GASTROENETEROLOGY:

MANAGEMENT OF COMMON
CONDITIONS
CONTENT

a. Abdominal pain causes including indigestion.

b. Dysphagia
c. Hematemesis
d. Constipation
e. Jaundice
f. Liver enzymes abnormalities in adults (blood
results)
ABDOMINAL PAIN

Example presentations of abdominal pain:

➢ A female with lower abdominal (R or L lower quadrant)

➢ A male/female patient with lower abdominal suprapubic
pain
➢ A patient central upper abnormal pain
➢ A patient with generalized abdominal pain
➢ A patient R upper quadrant pain
➢ A patient with R/L flank pain

DDs (According to site)

Upper abdominal central pain

- MI (inferior wall MI causes epigastric pain).

- AAA (Abdominal Aortic Aneurysm)
- Pancreatitis
- PUD (Peptic Ulcer Disease)
- Liver and Gall Bladder (Lt lobe of the liver and GB)
- GORD
- Trauma
Right upper quadrant pain
- Liver and Gall Bladder causes including
o Acute hepatitis
o Acute Cholecystitis
o Biliary Colic
o Acute Cholangitis
- Trauma
- Muscle spams
- Herpes Zoster

Generalised abdominal pain causes.

- Intestinal Obstruction
- Other bowl causes: IBS- IBD- cancer (change in bowl
habits- bleeding per rectum – alternating)
- Gastroenteritis - fever/D/V, dehydration/contact/eating
out.
- DKA: pain- vomiting- dehydration- uncontrolled DM).

Lower abdominal pain causes

- Female causes: PID, Ectopic, Ovarian Torsion, miscarriage
- Cystitis (suprapubic pain)
- Urinary retention (in old male: look for prostate causes,
including BPH and prostate cancer)
- UTI (upper and lower)
- Appendicitis
- Diverticulitis (L iliac fossa)
- Trauma
MANAGEMENT OF IBS:

- Talk to Senior.
- Investigation: FBC- infection makers- LFT/KFT/TFT-
vitamins level- U&E- Faecal calprotectin- TTG (celiac)- stool
analysis- faecal occult blood (rule out cancer) especially if
older than 50 with new onset or unexplained bowl
symptoms.
- Symptomatic:
o Keep diary of foods that cause the symptoms, if you
find relate it certain products, eliminate it.
o Example of such foods might be coffee, artificial
sweeteners, spices, leafy vegetables, bran, etc.
Smoking and stress exacerbate the symptoms.
Buscupan/loperamide if diarrhea and laxatives if
constipation.
o Stress management (includes exercise- Yoga-
Meditation- talk therapy).

- Specialist: urgent referral for colonoscopy (exclude

something serious. It is a thin flexible tube while in sedation
to visualise your colon and take a sample where needed).
o If the patient is 60 years and older with unexplained
bowl symptoms or iron deficiency anaemia.
o Or if the patient is 50 years old with unexplained rectal
bleeding,
o Or if the patient is 50 years old with rectal bleeding
and unexplained blow symptoms.
- Safety net for bowl cancer symptoms+ FLAWS+ persistence.
MANAGEMENT OF ACUTE PANCREATITIS

- Admit
- Talk to your senior.
- Investigations (all bloods esp. FBC, infection markers, S.
amylase, S. lipase, Blood sugar, KFT, LFT, U&E, ABG, LDH,
Cholesterol)- ECG – Abdominal US (exclude AAA,
complications) - urine dipstick- CT abdomen by senior.

- Symptomatic:
o Resuscitation: O2, IV fluids, pain killer, NG tube,
insulin in hyperglycaemia.
o Long-term management includes advice against
excessive alcohol consumption, statin if high
cholesterol, manage the cause (If Gall bladder stones,
pancreatic tumour).
o Continuous monitoring of observations, abdominal
symptoms. Blood sugar and S. amylase level.

- Specialist management: once recovered and if alcohol

abuse, referral to rehabilitation.

- Safety net: persistence, drowsy, fever, not passing urine.

