What s New & Common Presentations in Upper GI. Dr Philip Woodland Consultant Gastroenterologist Royal London Hospital

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1 What s New & Common Presentations in Upper GI Dr Philip Woodland Consultant Gastroenterologist Royal London Hospital

2 Reflux Dysphagia Dyspepsia (inc H.pylori) Vomiting

3 The patient with reflux symptoms

4 The patient with reflux symptoms Young Short history Intermittent symptoms No red flags Middle age Longer history of reflux No red flags Any patient with red flags Lifestyle changes Alginate 4 weeks PPI Endoscopy What if symptoms persist?

5 The patient with reflux symptoms Young Short history Intermittent symptoms No red flags Middle age Longer history of reflux No red flags Any patient with red flags Lifestyle changes Alginate Endoscopy 4 weeks PPI

6 Young Short history Intermittent symptoms No red flags Middle age Longer history of reflux No red flags Any patient with red flags Endoscopy: Grade C/D oesophagitis or Barrett s Needs long term PPI / reflux control

7 Young Short history Intermittent symptoms No red flags Middle age Longer history of reflux No red flags Any patient with red flags Endoscopy: Normal Is reflux the cause? Do PPIs help? Is the patient happy to continue PPI? Are there alternatives?

9 Dysphagia Endoscopy (of course) If normal, and patient very symptomatic, please refer But, be aware the persistent feeling of a lump in throat is usually benign (globus)

10 Dyspepsia Not a diagnosis, and no universally agreed definition NICE: A range of symptoms arising from the upper GI tract (PW): Excluding reflux

12 Causes of dyspepsia Organic pathology Peptic ulcer disease H. pylori GI malignancy Biliary pain Drug-induced Others (chronic pancreatitis, coeliac, hypercalcaemia..) Functional dyspepsia No organic cause found (motility) (hypersensitivity) (microbiota)

13 NICE GUIDANCE IN ABSENCE OF RED FLAGS FOR ULCER TYPE DYSPEPSIA (i.e. not reflux) Test and treat for H.pylori (most suitable 1 st if true dyspeptic symptoms) Initial trial of 4 week full dose PPI (most suitable 2 nd line, or 1 st line for reflux)

14 Test and treat (H.pylori) Associated with low socioeconomic status Incidence is decreasing (particularly in tandem with economic development) UK - Infection in 20% under 40yrs, 50% over 60yrs Almost always colonised <10 yrs

15 Test and treat (H.pylori) Peptic ulcer disease Asthma / atopy Functional dyspepsia MALT lymphoma H. pylori Stomach cancer Oesophageal disease Iron deficiency

16 H pylori eradication in peptic ulcer disease 12-month ulcer remission 97%-98% if eradicated vs 61-65% if persistent infection (hence probable rationale in test and treat before empirical PPIs) Eradication better than short course PPI for healing of duodenal ulcers; superior to maintenance PPI in preventing gastric ulcer; superior to no treatment in preventing recurrence

17 Non-invasive testing for H. pylori Stool antigen or C13 urea breath test Stop PPI for 2 weeks before Urine or serum serology does not perform well in comparison

18 Treatment for H. pylori NICE: Offer people who test positive for H pylori a 7-day, twice-daily course of treatment with: a PPI and amoxicillin and either clarithromycin or metronidazole take into account previous exposure to clarithromycin or metronidazole. [new 2014]

19 Treatment for H. pylori Beware of drug resistance, NICE is probably outdated Clarithromycin and metronidazole resistance are increasing problems (>15% UK), and can develop during treatment More recent regimes include 14 day sequential therapies, quadruple therapies, fluoroquinolonecontaining therapies Ideally local guidelines should be drawn up and followed

20 Treatment for H. pylori (Royal London Hospital)

21 Treatment for H. pylori (Royal London Hospital) 14 days

22 Treatment for H. pylori Retest for successful eradication if: Symptoms persist Known peptic ulcer, other high risk situation Reinfection after successful eradication is rare (3-8%)

23 H. pylori negative dyspepsia without red flags Consider 4 week PPI therapy empirically But, consider other diagnoses

24 Dyspepsia differential diagnosis

25 Occasionally GORD can cause solely epigastric symptoms

26 MALIGNANCY CAN BE CONSIDERED WHERE: Red flags Abnormal bloods (LFTs, high platelets) At-risk patient group (FH, lifestyle) Concern by patient / GP ENDOSCOPY +/- IMAGING REFERRAL

27 DRUGS CAN CAUSE DYSPEPSIA IN ABSENCE OF PUD NSAIDS COX-2 inhibitors Calcium channel blockers Alendronate Orlistat Methylxanthines Potassium supplements Antibiotics (e.g. erythromycin)

28 BILIARY COLIC Intermittent episodes (30 mins to several hours) Severe epigastric / RUQ pain, not colicky Can radiate to back Sweating, nausea, vomiting, restlessness

29 Other causes: Rarely chronic pancreatitis Coeliac disease Rarely infiltration (Crohn s, sarcoid, lymphoma) Diabetes (gastroparesis) Hypercalcaemia Lead poisoning Mesenteric angina Abdominal wall pain

