detection, but uptake of this programme is lower than for other cancer screening programmes.

COELIAC DISEASE

Inflammatory disorder of the small intestine, caused by a reaction to gliadin, a gluten protein found in wheat, barley and rye. Inflammation results in malabsorption. Symptoms include chronic diarrhoea and fatigue, and failure to thrive in children. Patients are at risk of osteoporosis, and need referral to a dietitian for advice on life-long gluten-free diet, and prescriptions (ACBS endorsed) for adequate amounts of gluten-free foods.

CONSTIPATION

Bristol stool chart A useful definition of constipation is ‘the passage of hard stools less frequently than the patient's own normal pattern’ (BNF) The Bristol stool form scale is a means of assessing intestinal transit time.

• Types 1 and 2 indicate constipation: will be passed infrequently
• Types 3 and 4 indicate ‘normal’ ideal stools; should be passed once every 1-3 days, depending on individual normal bowel emptying patterns.
• Type 5 to 7 suggest diarrhoea or urgency; passed very frequently.

Bristol Stool Chart – see main entry for Constipation

DIARRHOEA

Increased frequency of defecation, with a loosening consistency. In general:

• Organic aetiology: copious watery diarrhoea/nocturnal diarrhoea – see Lower GI Red Flags
• Functional bowel disease (i.e. irritable bowel syndrome, anxiety): frequent small amounts of diarrhoea
• Colonic disease: bloody diarrhoea
• Infective aetiology: acute diarrhoea.

Diarrhoea in children Infectious diarrhoea is common and in most cases viral (usually rotavirus). Be alert for signs of a serious cause, e.g. blood in stool. Often environmental, reasons being poverty, poor personal hygiene, malnutrition, poor sterilisation if bottle feeding

GASTROENTERITIS

Common infection of the stomach and intestines, transmitted mainly by the faecal–oral route and usually highly infectious. Presents with diarrhoea, vomiting and abdominal pain following consumption of infected food or drink (food poisoning) or contact with an infected individual. The rotavirus is the leading cause of gastroenteritis in children. Always ask about recent travel. Usually mild and self-limiting. Individuals with severe symptoms or vulnerable because of age or other illness may need hospital treatment to manage dehydration. Patients should stay away from work or school until 48 hours after last episode of diarrhoea or vomiting.

 HEPATITIS

The hepatitis viruses (HPV) A, B, C, D and E cause acute hepatitis. HPVB and, particularly, HPVC, can cause chronic infection that can lead to cirrhosis, liver failure, and liver cancer. All types of viral hepatitis are notifiable diseases in UK. Practices will have a policy for vaccinations against hepatitis A and B. Acute infection may present with:

• nausea and vomiting
• myalgia
• fatigue/malaise
• right upper quadrant pain
• change in sense of smell or taste
• coryza
• photophobia
• headache.

Diarrhoea (with pale stools) and dark urine may also be present. However, often no signs unless jaundice develops, when hepatomegaly, splenomegaly and lymphadenopathy may occur.

Hepatitis A Previously a common childhood infection in the UK but now unusual. May occur in outbreaks in institutions, and is common in travellers. Infection confers immunity. Spread normally by the faecal-oral route (ingestion of food or drink contaminated by infected stool) but occasionally through blood. Usually self-limiting (rarely fulminant); there is no carrier state, and chronic liver disease does not occur. HPVA vaccine can protect people at high risk, eg, those who have been in contact with an infected person, travellers to countries where the infection is common, and injecting drug users.

Hepatitis B Early symptoms flu-like; infection can lead to liver disease and liver cancer. HPVB is 10-100 times more infectious than HIV. Transmitted by contact with infected blood or body fluids, e.g. by:

• sharing or use of contaminated equipment during injecting drug use
• vertical transmission (mother to baby) from an infectious mother to her unborn child
• sexual transmission
• receipt of infectious blood (via transfusion) or infectious blood products (e.g. clotting factors)
• needlestick or other sharps injuries (in particular those sustained by healthcare workers)
• tattooing and body piercing.

HPVB vaccination:

• should be given to all individuals at risk, including health professionals.
• is usually provided free (on the NHS) to people in a high-risk group.
• is not free if requested for travel abroad.

GPs are not obliged to offer HPVB vaccine free for occupational purposes; if it is required, many employers will offer to pay.

