Hepatocellular carcinoma is primarily caused by hepatitis B worldwide, while in Europe, hepatitis C is the most common cause.

Hepatocellular carcinoma (HCC) is a type of cancer that ranks as the third most common cause of cancer worldwide. The leading cause of HCC globally is chronic hepatitis B, while chronic hepatitis C is the most common cause in Europe. The primary risk factor for developing HCC is liver cirrhosis, which can result from various factors such as hepatitis B and C, alcohol, haemochromatosis, and primary biliary cirrhosis. Other risk factors include alpha-1 antitrypsin deficiency, hereditary tyrosinosis, glycogen storage disease, aflatoxin, certain drugs, porphyria cutanea tarda, male sex, diabetes mellitus, and metabolic syndrome.

HCC tends to present late, and patients may exhibit features of liver cirrhosis or failure such as jaundice, ascites, RUQ pain, hepatomegaly, pruritus, and splenomegaly. In some cases, decompensation may occur in patients with chronic liver disease. Raised AFP levels are also common. Screening with ultrasound and alpha-fetoprotein may be necessary for high-risk groups, including patients with liver cirrhosis secondary to hepatitis B and C or haemochromatosis, and men with liver cirrhosis secondary to alcohol.

Management options for early-stage HCC include surgical resection, liver transplantation, radiofrequency ablation, transarterial chemoembolisation, and sorafenib, a multikinase inhibitor. It is important to note that Wilson’s disease is an exception to the typical causes of liver cirrhosis and HCC.

Elevated serum amylase levels are not always indicative of acute pancreatitis, as they can also be seen in cases of small bowel obstruction. In this scenario, the patient is experiencing abdominal pain, vomiting, and a lack of bowel movements or gas, which are all typical symptoms of small bowel obstruction. The fact that the patient has a history of abdominal surgery further supports this diagnosis, despite the misleading blood test results. Acute cholecystitis, on the other hand, presents with different symptoms such as fever, right upper quadrant pain, and systemic distress, and does not typically cause elevated amylase levels. Acute pancreatitis may also be considered as a differential diagnosis, but it is not associated with a lack of bowel movements or gas, and previous bowel surgery is not a risk factor. Ascending cholangitis and large bowel obstruction can also be ruled out based on the patient’s symptoms and test results.

Small bowel obstruction occurs when the small intestines are blocked, preventing the passage of food, fluids, and gas. The most common cause of this condition is adhesions, which can develop after previous surgeries, followed by hernias. Symptoms of small bowel obstruction include diffuse, central abdominal pain, nausea and vomiting (often bilious), constipation, and abdominal distension. Tinkling bowel sounds may also be present in early stages of obstruction. Abdominal x-ray is typically the first-line imaging for suspected small bowel obstruction, showing distended small bowel loops with fluid levels. CT is more sensitive and considered the definitive investigation, particularly in early obstruction. Management involves initial steps such as NBM, IV fluids, and nasogastric tube with free drainage. Some patients may respond to conservative management, but others may require surgery.

Distinguishing Causes of Obstructive Jaundice: A Medical Overview

Obstructive jaundice is a condition characterized by the yellowing of the skin and eyes due to the blockage of the bile ducts. Ascending cholangitis is a common cause of this condition, often associated with gallstone disease. Patients with this condition may experience fever, tachycardia, and abdominal pain. Influenza, on the other hand, rarely causes localized pain in the right upper quadrant and is unlikely to result in obstructive jaundice. Pancreatic cancer typically presents with painless jaundice, while acute hepatitis is often associated with a history of travel or high-risk behaviors. Biliary colic, which is caused by gallstones, can lead to colicky pain after eating. Understanding the different causes of obstructive jaundice is crucial in determining the appropriate treatment plan for patients.