30 Dyspepsia Refer if red flags Consider referral if patient or GP concern Test and treat H.pylori probably first line otherwise Antigen test Off PPI Remember drug resistance Otherwise 4 weeks PPI, but remember other possible causes (e.g. imaging with US may be helpful)

31 Vomiting Psychogenic Alcohol Central Raised intracranial pressure Migraine Ves7bular neuroni7s Meningi7s Drugs NSAIDS Opiates Digoxin An7bio7cs Chemotherapy Upper GI Pep7c ulcer disease Gastric cancer Gastric outlet obstruc7on Gastroparesis Infec7on Hepa77s Gastroenteri7s Abdominal infec7on Func7onal syndromes Acute abdomen Appendici7s Biliary colic Cholecys77s Acute pancrea77s Acute small bowel obstruc7on Systemic Uraemia Diabe7c ketoacidosis Addison s

32 Upper GI Pep)culcer disease Gastric cancer Gastric outlet obstruc) on Gastroparesis Func) onal syndromes PEPTIC ULCER DISEASE Hopefully we have covered GASTRIC CANCER Weight loss Anaemia Pain More prevalent East Asia and areas of high H pylori prevalence

33 Upper GI Pep)culcer disease Gastric cancer Gastric outlet obstruc) on Gastroparesis Func) onal syndromes GASTRIC OUTLET OBSTRUCTION Most commonly in the context of peptic ulcer disease / malignancy (distal gastric cancer, pancreatic cancer) Nausea and vomiting within hours of eating (not immediate) Epigastric pain Early satiety Weight loss

34 Upper GI Pep)culcer disease Gastric cancer Gastric outlet obstruc) on Gastroparesis Func) onal syndromes GASTROPARESIS Objectively delayed gastric emptying in absence of mechanical obstruction Quite rare (prevalence 9 (male) 38 (female) per 100,000) Similar clinical features to gastric outlet obstruction Most commonly Diabetes (poor control) Post-surgical (vagal nerve injury) Idiopathic

35 Upper GI Pep)culcer disease Gastric cancer Gastric outlet obstruc) on Gastroparesis Func) onal syndromes FUNCTIONAL SYNDROMES Absence of organic pathology Cyclical vomiting syndrome Cannabis hyperemesis syndrome Rumination syndrome Chronic nausea vomiting syndrome

36 FUNCTIONAL VOMITING SYNDROMES: Cyclical vomiting syndrome 3 or more discreet episodes of vomiting with acute onset and lasting hours to days Absence of vomiting between episodes Episodes are stereotypical with regards to onset timing, symptoms and duration Association with migraine, mitochondrial disorders Can respond to migraine therapy, tricyclic antidepressants

37 FUNCTIONAL VOMITING SYNDROMES: Cannabis hyperemesis syndrome Similar to cyclical vomiting syndrome, but characterised by frequent cannabis use and more frequent symptoms (can be daily) Some patients exhibit frequent bathing/showering behaviour during attacks Treated with cannabis cessation (if symptoms persist, consider CVS)

38 FUNCTIONAL VOMITING SYNDROMES: Rumination syndrome Recurrent regurgitation of food contents into mouth with subsequent spitting or reswallowing Occurs soon (usually minutes) after meals Vomiting is effortless, without significant retching Nausea is not a feature Behavioural phenomenon

39 FUNCTIONAL SYNDROMES: Chronic nausea vomiting syndrome A diagnosis when all else is excluded

40 Questions on upper GI?

41 What s New & Common Presentations in Lower GI Dr Philip Woodland Consultant Gastroenterologist Royal London Hospital

42 Abdominal pain IBS Constipation Diarrhoea IBD

43 Chronic abdominal pain

44 Chronic abdominal pain i.e. History Examination Then, depending on findings choose from: Full blood count Liver function tests Inflammatory markers Coeliac serology Calcium Faecal calprotectin Ultrasound biliary, hepatic CT malignancy, pancreatic Gastroscopy Colonoscopy

45 IBS Up to 10-15% population Women more frequent than men (14% vs 9% prevalence) Up to 40% of gastroenterologists work, and we only see the tip of the iceberg May present with other functional disorders

46 IBS Diagnosis (Rome IV) Abdominal pain at least once per week for 3 months AND 2 of: Temporal relation to defecation Associated with change in stool frequency Associated with a change in stool form (appearance)

47 IBS Diagnosis (Rome IV) IBS - C IBS - D IBS with mixed bowel habits IBS unclassified

48 Most important differentials to exclude Inflammatory bowel disease (esp in younger) Colorectal cancer (esp in older) Coeliac disease (all)

49 Alarm features Age of onset after age 50 years Rectal bleeding or melena Very large volume or nocturnal diarrhoea Progressive abdominal pain Unexplained weight loss Laboratory abnormalities (iron deficiency anaemia, elevated C- reactive protein or faecal calprotectin) Family history of IBD or colorectal cancer

50 Sensible initial investigations FBC Coeliac serology (3% IBS ) CRP Faecal calprotectin (see later) History and examination consistent with IBS, absence of alarm symptoms and normal findings as above rules out organic disease in 95%

51 NICE guidelines (updated 2017) The following tests are not necessary to confirm diagnosis in people who meet the IBS diagnostic criteria: ultrasound rigid/flexible sigmoidoscopy colonoscopy; barium enema thyroid function test faecal ova and parasite test faecal occult blood hydrogen breath test (for lactose intolerance and bacterial overgrowth).