- Follow up: it improves within few days or a week in most
situation unless complications develop. Complications
include Pseudocyst (resolves on its own). Infection/necrosis
which is treated by antibiotic according to hospital protocol
and surgery. Chronic pancreatitis is also another
complication.
MANAGEMENT OF ACUTE CHOLECYSTITIS

- Admit
- Investigations: FBC, infection markers, LFT/KFT/U&E, S.
cholesterol, S. Calcium, Abdominal US- ECG- urine
dipstick.

- Symptomatic:
o O2- IV fluids- IV antibiotics (broad spectrum according
to hospital protocol)- Pain killers.
o Elective surgical removal after resolution of infection
(Lap Chol Vs open according to patient’s situation).
o Long-term management of the cause: manage high
cholesterol, Statins if needed, if taking OCPs, it can be
changed after consultation with the patient.
o Regular monitoring of observations, symptoms and US.

- Specialist referral to surgery for evaluation and elective

surgery.

- Safety net: fever, jaundice, persistence of symptoms.

MANAGEMENT OF DKA

- If in GP- refer to A&E while stabilising the patient. If in

A&E, keep the patient in the hospital.
- Talk to you senior.
- Investigations: FBC- Random Blood sugar- Urine dipstick
(Ketones, Glucose)- U&E- ECG – ABG- KFT+ other basic
bloods.

- Symptomatic:
o O2- IV Fluids- IV insulin and correction of electrolyte
imbalance.
o If taking medications, make sure they are taken as
prescribed.
o If compliant, review the medication and adjust the
dosage.
o Give advice against sugary drinks and sweets and
following healthy die. Referral to a dietitian.
o Control BP and Cholesterol to avoid cardiovascular
complications.

- Specialist: Diabetes Clinic follow up. Screening for

retinopathy, neuropathy in foot clinic.
- Safety net: for recurrence, dehydration symptoms, FAST,
Chest pain, blurring of vision, pins and needles of hands
and feet.
MANAGEMENT OF INTESTINAL OBSTRUCTION

- Admit while regularly reviewing observations and

symptoms.
- Investigations: FBC- infection marker- ABG-
LFT/KFT/U&E- Abdominal X-ray erect- US- urine dip.
- Symptomatic: pain killer- IV fluids- O2- NG tube.
- Specialist: surgery specialist review for the cause- CT SCAN
abdomen
- Safety net: persistent- fever- dehydration.
MANAGEMENT OF GASTROENTERITIS

- Assess symptoms of dehydration and exclude other causes

of vomiting including IO, MI, DKA, pancreatitis and
hepatitis A.
- Investigations: FBC- infection markers- stool analysis/ +or –
culture - U&E- LFT.

- Symptomatic:
o usually require not treatment apart from rehydration
and plenty of fluids and small simple frequent meals.
o Avoid surgery drinks, spices or heavy fatty meals as it
can increase the diarrhea.
o Exclude Hep A. No medications to be given.
o Hand hygiene, use own utensils, cutlery not to be
shared, do not prepare meals for others until
symptom-free.
o Do not to go to work/school/nursery until you are
symptom-free.
o Report to Local Health Protection Team is suspected
food poisoning outbreak.

- Safety net for dehydration symptoms or persistence for more

than a week, fever, jaundice.
MANAGEMENT OF GORD

- Investigations: FBC- infection markers- LFT- U&E-

ECG/Heart attack markers if old patient and suspecting
inferior wall MI. Consider H-Pylori testing (breath test or
antigen in stool).

- Symptomatic:
o PPIs tablets in the morning before breakfast.
o Avoid smoking, alcohol, heavy fatty meals and
caffeinated drinks including energy drinks, hot liquids,
peppermint and citric fruits and juices.
o Eat small frequent meals.
o Elevate the bed from head side when you lay down.
o Do not at least 3 hours before bedtime.
o If dysphagia: exclude other causes including
oesophageal cancer, strictures, motility disorder.

- Referral to gut specialist: Tonometry to assess the tone of

Lower Oesophageal Sphincter (LES). If suspected Barret’s
Oesophagus, oesophageal cancer, Gastric Ulcer, Upper GI
endoscopy and biopsy.