Management of a Patient with ‘Red Flag’ Symptoms: Urgent Referral for Endoscopy

When managing a patient aged over 55 years with ‘red flag’ symptoms such as gastrointestinal bleeding, anorexia, weight loss, dysphagia, or the presence of an epigastric mass, it is crucial to refer them for an urgent endoscopy to exclude serious pathology such as malignancy. In such cases, it would be inappropriate to manage the patient with medication alone, even if a previous trial of proton pump inhibitors (PPIs) provided effective symptom relief. While dietary and lifestyle advice could be provided, it would not be an appropriate management strategy as a single intervention. Additionally, retesting for H. pylori would not be necessary as adequate triple therapy for H. pylori eradication has reported high cure rates. The priority in managing such patients is to refer them for urgent endoscopy to ensure timely diagnosis and appropriate treatment.

Studies have demonstrated that topical steroids are not very effective in the treatment of anal fissures.

Understanding Anal Fissures: Causes, Symptoms, and Treatment

Anal fissures are tears in the lining of the distal anal canal that can be either acute or chronic. Acute fissures last for less than six weeks, while chronic fissures persist for more than six weeks. The most common risk factors for anal fissures include constipation, inflammatory bowel disease, and sexually transmitted infections such as HIV, syphilis, and herpes.

Symptoms of anal fissures include painful, bright red rectal bleeding, with around 90% of fissures occurring on the posterior midline. If fissures are found in other locations, underlying causes such as Crohn’s disease should be considered.

Management of acute anal fissures involves softening stool, dietary advice, bulk-forming laxatives, lubricants, topical anaesthetics, and analgesia. For chronic anal fissures, the same techniques should be continued, and topical glyceryl trinitrate (GTN) is the first-line treatment. If GTN is not effective after eight weeks, surgery (sphincterotomy) or botulinum toxin may be considered, and referral to secondary care is recommended.

In summary, anal fissures can be a painful and uncomfortable condition, but with proper management, they can be effectively treated. It is important to identify and address underlying risk factors to prevent the development of chronic fissures.

Approaches to Managing Dyspepsia in Patients with Gastro-Oesophageal Reflux Disease

Patients with chronic gastro-oesophageal reflux disease (GORD) are at risk of developing Barrett’s oesophagus and oesophageal cancer. Therefore, patients aged 50 years or older with a history of chronic GORD should undergo at least one upper gastrointestinal (GI) endoscopy to screen for these conditions. In younger patients, long-term low-dose proton pump inhibitor (PPI) therapy may be considered, with dose adjustment if necessary. However, ongoing dyspepsia in a patient over 50 years old warrants further investigation to exclude serious pathology. Intermittent high-dose PPI therapy is currently only used in hospital for specific indications. Counselling with false reassurance should be avoided in patients with concerning symptoms.

Understanding and Managing Irritable Bowel Syndrome (IBS)

Irritable bowel syndrome (IBS) is a common functional gastrointestinal disorder that affects 10-20% of the population, with women being more likely to develop it than men. It is characterized by abdominal pain, bloating, and altered bowel habits without any specific organic pathology.

Diagnosis of IBS is based on the presence of symptoms such as abdominal pain or discomfort, bloating, and change in bowel habit for at least 6 months. Physical examination and further investigations are necessary to exclude other differential diagnoses.

Management of IBS primarily involves psychological support and dietary measures such as fiber supplementation, low FODMAP diets, increased water intake, and avoiding trigger foods. Pharmacological treatment is adjunctive and should be directed at symptoms. Anti-spasmodics, anti-diarrheals, and antidepressants may have a positive effect on symptoms.

It is important to note that symptoms not consistent with IBS, such as rectal bleeding, anorexia/weight loss, nocturnal symptoms, or fecal incontinence, should alert the clinician to the possibility of an organic pathology. Referral for psychological therapies should be considered for patients who do not respond to pharmacological treatments after 12 months and who develop a continuing symptom profile.

In certain studies, it has been demonstrated that fibre supplementation is equally effective to injection sclerotherapy.

