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.

Alcohol consumption guidelines were revised in 2016 by the Chief Medical Officer, based on recommendations from an expert group report. The most significant change was a reduction in the recommended maximum number of units of alcohol for men from 21 to 14, aligning with the guidelines for women. The government now advises that both men and women should not exceed 14 units of alcohol per week, and if they do, it is best to spread it evenly over three or more days. Pregnant women are advised not to drink alcohol at all, as it can cause long-term harm to the baby. One unit of alcohol is equivalent to 10 mL of pure ethanol, and the strength of a drink is determined by its alcohol by volume (ABV). Examples of one unit of alcohol include a 25ml single measure of spirits with an ABV of 40%, a third of a pint of beer with an ABV of 5-6%, and half a 175ml standard glass of red wine with an ABV of 12%. To calculate the number of units in a drink, multiply the number of millilitres by the ABV and divide by 1,000.

If a patient experiences new-onset dysphagia, urgent endoscopy is necessary regardless of age or other symptoms. In the case of progressive dysphagia, it is crucial to rule out oesophageal or stomach cancer with a two week wait referral for gastroscopy. Gastroparesis, a delay in gastric emptying associated with diabetes, can be treated with metoclopramide. Plummer-vinson syndrome, which is characterized by iron deficiency anaemia and oesophageal webs, can also cause dysphagia along with glossitis and stomatitis. Gaviscon is not a suitable treatment for dysphagia as it only helps with dyspepsia. While a stroke can cause difficulties in initiating swallowing, it is typically sudden onset rather than progressive.

Understanding Dysphagia and its Causes

Dysphagia, or difficulty in swallowing, can be caused by various conditions affecting the esophagus, such as oesophageal cancer, oesophagitis, oesophageal candidiasis, achalasia, pharyngeal pouch, systemic sclerosis, and myasthenia gravis. Each condition has its own characteristic features, which can help in identifying the underlying cause of dysphagia. For instance, dysphagia associated with weight loss, anorexia, or vomiting during eating may indicate oesophageal cancer, while dysphagia of both liquids and solids from the start may suggest achalasia.

To determine the cause of dysphagia, patients usually undergo an upper GI endoscopy, which allows doctors to examine the esophagus and detect any abnormalities. Fluoroscopic swallowing studies may also be done to evaluate motility disorders. Additionally, a full blood count and ambulatory oesophageal pH and manometry studies may be required for certain conditions.

It’s important to note that new-onset dysphagia is a red flag symptom that requires urgent endoscopy, regardless of age or other symptoms. Therefore, understanding the different causes of dysphagia and their characteristic features can aid in prompt diagnosis and treatment.

Pharmacological Management of Irritable Bowel Syndrome

Irritable bowel syndrome (IBS) is a common gastrointestinal disorder that affects 10-20% of the population, with women being more susceptible than men. The condition is characterized by abdominal pain, bloating, and altered bowel habits without any specific organic pathology. Management of IBS involves psychological support, dietary measures, and pharmacological treatment for symptom relief.

Antispasmodics, such as mebeverine hydrochloride, are commonly used to alleviate pain and bloating in IBS patients. Loperamide is the first choice of antimotility agent for diarrhea, while laxatives are recommended for constipation. Tricyclic antidepressants (TCAs), such as amitriptyline, are considered a second-line treatment option for IBS patients who do not respond to other medications. However, the use of opioids, such as tramadol, is not recommended due to the risk of constipation, dependence, and tolerance.

In conclusion, pharmacological management of IBS should be tailored to the individual patient’s symptoms and needs, with a focus on providing relief from pain, bloating, and altered bowel habits. Regular review and adjustment of medication dosages are necessary to ensure optimal treatment outcomes.

According to NICE, the initial serological test for coeliac disease should be tissue transglutaminase antibodies.