- Safety net for: Dysphagia, FLAWS, Dizziness, SOB, feeding

problems, chest pain.

- Follow up appointment to check for improvement or

development of warning signs.
INDIGESTION

Indigestion is a vague term, explore the meaning. It could mean

heart burn, bloating, diarrhea, abdominal discomfort, difficulty
swallowing, upper tummy pain, abdominal distension, etc.

Causes of indigestion include:

- MI
- GORD
- PUD
- IBS
- Oesophageal motility disorder
- Dysphagia
- Malabsorption syndromes
- Bowl Cancer
DYSPHAGIA

Example presentations of dysphagia:

➢ A patient with progressive difficulty swallowing oto

solids and fluids but more to solids+/- difficulty feeding
+/- weight loss, loss of appetite, tiredness, dizziness,
heart racing, night fever, swollen glands, increasing
abdominal girth, repeated chest infections.
➢ A Patient with intermitted difficulty swallowing to
fluids.
➢ A Patient with a feeling that food getting stuck behind
chest bone.
➢ A Patient with pain while swallowing hot or cold drinks.

DD for Dysphagia:

▪ Oesophageal cancer: (FLAWS- to solids) vs Achalasia (to

fluids)
▪ GORD (bad breath- sour taste in mouth- painful
swallowing- heart burn- more when laying down)
▪ PU (upper tummy pain after food)
▪ Corrosives (ingestion)
▪ Procedures (had any)
Others:
- Painful dysphagia causes: (upper, middle, lower) mouth
ulcers- oesophageal motility disorder (sensitivity to
swallowing hot/cold drinks), tonsilitis (fever- sore throat-
difficult &painful swallowing)
- Pharyngeal pouch: neck swelling+ food particles
regurgitated in the morning+ foul smell.
- Neurological causes: stroke (FAST)- Multiple Sclerosis -
Globus hystericus (sense of ball in the neck) by exclusion.

MANAGEMENT OF SUSPECTED OESPHAGEAL

CANCER

- Fast track referral within 2 weeks for gut specialist if in GP/

if in hospital, admit if dehydrated, hypoglycemia, electrolyte
in balance.
- Talk to your senior.
- Investigations: (FBC- infection markers- Blood Sugar -ABG-
U&E- vitamin levels- LFT/KFT)- CXR (chest infections)
- Symptomatic: IV fluids to correct dehydration- correct
dehydration- Eat semi-solids or soft food. Avoid raw fruits
and vegetables. If failed, NG tube for feeding. If advanced,
administer a Stent in the gullet to help you eat.
- stent in gullet. BS: correct if low.
- Specialist: gut specialist for camera test (urgent)-
biopsy- CT SCAN CHEST. Management according to site,
size, stage and grade.
- Safety netting: spread- chest infections.
HEMATEMSIS

Red or brown?

DDs:

- Mouth: procedure- oral surgery

- Oesophagus: cancer- varices- Mallory Weiss
o For varices: fresh blood- liver problem- LL swelling-
tummy distension- change is skin colour/stool-
alcohol- history of blood transfusion- IV drug abuse-
sexual for hepatitis)
o Cancer: difficulty swallowing+ FLAWS
- Stomach: cancer- Ulcer
o Cancer: flaws
o PU: tummy pain pointed by fingers- coffee colour
blood- PMHx of PU- NSAID/aspirin /Steroids.
- Duodenum: ulcer
MANAGEMENT

- Admit
- Senior
- Investigations: FBC- clotting profile- LFT- blood group
and cross matching- KFT- U&E- US on tummy- erect
abdomen x ray to exclude perforation- CXR
- Symptomatic:
o Resuscitation: O2 if needed+ IV fluids+ PPI+ stop
the NSAID of taking+ blood if needed- management
of the cause.
o Long-term management and advice: DESA when
stable- arrange appointment+ iron if iron deficiency
anaemia.
- Specialist: camera test by gut specialist from mouth-
biopsy if needed. Injection of varices if any. (Diagnostic and
therapeutic).
- Safety net: persistent- drowsy- fainting.
CONISTIPATION