Understanding Haemorrhoids

Haemorrhoids are a normal part of the anatomy that contribute to anal continence. They are mucosal vascular cushions found in specific areas of the anal canal. However, when they become enlarged, congested, and symptomatic, they are considered haemorrhoids. The most common symptom is painless rectal bleeding, but pruritus and pain may also occur. There are two types of haemorrhoids: external, which originate below the dentate line and are prone to thrombosis, and internal, which originate above the dentate line and do not generally cause pain. Internal haemorrhoids are graded based on their prolapse and reducibility. Management includes softening stools through dietary changes, topical treatments, outpatient procedures like rubber band ligation, and surgery for large, symptomatic haemorrhoids. Acutely thrombosed external haemorrhoids may require excision if the patient presents within 72 hours, but otherwise can be managed with stool softeners, ice packs, and analgesia.

Overall, understanding haemorrhoids and their management is important for individuals experiencing symptoms and healthcare professionals providing care.

It is not recommended to use faecal occult blood testing for colorectal cancer screening in symptomatic patients who are under the age of 60. This woman is displaying symptoms of irritable bowel syndrome and has normal blood results, without any red flag symptoms. Repeating the full blood count is unlikely to provide any additional information. The use of steroids and azathioprine is not appropriate for treating irritable bowel syndrome, as they are typically used for ulcerative colitis, which is not likely in this case.

Colorectal Cancer Screening: Faecal Immunochemical Test (FIT)

Colorectal cancer is often developed from adenomatous polyps. Screening for this type of cancer has been proven to reduce mortality by 16%. The NHS offers a home-based screening programme called Faecal Immunochemical Test (FIT) to older adults. A one-off flexible sigmoidoscopy was trialled in England for people aged 55 years, but it was abandoned in 2021 due to the inability to recruit enough clinical endoscopists, which was exacerbated by the COVID-19 pandemic. The trial, partly funded by Cancer Research UK, showed promising early results, and it remains to be seen whether flexible sigmoidoscopy will be used as part of a future bowel screening programme.

Faecal Immunochemical Test (FIT) Screening:
The NHS now has a national screening programme that offers screening every two years to all men and women aged 60 to 74 years in England and 50 to 74 years in Scotland. Patients aged over 74 years may request screening. Eligible patients are sent FIT tests through the post. FIT is a type of faecal occult blood (FOB) test that uses antibodies that specifically recognise human haemoglobin (Hb). It is used to detect and quantify the amount of human blood in a single stool sample. FIT has advantages over conventional FOB tests because it only detects human haemoglobin, as opposed to animal haemoglobin ingested through diet. Only one faecal sample is needed compared to the 2-3 for conventional FOB tests. While a numerical value is generated, this is not reported to the patient or GP. Instead, they will be informed if the test is normal or abnormal. Patients with abnormal results are offered a colonoscopy. At colonoscopy, approximately 5 out of 10 patients will have a normal exam, 4 out of 10 patients will be found to have polyps that may be removed due to their premalignant potential, and 1 out of 10 patients will be found to have cancer.

Comparison of Crohn’s Disease and Ulcerative Colitis

Crohn’s disease and ulcerative colitis are two types of inflammatory bowel disease that affect the gastrointestinal tract. Crohn’s disease can occur anywhere along the GI tract, while ulcerative colitis typically only affects the large intestine.

One characteristic of Crohn’s disease is the presence of skip lesions, or areas of inflammation discontinuity. The colon wall may also appear thickened and have a cobblestone appearance. In contrast, ulcerative colitis shows continuous inflammation in affected areas, with a thinner colon wall and ulcers limited to the mucous lining of the large intestine.

Both diseases can cause rectal bleeding, but it is more common in ulcerative colitis. Other symptoms of ulcerative colitis include frequent stools and mucus discharge from the rectum, while Crohn’s disease often presents with prolonged diarrhea and abdominal pain.

Pseudopolyps, or benign lesions originating from the mucosa, can occur in both diseases but are more prevalent in ulcerative colitis. Crypt abscess formation, characterized by intense infiltration of the mucosa and submucosa with neutrophils and crypt abscesses, is a hallmark of ulcerative colitis.