52 IBS treatment: diet and lifestyle (NICE)

53 IBS treatment: diet and lifestyle (NICE, new in 2015) If symptoms persist after simple measures, offer advice on further dietary management (to be given by an expert)

54 Low FODMAP Fermentable Oligosaccharides Disaccharides Monosaccharides And Polyols

55 Low FODMAP I.e. foods that, if poorly digested, can be fermented in large intestine Water drawn in, CO 2 and methane produced Low FODMAP 40 70% response

56 Low FODMAP

57 IBS treatment: drugs (NICE) Consider anti-spasmodics Consider laxatives (not lactulose) for constipation Consider TCAs as second line if laxatives, antidiarrhoeals or antispasmodics have not helped Consider SSRIs if TCAs ineffective

58 IBS-C treatment: drugs (NICE) Consider linaclotide if: Optimal doses of different laxative classes have not helped Patients have had constipation for 12 months Follow up at 3 months

59 IBS treatment: drugs (NICE)

60 IBS-D treatment: drugs (NICE) Loperamide 1 st line anti-diarrhoeal in IBS-D Beware pancreatitis (especially if previous cholecystectomy

61 IBS-D treatment: drugs (NICE) Eluxadoline is recommended as an option for treating irritable bowel syndrome with diarrhoea in adults, only if: the condition has not responded to other pharmacological treatments (for example, antimotility agents, antispasmodics, tricyclic antidepressants) or pharmacological treatments are contraindicated or not tolerated and it is started in secondary care. Stop eluxadoline at 4 weeks if there is inadequate relief of the symptoms of irritable bowel syndrome with diarrhoea

62 IBS treatment: psychological (NICE) Consider referral for CBD / hypnotherapy / psychotherapy if refractory to pharmacological treatments at 12 months

63 Individualised approach

64 Individualised approach 1. Low FODMAP 2. Loperamide 3. Consider TCA 4. Consider eluxadoline

65 Individualised approach 1. Simple laxatives 2. Consider SSRI 3. Consider linaclotide 4. Consider CBT / hypnotherapy

66 Constipation Secondary causes to consider Colorectal cancer Diabetes, hypothyroidism, hypercalcaemia Parkinson s, MS, autonomic neuropathy, spinal cord injury Myotonic dystrophy, scleroderma, amyloidosis Anal fissure, anal stenosis Drugs (opiates, TCAs, iron supplements) Low fibre diet, dehydration, sedentary lifestyle

67 Constipation Primary constipation Slow transit (self-explanatory) Dyssynergic defecation (difficulty expelling from anorectum) Irritable bowel syndrome (IBS-C) Primary idiopathic constipation

68 Constipation Lifestyle modification (activity, timing of defecation, diet and fibre) Laxatives Bulk forming (e.g. psyllium husk) Osmotic (lactulose, PEG) Stimulants (senna, bisacodyl) Stool softeners (glycerine suppositories) Multiple actions (Movicol) Can consider cause when choosing. Dyssernergic defecation (e.g. soft stools but cannot pass bulk forming and lifestyle) Slow transit (stimulants, osmotic)

69 Constipation - other drugs Lubiprostone (oral fatty acid activates chloride channels)

70 Constipation - other drugs Prucalopride (5HT-4 agonist)

71 Diarrhoea Rule out colorectal cancer / IBD / coeliac if chronic diarrhoea

72 Diarrhoea Other considerations: Bile salt malabsorption (esp if cholecystectomy) Microscopic colitis (middle aged / elderly, profuse watery diarrhoea all day Chronic pancreatitis (abdo pain, alcohol) Chronic infections (giardia, amoeba, C.diff travel or antibiotic history)

73 Inflammatory bowel disease It s near the end..you don t want a long lecture on IBD!

74 Inflammatory bowel disease What is worth knowing: Faecal calprotectin Useful test. Excellent sensitivity, so-so specificity Neutrophil derived protein Only use where IBD is suspected (will not diagnose e.g. cancer) In our lab <100 µg/g normal >200 µg/g clearly abnormal

75 Inflammatory bowel disease What is worth knowing: Drugs 5-ASAs can be safely prescribed (yearly U&E) Azathioprine / 6-MP require 3-monthly bloods Use steroids with caution (especially Crohn s not without specialist advice) Many patients are being switched to biosimilars

76 Inflammatory bowel disease What is worth knowing: Most patients have a comprehensive support network of nurses, doctors and pharmacists in secondary care

77 Inflammatory bowel disease What is worth knowing: Faecal transplant the solution to everything Good evidence in C.diff Some evidence in IBD Loads of coverage on media More info needed

78 Thank you

Irritable bowel syndrome in adults

Irritable bowel syndrome in adults NICE provided the content for this booklet which is independent of any company or product advertised Welcome In February 2008, NICE published a clinical guideline on