Investigating Coeliac Disease

Coeliac disease is a condition caused by sensitivity to gluten, which can lead to villous atrophy and malabsorption. It is often associated with other conditions such as dermatitis herpetiformis and autoimmune disorders. Diagnosis of coeliac disease is made through a combination of serology and endoscopic intestinal biopsy. The gold standard for diagnosis is the biopsy, which should be performed in all patients with suspected coeliac disease to confirm or exclude the diagnosis. The biopsy traditionally takes place in the duodenum, but jejunal biopsies are also sometimes performed. Findings supportive of coeliac disease include villous atrophy, crypt hyperplasia, an increase in intraepithelial lymphocytes, and lamina propria infiltration with lymphocytes. Serology tests for coeliac disease include tissue transglutaminase antibodies and endomyseal antibodies, while anti-gliadin antibodies are not recommended. Patients who are already on a gluten-free diet should reintroduce gluten for at least six weeks prior to testing. Rectal gluten challenge is not widely used. A gluten-free diet can reverse villous atrophy and immunology in patients with coeliac disease.

Treatment and Diagnosis of Acute Pancreatitis

Acute pancreatitis can lead to systemic inflammatory response syndrome and multiple organ dysfunction syndromes. The mainstay of treatment is supportive measures such as fluid resuscitation and oxygen supplementation. Abdominal ultrasound can be useful to identify gallstones as the cause of pancreatitis, but fluid resuscitation takes priority. IV antibiotics are not indicated unless complications occur. Enteral feeding is preferred over nil by mouth, and parenteral feeding should be considered if enteral feeding is not tolerated. Urgent CT of the abdomen is not necessary in the acute stage unless complications are suspected. However, for severe pancreatitis, contrast-enhanced CT may be indicated four days after initial symptoms to assess for complications.

If a patient is taking aminosalicylates, they may experience various haematological adverse effects, such as agranulocytosis. Therefore, it is crucial to conduct a full blood count promptly if the patient presents with symptoms like fever, fatigue, bleeding gums, or a sore throat to rule out agranulocytosis. While C-reactive protein may be a part of the overall management plan, it is not the most critical initial investigation and is unlikely to alter the management plan. Similarly, while a throat swab may be necessary, it is not the most crucial initial investigation. The monospot test for glandular fever may be useful if glandular fever is suspected, but it is not the most important initial investigation.

Aminosalicylate drugs, such as 5-aminosalicyclic acid (5-ASA), are released in the colon and act locally as anti-inflammatories. The exact mechanism of action is not fully understood, but it is believed that 5-ASA may inhibit prostaglandin synthesis. Sulphasalazine is a combination of sulphapyridine and 5-ASA, but many of its side-effects are due to the sulphapyridine component, including rashes, oligospermia, headache, Heinz body anaemia, megaloblastic anaemia, and lung fibrosis. Other side-effects are common to 5-ASA drugs, such as mesalazine, which is a delayed release form of 5-ASA that avoids the sulphapyridine side-effects seen in patients taking sulphasalazine. However, mesalazine is still associated with side-effects such as gastrointestinal upset, headache, agranulocytosis, pancreatitis, and interstitial nephritis. Olsalazine is another aminosalicylate drug that consists of two molecules of 5-ASA linked by a diazo bond, which is broken by colonic bacteria.

It is important to note that aminosalicylates are associated with various haematological adverse effects, including agranulocytosis, and a full blood count (FBC) is a key investigation in an unwell patient taking them. Additionally, pancreatitis is seven times more common in patients taking mesalazine than in those taking sulfasalazine.

Common Gastrointestinal Conditions and Their Symptoms

Gastrointestinal conditions can present with a variety of symptoms, making diagnosis challenging. Here are some common conditions and their associated symptoms:

Oesophagitis: Inflammation of the oesophagus can cause asymptomatic, epigastric or substernal burning pain, dysphagia, and increased discomfort when lying down or straining. It is often caused by gastro-oesophageal reflux disease, alcohol, non-steroidal anti-inflammatory drugs, bisphosphonates, smoking, or Candida albicans infection. Treatment involves eliminating precipitating causes and using proton-pump inhibitors.