Management of these diseases includes medical therapy, endoscopy, and surgery for complications such as bleeding or obstruction. Understanding the differences between Crohn’s disease and ulcerative colitis is crucial for proper diagnosis and treatment.

Abnormal liver function tests in the context of obesity may suggest the presence of non-alcoholic fatty liver disease.

Non-Alcoholic Fatty Liver Disease: Causes, Features, and Management

Non-alcoholic fatty liver disease (NAFLD) is a prevalent liver disease in developed countries, primarily caused by obesity. It encompasses a range of conditions, from simple steatosis (fat accumulation in the liver) to steatohepatitis (fat with inflammation) and may progress to fibrosis and liver cirrhosis. Insulin resistance is believed to be the primary mechanism leading to steatosis, making NAFLD a hepatic manifestation of metabolic syndrome. Non-alcoholic steatohepatitis (NASH) is a type of liver damage similar to alcoholic hepatitis but occurs in the absence of alcohol abuse. It affects around 3-4% of the general population and may be responsible for some cases of cryptogenic cirrhosis.

NAFLD is usually asymptomatic, but hepatomegaly, increased echogenicity on ultrasound, and elevated ALT levels are common features. The enhanced liver fibrosis (ELF) blood test is recommended by NICE to check for advanced fibrosis in patients with incidental NAFLD. If the ELF blood test is not available, non-invasive tests such as the FIB4 score or NAFLD fibrosis score, in combination with a FibroScan, may be used to assess the severity of fibrosis. Patients with advanced fibrosis should be referred to a liver specialist for further evaluation, which may include a liver biopsy to stage the disease more accurately.

The mainstay of NAFLD treatment is lifestyle changes, particularly weight loss, and monitoring. Research is ongoing into the role of gastric banding and insulin-sensitizing drugs such as metformin and pioglitazone. While there is no evidence to support screening for NAFLD in adults, NICE guidelines recommend the management of incidental NAFLD findings.

Acute mesenteric ischaemia (AMI) is a rare but potentially life-threatening condition caused by inadequate blood flow through the mesenteric vessels, leading to ischaemia and gangrene of the bowel wall. It can be classified as either arterial or venous, with embolic phenomena being the most common cause. Symptoms include sudden and severe abdominal pain, vomiting, and diarrhoea, with physical signs developing late in the disease process. Early and aggressive diagnosis and treatment are crucial to reduce mortality, but once bowel wall infarction has occurred, the mortality rate may be as high as 90%. Appendicitis, diverticulitis, pseudomembranous colitis, and ruptured AAA are important differential diagnoses to consider.

Treatment Options for Gastric Ulcers

Gastric ulcers can be caused by long-term use of non-steroidal anti-inflammatory drugs (NSAIDs) and can lead to severe symptoms requiring hospitalization. Treatment options for gastric ulcers include intravenous proton pump inhibitors (PPIs) followed by long-term oral PPIs. A repeat gastroscopy is usually carried out to ensure that the ulcer has healed. In cases where the ulcer has perforated or is malignant, a partial gastrectomy may be indicated. Retesting for H. pylori may be necessary if the patient had previously tested positive. Adrenalin injection is only indicated for bleeding gastric ulcers. Placing the patient nil by mouth is not necessary for healing the ulcer.

Gastric emptying dysfunction can cause upper gastrointestinal symptoms and disrupt glucose control. Metoclopramide, a pro-kinetic medication, can help improve gastric emptying and alleviate these issues.

Diabetes can cause peripheral neuropathy, which typically results in sensory loss rather than motor loss. This often affects the lower legs first due to the length of the sensory neurons supplying this area, resulting in a glove and stocking distribution. Painful diabetic neuropathy is a common issue that can be managed with drugs such as amitriptyline, duloxetine, gabapentin, or pregabalin. If these drugs do not work, tramadol may be used as a rescue therapy, and topical capsaicin may be used for localized neuropathic pain. Pain management clinics may also be helpful for patients with resistant problems.

