Upper GI bleeding is a common medical emergency with an incidence in the UK of 103 cases per 100,000 adults per year and is much more common in the elderly. A national audit on the management of upper GI bleeding in the UK, conducted between 1993 and 1994, showed 30-day mortality to be 14%. Several recommendations were made, including urgent endoscopy in high-risk patients and admission or early referral of patients with upper GI bleeding to gastroenterology teams. However, despite improvements in endoscopy, recognition of provoking factors and pharmacological interventions available when the audit was repeated in 2007 the mortality rate still remained significant at 10%.Rapid appropriate assessment and referral for early endoscopy can prevent morbidity and possibly reduce mortality. The use of reliable scoring systems has enabled early discharge and an evidence-based approach to subsequent secondary prevention can avoid recurrence.

Adenocarcinoma of the pancreas is one of the top ten leading causes of cancer deaths and in the UK approximately 8,000 people are diagnosed with the disease each year. The incidence is similar in men and women and rises with age. Rates increase significantly in people aged 45 years and over and around three-quarters of patients diagnosed with pancreatic cancer are over the age of 65. Treatment options include resectional surgery, which is the only chance of cure from the disease; and palliative stenting, chemotherapy and radiotherapy. Overall, the long-term prognosis of the disease is poor with a one-year survival rate of approximately 10-20%. For non-metastatic disease, median survival is six to ten months, although for those with metastatic disease at presentation median survival is only three to six months. Both one- and five-year survival rates for pancreatic cancer in the UK are lower than the European average. Despite improvements in imaging, surgical techniques and chemotherapy, overall survival has not improved appreciably in the past few decades.

In western societies about 80% of AP diagnoses occur secondary to gallstone disease and alcohol misuse. In the UK, AP is currently diagnosed in 150-420 per million population per annum, with a male to female ratio of 1.9:1.1 The incidence of AP in the UK has doubled since the 1960s, rising particularly in women under the age of 35 (by 11% per annum), which may be associated with altered patterns of alcohol consumption. AP of any cause can result in the initiation of multiple inflammatory cascades and the systemic inflammatory response syndrome, which can lead to multi-organ failure and even death early in the course of disease. If the disease is severe or prolonged, third space fluid losses and hypoperfusion can result in pancreatic necrosis, which is particularly susceptible to infection, and is responsible for most late deaths occurring secondary to acute pancreatitis. CP follows continued, repetitive or sustained injury to the pancreas, and 70% of diagnoses occur secondary to alcohol abuse. The pain and weight loss associated with CP remain extremely challenging to manage and all patients whose pain or weight loss is inadequately managed in the community setting should be referred for multidisciplinary assessment and consideration of interventional therapies.

Colorectal cancer is the third most common cancer in the UK, with an annual incidence of 36,100 in England and Wales. It is also the second leading cause of death from cancer in the UK. There has been a significant increase in five-year survival over the past decade, from 22% to 50% despite more than 55% of patients presenting with lymph node or distant metastases.Guidelines published by the Department of Health and subsequently by NICE have set down criteria for the urgent referral of patients with clinical features suggestive of colorectal cancer. However, analysis of this referral system  shows that it lacks sensitivity for detecting cancers (only 10.3% of referrals are ultimately found to have cancer) and that it fails to identify those with earlier, more treatable disease. Nevertheless, it is important to remember that the clinical features included within the guidelines have been selected because of their strong association with the disease.

Historically coeliac disease has been considered an uncommon, paediatric condition presenting with diarrhoea, weight loss, and failure to thrive. However, recent population studies show that coeliac disease is a common condition affecting around 1 in 100 people. The primary care team need to be alert to the complications of coeliac disease and other associated conditions.Patients with coeliac disease should be followed up on an annual basis to allow assessment of adherence with the diet, manage complications and detect any micronutrient deficiencies.

In general practice patients frequently present with pain or discomfort associated with eating. Dyspepsia can be defined as pain or discomfort centred in the upper abdomen which may be accompanied by nausea, vomiting, early satiety, bloating, pain or heartburn. Immediate referral is recommended for patients with dyspepsia and significant acute GI bleeding and urgent specialist referral for investigation if any of the following alarm symptoms are present: progressive difficulty swallowing; chronic GI bleeding; unintentional weight loss; persistent vomiting; abdominal mass;iron deficiency anaemia; or suspicious findings on barium meal. These features are suggestive of an increased likelihood of serious disease but are not at all specific.

Ulcerative colitis (UC) and Crohn's disease together constitute inflammatory bowel disease (IBD). The prevalence of UC is about 30-100 per 100,000 and 30-50 per 100,000 for Crohn's disease. They characteristically present in young adults, but may present at any time of life, including childhood and old age, and a second peak of incidence is now recognised in the sixth decade of life. UC always affects the rectum and then progresses to a variable extent around the colon, but never extends into the small bowel. By contrast, Crohn's disease may occur anywhere in the GI tract, from the mouth to the anus, with skip lesions - inflamed areas affected by Crohn's disease - separated by areas of apparently normal mucosa. The ileocaecal region is the most common site. Crohn's also frequently affects the colon, and can diffusely affect the small bowel. It rarely occurs in the oesophagus, stomach and duodenum. It is important that GPs have a high index of suspicion of IBD and initiate appropriate treatment for patients undergoing relapse of the disease. GPs also have a vital role in the monitoring of patients, often in collaboration with gastroenterologists, particularly for those patients on immunosuppressant therapy.

What dietary changes may help patients with irritable bowel syndrome? What drug treatments should be considered? When should patients be referred?

Which patients should be referred for endoscopy? When should H.pylori testing be carried out? Which symptoms are suggestive of gastric carcinoma?

Who is at risk of diverticular disease? When is surgery indicated? What are the non-surgical options?

What are the typical presenting features of coeliac disease? How can GPs screen for coeliac disease? Is there an association with other conditions?