Oesophageal carcinoma: This type of cancer typically presents with worsening dysphagia, weight loss, heartburn, and changes in voice due to compression of the recurrent laryngeal nerve.

Gastric carcinoma: Symptoms of gastric cancer are often non-specific and include weight loss, anorexia, and fatigue. Heartburn and indigestion are rare.

Duodenal ulcer: Pain associated with duodenal ulcers is typically improved with eating and severe enough to impact nutritional intake, leading to weight loss. Patients at high risk of gastric ulceration due to medication use may be prescribed a proton-pump inhibitor.

Pancreatic carcinoma: This type of cancer often presents very late with painless jaundice and weight loss, which are not seen in the presented case.

Treatment Options for Helicobacter pylori Infection

Helicobacter pylori is a common bacterial infection that can cause dyspepsia and gastro-oesophageal reflux disease (GORD). There are several treatment options available for patients who test positive for H. pylori.

One option is a 7-day course of a proton pump inhibitor (PPI), amoxicillin, and either clarithromycin or metronidazole. This should be followed by a PPI for 4-8 weeks. Patients who are allergic to penicillin and have had previous exposure to clarithromycin should be offered a 7-day course of a PPI, bismuth, metronidazole, and tetracycline.

Long-term PPI and dietary advice alone will not eradicate H. pylori. If symptoms return after initial care strategies for dyspepsia, step down PPI therapy to the lowest dose needed to control symptoms. Patients with GORD should be offered full-dose PPI.

It is important to consult the British National Formulary (BNF) for appropriate doses of each drug, as they may vary. Sucralfate has no role in the eradication of H. pylori.

If you have been diagnosed with asymptomatic gallbladder stones, there is no need to worry. These stones are often found incidentally during imaging tests that are unrelated to gallstone disease. As long as you have not experienced any symptoms for at least a year before the diagnosis and the stones are located in a normal gallbladder and biliary tree, no intervention is necessary.

However, if you are experiencing symptoms or if the stones are located in the common bile duct, intervention is required. This can be done through surgical removal during laparoscopic cholecystectomy or through endoscopic retrograde cholangiopancreatography (ERCP) before or during the surgery. Rest assured that with proper intervention, you can effectively manage your gallbladder stones and prevent any complications.

Gallstones: Symptoms, Diagnosis, and Treatment

Gallstones are a common condition, with up to 24% of women and 12% of men affected. Local infection and cholecystitis may develop in up to 30% of cases, and 12% of patients undergoing surgery will have stones in the common bile duct. The majority of gallstones are of mixed composition, with pure cholesterol stones accounting for 20% of cases. Symptoms typically include colicky right upper quadrant pain that worsens after fatty meals. Diagnosis involves abdominal ultrasound and liver function tests, with magnetic resonance cholangiography or intraoperative imaging used to confirm the presence of stones in the bile duct. Treatment options include expectant management for asymptomatic gallstones, laparoscopic cholecystectomy for symptomatic gallstones, and early ERCP or surgical exploration for stones in the bile duct. Intraoperative cholangiography or laparoscopic ultrasound may be used to confirm anatomy or exclude CBD stones during surgery. ERCP carries risks such as bleeding, duodenal perforation, cholangitis, and pancreatitis.

Understanding Alcoholic Liver Disease and its Management

Alcoholic liver disease is a range of conditions that includes alcoholic fatty liver disease, alcoholic hepatitis, and cirrhosis. One of the characteristic findings in this disease is an elevated gamma-GT level. Additionally, a ratio of AST:ALT greater than 2, and especially greater than 3, strongly suggests acute alcoholic hepatitis.

When it comes to managing alcoholic hepatitis, glucocorticoids such as prednisolone are often used during acute episodes. The Maddrey’s discriminant function (DF) is used to determine who would benefit from glucocorticoid therapy. This function is calculated using prothrombin time and bilirubin concentration. Pentoxyphylline is also sometimes used as a treatment option.