Gastrointestinal autonomic neuropathy can cause gastroparesis, which can lead to erratic blood glucose control, bloating, and vomiting. This can be managed with prokinetic agents such as metoclopramide, domperidone, or erythromycin. Chronic diarrhea, which often occurs at night, is another potential complication of diabetic neuropathy. Gastroesophageal reflux disease can also occur due to decreased lower esophageal sphincter pressure.

To screen for colorectal cancer, faecal immunochemical tests (FIT) are utilized. Patients aged 60-74 years in England and 50-74 years in Scotland receive screening kits every 2 years. If the test results are abnormal, the patient is provided with the option of undergoing a colonoscopy.

Colorectal Cancer Screening: Faecal Immunochemical Test (FIT)

Colorectal cancer is often developed from adenomatous polyps. Screening for this type of cancer has been proven to reduce mortality by 16%. The NHS offers a home-based screening programme called Faecal Immunochemical Test (FIT) to older adults. A one-off flexible sigmoidoscopy was trialled in England for people aged 55 years, but it was abandoned in 2021 due to the inability to recruit enough clinical endoscopists, which was exacerbated by the COVID-19 pandemic. The trial, partly funded by Cancer Research UK, showed promising early results, and it remains to be seen whether flexible sigmoidoscopy will be used as part of a future bowel screening programme.

Faecal Immunochemical Test (FIT) Screening:
The NHS now has a national screening programme that offers screening every two years to all men and women aged 60 to 74 years in England and 50 to 74 years in Scotland. Patients aged over 74 years may request screening. Eligible patients are sent FIT tests through the post. FIT is a type of faecal occult blood (FOB) test that uses antibodies that specifically recognise human haemoglobin (Hb). It is used to detect and quantify the amount of human blood in a single stool sample. FIT has advantages over conventional FOB tests because it only detects human haemoglobin, as opposed to animal haemoglobin ingested through diet. Only one faecal sample is needed compared to the 2-3 for conventional FOB tests. While a numerical value is generated, this is not reported to the patient or GP. Instead, they will be informed if the test is normal or abnormal. Patients with abnormal results are offered a colonoscopy. At colonoscopy, approximately 5 out of 10 patients will have a normal exam, 4 out of 10 patients will be found to have polyps that may be removed due to their premalignant potential, and 1 out of 10 patients will be found to have cancer.

The likelihood of having an adenoma increases with a positive result on a faecal occult blood test.

Colorectal Cancer Screening: Faecal Immunochemical Test (FIT)

Colorectal cancer is often developed from adenomatous polyps. Screening for this type of cancer has been proven to reduce mortality by 16%. The NHS offers a home-based screening programme called Faecal Immunochemical Test (FIT) to older adults. A one-off flexible sigmoidoscopy was trialled in England for people aged 55 years, but it was abandoned in 2021 due to the inability to recruit enough clinical endoscopists, which was exacerbated by the COVID-19 pandemic. The trial, partly funded by Cancer Research UK, showed promising early results, and it remains to be seen whether flexible sigmoidoscopy will be used as part of a future bowel screening programme.

Faecal Immunochemical Test (FIT) Screening:
The NHS now has a national screening programme that offers screening every two years to all men and women aged 60 to 74 years in England and 50 to 74 years in Scotland. Patients aged over 74 years may request screening. Eligible patients are sent FIT tests through the post. FIT is a type of faecal occult blood (FOB) test that uses antibodies that specifically recognise human haemoglobin (Hb). It is used to detect and quantify the amount of human blood in a single stool sample. FIT has advantages over conventional FOB tests because it only detects human haemoglobin, as opposed to animal haemoglobin ingested through diet. Only one faecal sample is needed compared to the 2-3 for conventional FOB tests. While a numerical value is generated, this is not reported to the patient or GP. Instead, they will be informed if the test is normal or abnormal. Patients with abnormal results are offered a colonoscopy. At colonoscopy, approximately 5 out of 10 patients will have a normal exam, 4 out of 10 patients will be found to have polyps that may be removed due to their premalignant potential, and 1 out of 10 patients will be found to have cancer.