Hepatitis C Often asymptomatic initially; 15-20% clear their infection within 2-6 months. Of those with chronic infection, some remain well but many develop mild to moderate liver damage (with or without symptoms); of these, 20% progress to cirrhosis over 20–30 years. Excessive alcohol consumption increases risk of severe liver complications. HPVC blood borne and most often acquired through injecting drug use; also by sharing razors or toothbrushes or during body piercing (eg, tattooing, acupuncture) with non-sterile needles. Was also spread by blood transfusions before September 1992, when screening for hepatitis C was brought in. There is no vaccine. Increasingly effective drug treatment (not suitable for everyone, lasts 6 or 12 months) can clear the virus in c. 50%. Around 100,000 people in England are thought to have undiagnosed HPVC; DH runs awareness campaigns to promote diagnosis and treatment.

Hepatitis D An important cause of acute and severe chronic liver damage in some parts of the world (Mediterranean, parts of Eastern Europe, Middle East, Africa, and South America). Occurs only in people infected with HPVB.

Hepatitis E Uncommon in the UK, but common in Asia, Africa and Central America, particularly where sanitation is poor. Disease is usually mild but rarely can be fatal, particularly in pregnant women. Transmission and clinical features similar to HPVA. See also Travel health, Sexual health

Upper abdominal pain/discomfort, often with combination of other symptoms, e.g. bloating, early satiety, nausea or vomiting, heartburn. A complaint of ‘indigestion’ requires consideration of all possible sources, including oesophagus, stomach, heart, liver, gall bladder, pancreas, bowel, NSAIDs (common precipitants of dyspepsia) and other drugs. Enquiry about a predominant symptom, eg upper abdominal discomfort, pain, heartburn or reflux, can help distinguish dyspepsia from gastro-oesophageal reflux disease (GORD).

Dyspepsia

In uncomplicated dyspepsia (pathology outside stomach and proximal duodenum thought unlikely), initial therapeutic strategies are empirical treatment with a proton pump inhibitor or testing for, and treating Helicobacter pylori (a bacterium associated with upper GI disease). If symptoms recur or persist after eradication therapy, further assessment may be considered, including endoscopy, irrespective of age.

GASTRO-OESOPHAGEAL REFLUX DISEASE (GORD)

Patients present with heartburn/acid regurgitation (and may also have mucosal damage) that is caused by abnormal reflux of gastroduodenal contents into the oesophagus (acid reflux). In patients under 55 years with symptoms of reflux, endoscopy for the detection of cancer is indicated only if an alarm symptom is also present. See below, Upper GI red flags. Antacids and acid-suppressing drugs, in short courses or long term, can control symptoms

INFLAMMATORY BOWEL DISEASE

Chronic, relapsing-remitting diseases in which the gut is acutely inflamed.

Ulcerative colitis is confined in the gut to the colo-rectal mucosa; eyes, skin or joints also may be inflamed. Main symptom is frequent, watery diarrhoea (may contain blood and/or mucus); may also be abdominal cramping during bowel movements. Increased risk of colon cancer, so patients should have regular colonoscopy. Affects about 1 in 500 people; 55% have flare-ups every few months, some monthly or weekly, others less often.

Crohn’s disease can affect any part of the GI tract from mouth to anus Symptoms include: diarrhoea (may contain blood, pus or mucus); painful and swollen abdomen; fever; rectal bleeding; fissures, ulcers, abscesses around anus. Other problems during active disease include mouth and skin ulcers, joint pain, eye inflammation, rashes, fertility problems. May be complications if severe, long-term inflammation. Affects c. 1 in 700 people; some have frequent flare-ups, others one or two in their lifetime

IRRITABLE BOWEL SYNDROME (IBS)

Common, long-term, relapsing and remitting lifelong condition. Symptoms include abdominal pain/discomfort associated with defecation, abdominal distension, and change in bowel habit (constipation or diarrhoea).

NON-ALCOHOLIC FATTY LIVER DISEASE (NAFLD)

Accumulation in the liver of triglycerides, the most common fats in the body, associated with obesity. Often noted incidentally on ultrasound examination. Patients usually asymptomatic, and NAFLD usually causes no harm. But for increasing numbers, NAFLD over a long period leads to inflammation (hepatitis) and scarring (fibrosis), which may progress to life-threatening cirrhosis.