A study called STOPAH compared the two common treatments for alcoholic hepatitis, pentoxyphylline and prednisolone. The study showed that prednisolone improved survival at 28 days, while pentoxyphylline did not improve outcomes. Understanding the different types of alcoholic liver disease and their management options is crucial for healthcare professionals in providing effective care for patients.

Irritable bowel syndrome (IBS) is a gastrointestinal disorder that causes abdominal pain, bloating, and changes in bowel habits without any identifiable organic pathology. It is more common in women and can be worsened by stress and the perimenstrual period. Diagnosis is made by ruling out other potential causes of symptoms. Management includes dietary changes, such as increasing fiber intake and avoiding trigger foods, as well as psychological support. Medications may also be used to alleviate symptoms. This patient’s symptoms are not consistent with chronic pancreatitis, ulcerative colitis, peptic ulcer disease, or diverticulitis.

According to NICE, it is not recommended to consume foods that are marketed exclusively for individuals with diabetes.

NICE updated its guidance on the management of type 2 diabetes mellitus (T2DM) in 2022, reflecting advances in drug therapy and improved evidence regarding newer therapies such as SGLT-2 inhibitors. The first-line drug of choice remains metformin, which should be titrated up slowly to minimize gastrointestinal upset. HbA1c targets should be agreed upon with patients and checked every 3-6 months until stable, with consideration for relaxing targets on a case-by-case basis. Dietary advice includes encouraging high fiber, low glycemic index sources of carbohydrates and controlling intake of foods containing saturated fats and trans fatty acids. Blood pressure targets are the same as for patients without type 2 diabetes, and antiplatelets should not be offered unless a patient has existing cardiovascular disease. Only patients with a 10-year cardiovascular risk > 10% should be offered a statin, with atorvastatin 20mg as the first-line choice.

Differential Diagnosis for a Patient with Worsening Ascites

Worsening ascites can be a sign of various underlying conditions. One possible diagnosis is hepatocellular carcinoma (HCC), which is a primary malignancy of the liver that often occurs in patients with chronic liver disease and cirrhosis. Another possible diagnosis is chronic active hepatitis, which is caused by the hepatitis C virus and can result in joint and muscle pain, nausea, and exhaustion. Superimposed hepatitis B infection can also cause liver injury and jaundice. Alcoholism, which can lead to alcoholic hepatitis, is another possible diagnosis, but it is not consistent with the clinical scenario given if there has been no further alcohol consumption. Spontaneous bacterial peritonitis is an acute bacterial infection of ascitic fluid that can cause fever, abdominal pain, and other symptoms. It is important to consider these and other possible diagnoses when evaluating a patient with worsening ascites.

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.

To undergo a urea breath test, one must not have taken antibiotics within the last four weeks and must not have taken any antisecretory drugs, such as PPI, within the last two weeks.

Tests for Helicobacter pylori

There are several tests available to diagnose Helicobacter pylori infection. One of the most common tests is the urea breath test, where patients consume a drink containing carbon isotope 13 (13C) enriched urea. The urea is broken down by H. pylori urease, and after 30 minutes, the patient exhales into a glass tube. Mass spectrometry analysis calculates the amount of 13C CO2, which indicates the presence of H. pylori. However, this test should not be performed within four weeks of treatment with an antibacterial or within two weeks of an antisecretory drug.

Another test is the rapid urease test, also known as the CLO test. This involves mixing a biopsy sample with urea and a pH indicator. If there is a color change, it indicates the presence of H. pylori urease activity. Serum antibody tests can also be used, but they remain positive even after eradication. Culture of gastric biopsy can provide information on antibiotic sensitivity, while histological evaluation alone can be done through gastric biopsy. Lastly, the stool antigen test has a sensitivity of 90% and specificity of 95%.

Overall, these tests have varying levels of sensitivity and specificity, and the choice of test depends on the patient’s clinical presentation and the availability of resources.