When dealing with a severe flare of ulcerative colitis, it is important to evaluate the severity of the condition. In this case, the patient is experiencing more than six bloody stools per day, as well as systemic upset indicated by raised inflammatory markers and anaemia. This places him in the severe category. The first line of treatment would be IV corticosteroids, with IV ciclosporin as a second-line option if the steroids do not induce remission. Hospital admission for IV steroids is the appropriate course of action to induce remission, after which maintenance treatment can be assessed. For moderate extensive disease, oral aminosalicylate and oral steroids can be used. It would be inappropriate to send this patient home without any treatment, as he is clearly unwell and experiencing a flare of UC.

Ulcerative colitis can be managed through inducing and maintaining remission. The severity of the condition is classified as mild, moderate, or severe based on the number of stools and presence of systemic upset. Treatment for mild-to-moderate cases of proctitis involves using topical aminosalicylate, while proctosigmoiditis and left-sided ulcerative colitis may require a combination of oral and topical medications. Extensive disease may require a high-dose oral aminosalicylate and topical treatment. Severe colitis should be treated in a hospital with intravenous steroids or ciclosporin. Maintaining remission can involve using a low maintenance dose of an oral aminosalicylate or oral azathioprine/mercaptopurine. Methotrexate is not recommended, but probiotics may prevent relapse in mild to moderate cases.

Management of Primary Anal Fissure: Treatment Options and Referral Guidelines

Primary anal fissure is a common condition that can cause significant pain and discomfort. The National Institute for Health and Care Excellence (NICE) provides guidelines for the management of this condition, which include prescribing rectal topical glyceryl trinitrate (GTN) 0.4% ointment for 6-8 weeks to relieve pain and aid healing. Referral to a colorectal surgeon is warranted if the fissure does not heal after this period. Botulinum toxin injections can be considered in secondary care settings for chronic and recurrent cases, but only after a trial of topical GTN. Taking no action is not recommended, as it can lead to chronic non-healing ulcers. Trying different laxatives, such as senna, is also unlikely to help and should not be the first-line treatment for anal fissure. Overall, early intervention with topical GTN and appropriate referral can improve outcomes for patients with primary anal fissure.

Ulcerative colitis is a type of inflammatory bowel disease that affects only the large bowel. Symptoms include rectal bleeding, frequent stools, and mucus discharge from the rectum. Diagnosis is confirmed through sigmoidoscopy, which reveals continuous inflammation with loss of normal mucosa and intense infiltration of the mucosa and submucosa with various immune cells. The presence of p-ANCA is highly associated with UC. Crohn’s disease, coeliac disease, ischaemic colitis, and diverticulitis have different clinical presentations and diagnostic criteria, which do not match the symptoms and test results of this patient.

Gastric Cancer: Risk Factors, Features, Investigations, and Management

Gastric cancer is a relatively uncommon cancer, accounting for only 2% of all cancer diagnoses in developed countries. It is more prevalent in older individuals, with half of patients being over 75 years old, and has a higher incidence in males. Risk factors for gastric cancer include Helicobacter pylori infection, atrophic gastritis, dietary factors such as salt and nitrate consumption, smoking, and blood group.

Symptoms of gastric cancer can be vague and include abdominal pain, dyspepsia, weight loss, anorexia, nausea, vomiting, and dysphagia. Overt upper gastrointestinal bleeding is rare. If the cancer has spread to the lymph nodes, Virchow’s node and Sister Mary Joseph’s node may be affected.

Diagnosis of gastric cancer is typically made through oesophago-gastro-duodenoscopy with biopsy. Signet ring cells may be present in gastric cancer, and a higher number of these cells is associated with a worse prognosis. Staging is done through CT scans.

Management of gastric cancer depends on the extent and location of the cancer. Surgical options include endoscopic mucosal resection, partial gastrectomy, and total gastrectomy. Chemotherapy may also be used.

Overall, gastric cancer is a relatively rare cancer with specific risk factors and symptoms. Early diagnosis and appropriate management are crucial for improving outcomes.