Presentations
➢ Absolute with no flatus
➢ Hard stool/ reduced frequency

DDs
- Intestinal Obstruction (absolute- no flatus- +/- vomiting or
Nausea).
- Life-style causes: Diet- related and decreased mobility
- Medication side effects like opioids and iron
- Faecal impaction
- Bowl cancer
- Hypothyroidism
- Neuropathies such as Diabetic neuropathy
- Complications which become a cause later: anal
fissure/Haemorrhoids.
MANAGEMENT OF POST- OPERATIVE
CONISTIPATION

- Exclude intestinal obstruction, medication side effects,

faecal impaction, low fluid intake, low mobility, lack of fibre
in diet+ cancer colon in old patients.
- Examine: Observations, abdomen, DRE and BMI, skin
colour for pallor or jaundice and glands in the body
- Talk to senior.
- Investigations include FBC, LFT, U&E, TFT.
- Symptomatic: In faecal impaction:
o Stop the medication and replace by another pain killer.
o Oral laxative like Lactulose (Osmotic laxative), senna,
bisacodyl, and sodium pico-sulphate (Stimulant). If
failed suppository, bisacodyl suppository.
o If failed, inject a medication in fluid form through the
back passage (Enema, Docusate and sodium citrate).
o If failed, manual evacuation.
- If suspected other cause, investigate further. For example,
colonoscopy/Abdominal CT of suspected colon cancer,
abdominal X-ray erect, US and CT abdomen if intestinal
obstruction.
- Safety net: FLAWS, persistent, fever, vomiting.
- Prevention: Lifestyle advice: drink plenty of fluids, keep
active, have high fibre diet like vegetables, fruits and
wholemeal breads and pastas.
JAUNDICE IN ADULT

DDs
a. Hepatitis (A/B & C- Alcohol) (Nausea, Vomiting,
Diarrhea, eating out, travel- Hep B & Hep C: 3 IV
drug abuse/ sexual/blood transfusion- Alcohol)
b. Obstructive jaundice (Dark urine- pale stool-
itchiness)
c. Blood (hemolytic anemia, medication)
d. Others: Pancreatitis/ Pancreatic cancer
e. Liver Metastasis or Primary Tumor.

Presentations

➢ Deranged liver function

➢ Fever and R upper quadrant pain (cholecystic,
cholangitis, acute hepatitis)
➢ Epigastric pain radiating to the back+ fever+ Jaundice.
➢ Mild jaundice with stress and fasting that runs in
families.
➢ Jaundice in alcoholic patient
DERANGED LIVER FUNCTIONS (BLOOD TEST
RESULT)

According to result:
▪ Bilirubin (is raised in all causes)
▪ ALT/AST in any hepatitis. (viral)
▪ ALP raise in obstructive jaundice (with dark urine + pale
stool+ itch)
▪ AST+ GGT are raised in alcoholic hepatitis.
▪ All normal except slight rise in unconjugated bilirubin =
Gilbert $

Management
- Senior
- Investigations: Blood: (Retics- FBC-GGT- clotting factor-
Hep A, B, C if needed)- US for GB/liver- urine/stool.
- Symptomatic:
o Hep A- no medication- hand hygiene/ own utensils-
not to go to work until you are negative- Fluids- small
frequent meals.
o Alcohol management (rehab+ AA+ support+
Counselling+ Family Therapy+ management
withdrawal/craving).
o HEP B &C- anti viral treatment.
o Stress management for Gilbert.
 o Obstructive jaundice: resuscitation- IV fluids-
airsickness- pain killer.
- Specialist: liver specialist- obstructive- surgeon: (keyhole-
open).
- Safety net: Safe sex- STI- needle exchange- no blood
donation until treated.

Gilbert $

- Everything will be negative--Mild jaundice on stress

(fasting- infection- stress)- Isolated raise in the
unconjugated bilirubin- abnormality in liver enzymes- not
harmful.
- Reassure the patient.
- Exclude other causes as above,