Ischaemic colitis is a condition where a segment of the colon does not receive enough blood supply, resulting in varying degrees of tissue death. It is typically seen in older individuals with atherosclerosis of the mesenteric vessels, but can also be caused by other factors such as embolic disease, vasculitis, and trauma. The main symptom is severe pain that is not proportional to physical exam findings. Serum lactate levels may be elevated, but this does not necessarily indicate GI ischemia. Diagnosis can be confirmed with contrast-enhanced CT or early endoscopy. Prognosis is poor, especially in cases of occlusive mesenteric infarction. Colorectal cancer typically presents with bleeding, change in bowel habits, and abdominal pain, but the patient’s hyperacute onset of symptoms makes this diagnosis unlikely. Diverticulitis is inflammation of a diverticulum in the colon and presents with left lower quadrant pain, but the patient’s other symptoms are not consistent with this diagnosis. Community-acquired pneumonia and pyelonephritis also have different clinical presentations and are not likely in this case.

The elevated ferritin level can be attributed to the patient’s excessive alcohol consumption, as the typical transferrin saturation rules out iron overload as a potential cause.

Understanding Ferritin Levels in the Body

Ferritin is a protein found inside cells that binds to iron and stores it until it is needed in other parts of the body. When ferritin levels are increased, it is usually defined as being above 300 µg/L in men and postmenopausal women, and above 200 µg/L in premenopausal women. However, it is important to note that ferritin is an acute phase protein, meaning that it can be produced in higher quantities during times of inflammation. This can lead to falsely elevated results, which must be interpreted in the context of the patient’s clinical picture and other blood test results.

There are two main categories of causes for increased ferritin levels: those without iron overload (which account for around 90% of cases) and those with iron overload (which account for around 10% of cases). Causes of increased ferritin levels without iron overload include inflammation, alcohol excess, liver disease, chronic kidney disease, and malignancy. Causes of increased ferritin levels with iron overload include primary iron overload (hereditary hemochromatosis) and secondary iron overload (such as from repeated transfusions). To determine whether iron overload is present, the best test is transferrin saturation, with normal values being less than 45% in females and less than 50% in males.

On the other hand, reduced ferritin levels can indicate a deficiency in iron, which can lead to anemia. When iron and ferritin are bound together, a decrease in ferritin levels can suggest a decrease in iron levels as well. Measuring serum ferritin levels can be helpful in determining whether a low hemoglobin level and microcytosis are truly caused by an iron deficiency state.

There is insufficient evidence to support the use of PPIs in stopping bleeding, as in most cases, bleeding ceases without their administration. Administering IV proton pump inhibitors and fresh frozen plasma prior to endoscopy is incorrect, as PPIs should not be given and fresh frozen plasma should only be given to patients with specific blood clotting abnormalities.

Acute upper gastrointestinal bleeding is a common and significant medical issue that can be caused by various conditions, with oesophageal varices and peptic ulcer disease being the most common. The clinical features of this condition include haematemesis, melena, and a raised urea level due to the protein meal of the blood. The differential diagnosis for acute upper gastrointestinal bleeding includes oesophageal, gastric, and duodenal causes.

The management of acute upper gastrointestinal bleeding involves risk assessment using the Glasgow-Blatchford score, which helps clinicians decide whether patients can be managed as outpatients or not. Resuscitation is also necessary, including ABC, wide-bore intravenous access, and platelet transfusion if actively bleeding platelet count is less than 50 x 10*9/litre. Endoscopy should be offered immediately after resuscitation in patients with a severe bleed, and all patients should have endoscopy within 24 hours.

For non-variceal bleeding, proton pump inhibitors (PPIs) should not be given before endoscopy to patients with suspected non-variceal upper gastrointestinal bleeding. However, PPIs should be given to patients with non-variceal upper gastrointestinal bleeding and stigmata of recent haemorrhage shown at endoscopy. If further bleeding occurs, options include repeat endoscopy, interventional radiology, and surgery. For variceal bleeding, terlipressin and prophylactic antibiotics should be given to patients at presentation, and band ligation should be used for oesophageal varices and injections of N-butyl-2-cyanoacrylate for patients with gastric varices. Transjugular intrahepatic portosystemic shunts (TIPS) should be offered if bleeding from varices is not controlled with the above measures.

Overview of Common Cancers and Tumor Markers

Colorectal Cancer, Hepatocellular Cancer, Lung Cancer, Prostate Cancer, and Testicular Cancer are some of the most common types of cancer. Each type presents with different symptoms and may require different diagnostic tests. Tumor markers, such as carcinoembryonic antigen (CEA) for colorectal cancer, alpha-fetoprotein for hepatocellular and testicular cancer, and bombesin for lung cancer, can be used to screen high-risk groups, assess prognosis, detect recurrence, and monitor treatment. Digital rectal examination (DRE) is often used in conjunction with prostate-specific antigen (PSA) as a screening test for prostate cancer. Early detection and treatment can improve outcomes for patients with cancer.

The patient’s symptoms of dull, central abdominal pain that worsens after meals and radiates to the back, along with a history of regular alcohol consumption, suggest a diagnosis of chronic pancreatitis. Imaging studies, such as an abdominal X-ray or CT scan, may reveal pancreatic calcifications, which are a common finding in chronic pancreatitis. If imaging is inconclusive, a faecal elastase test may be used to assess pancreatic exocrine function. The presence of the football sign, air under the diaphragm, dilated loops of small bowel, or the Rigler sign on an abdominal X-ray would suggest other conditions such as gastrointestinal perforation or bowel obstruction, which do not fit the patient’s presentation.

If a patient has an enlarged gallbladder that is not tender and is accompanied by painless jaundice, it is unlikely to be caused by gallstones. Instead, it is important to consider the possibility of malignancy. Therefore, further investigation should be done to check for malignancy of the gallbladder or pancreas, as either of these conditions could lead to biliary obstruction, resulting in a mass and jaundice.

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.

Carcinoembryonic antigen can be utilized for post-operative recurrence monitoring in patients or evaluating the effectiveness of treatment in those with metastatic disease.

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.

Surgical repair is not necessary for the majority of patients with hiatus hernias. Instead, lifestyle advice and omeprazole are the recommended management options. In the case of a symptomatic hiatus hernia, such as acid reflux, ‘burning’ pain, halitosis, and frequent belching, pharmacological treatment is likely to be beneficial. While lifestyle advice is important, it should be combined with medication for symptom relief. Omeprazole alone is not sufficient, and patients should also be advised on the benefits of weight loss and dietary changes. Referral for laparoscopic fundoplication is not necessary for most patients with hiatus hernias, and initial management should focus on PPIs and lifestyle modifications.

Understanding Hiatus Hernia

Hiatus hernia is a medical condition that occurs when part of the stomach protrudes above the diaphragm. There are two types of hiatus hernia, namely sliding and rolling. The sliding type is the most common, accounting for 95% of cases, and occurs when the gastroesophageal junction moves above the diaphragm. On the other hand, the rolling type occurs when a separate part of the stomach herniates through the esophageal hiatus, while the gastroesophageal junction remains below the diaphragm.

Several risk factors can increase the likelihood of developing hiatus hernia, including obesity and increased intraabdominal pressure. Common symptoms of hiatus hernia include heartburn, dysphagia, regurgitation, and chest pain. To diagnose the condition, a barium swallow is the most sensitive test, although many patients undergo an endoscopy as a first-line investigation, with the hernia being found incidentally.

Conservative management, such as weight loss, is beneficial for all patients with hiatus hernia. Medical management involves proton pump inhibitor therapy, while surgical management is only necessary for symptomatic paraesophageal hernias. Understanding the causes, symptoms, and management options for hiatus hernia is crucial for effective treatment and improved quality of life.

To ensure proper identification of any pathology during the upper GI endoscopy, it is recommended that the patient discontinues the use of proton pump inhibitors, such as omeprazole, at least two weeks prior to the procedure.

Investigating Gastro-Oesophageal Reflux Disease

Gastro-oesophageal reflux disease (GORD) can be difficult to diagnose as there is often a poor correlation between symptoms and the appearance of the oesophagus during endoscopy. However, there are certain indications for upper GI endoscopy, including age over 55 years, symptoms lasting more than four weeks or persistent symptoms despite treatment, dysphagia, relapsing symptoms, and weight loss. If endoscopy is negative, further investigation may be necessary. The gold standard test for diagnosis is 24-hour oesophageal pH monitoring. It is important to consider these investigations in order to accurately diagnose and treat GORD.

Nicorandil, a medication used for angina, can lead to anal ulceration as a potential adverse effect. GTN spray may cause headaches, dizziness, and low blood pressure. Gastric discomfort is a possible side effect of both metformin and ibuprofen. Excessive use of paracetamol can result in liver damage.

Nicorandil is a medication that is commonly used to treat angina. It works by activating potassium channels, which leads to vasodilation. This process is achieved by stimulating guanylyl cyclase, which increases the levels of cGMP in the body. However, there are some adverse effects associated with the use of nicorandil, including headaches, flushing, and the development of ulcers in the skin, mucous membranes, and eyes. Additionally, nicorandil can cause gastrointestinal ulcers, including anal ulceration. It is important to note that nicorandil should not be used in patients with left ventricular failure.

When a young female experiences both abnormal liver function tests and a lack of menstrual periods, it is highly indicative of autoimmune hepatitis.

Understanding Autoimmune Hepatitis

Autoimmune hepatitis is a condition that affects mostly young females and has an unknown cause. It is often associated with other autoimmune disorders, hypergammaglobulinaemia, and HLA B8, DR3. There are three types of autoimmune hepatitis, which are classified based on the types of circulating antibodies present. Type I affects both adults and children and is characterized by the presence of anti-nuclear antibodies (ANA) and/or anti-smooth muscle antibodies (SMA). Type II affects children only and is characterized by the presence of anti-liver/kidney microsomal type 1 antibodies (LKM1). Type III affects adults in middle-age and is characterized by the presence of soluble liver-kidney antigen.

Autoimmune hepatitis may present with signs of chronic liver disease, and only 25% of cases present with acute hepatitis symptoms such as fever and jaundice. Amenorrhea is a common symptom. Diagnosis is made through the presence of ANA/SMA/LKM1 antibodies, raised IgG levels, and liver biopsy showing inflammation extending beyond the limiting plate, piecemeal necrosis, and bridging necrosis.

Management of autoimmune hepatitis involves the use of steroids and other immunosuppressants such as azathioprine. In severe cases, liver transplantation may be necessary.

Cholangitis can occur even in the absence of stones, although they are commonly associated with the condition. ERCP can be used to drain the biliary tree, but surgical exploration of the common bile duct may be necessary in certain cases.

Understanding Ascending Cholangitis

Ascending cholangitis is a bacterial infection that affects the biliary tree, with E. coli being the most common culprit. This condition is often associated with gallstones, which can predispose individuals to the infection. Patients with ascending cholangitis may present with Charcot’s triad, which includes fever, right upper quadrant pain, and jaundice. However, this triad is only present in 20-50% of cases. Other common symptoms include hypotension and confusion. In severe cases, Reynolds’ pentad may be observed, which includes the additional symptoms of hypotension and confusion.

To diagnose ascending cholangitis, ultrasound is typically used as a first-line investigation to look for bile duct dilation and stones. Raised inflammatory markers may also be observed. Treatment involves intravenous antibiotics and endoscopic retrograde cholangiopancreatography (ERCP) after 24-48 hours to relieve any obstruction.

Overall, ascending cholangitis is a serious condition that requires prompt diagnosis and treatment. Understanding the symptoms and risk factors associated with this condition can help individuals seek medical attention early and improve their chances of a successful recovery.

When a patient with type 2 diabetes and obesity presents with abnormal liver function tests, the most probable diagnosis is non-alcoholic fatty liver disease. To confirm this diagnosis, the patient will need to undergo a liver screen, ultrasound, and liver biopsy. While haemochromatosis should be considered in patients with both abnormal LFTs and diabetes, a normal ferritin level makes this diagnosis less likely.

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.