Gastroenterology

Liver cancer is the sixth most prevalent cancer and the third most common cause of cancer deaths worldwide with approximately 800,000 deaths globally per annum. Hepatocellular carcinoma (HCC), which arises from the liver cells, accounts for approximately 90% of liver cancer cases. Other primary liver cancers include intrahepatic cholangiocarcinomas (CC), arising from the bile ducts within the liver, which account for 9-10% of cases alongside rarer angiosarcomas and hepatoblastomas. HCC remains a challenge as it is commonly diagnosed late in its course, often in patients with other comorbidities, and only has limited treatment options leading to a poor five-year survival.

The combination of an aggressive disease, vague presenting symptoms and insensitive standard diagnostic tests is a key factor contributing to poor outcomes with only 15% of patients with pancreatic cancer having operable disease at diagnosis. The NICE guideline on referral for suspected cancer recommends urgent referral via a suspected cancer pathway referral if the patient is aged 40 and over with jaundice. It also recommends that an urgent direct access computerised tomography (CT) scan referral should be considered in patients aged 60 and over with weight loss and any of the following: diarrhoea; back pain; abdominal pain; nausea; vomiting; constipation; new onset diabetes. Pancreatic cancer requires a CT scan for diagnosis.

Non-alcoholic fatty liver disease (NAFLD) is now the most common cause of chronic liver disease in the Western world. Between 10 and 30% of NAFLD patients will develop non-alcoholic steatohepatitis (NASH) with a risk of progression to cirrhosis. Of those with NASH and fibrosis at presentation, studies have suggested that approximately 21% of patients will have some regression of fibrosis while 38% of patients will progress over five years’ follow-up.

Patients with inflammatory bowel disease (IBD) may previously have received a diagnosis of irritable bowel syndrome and there may be a delay in making the correct diagnosis. This is particularly the case in patients with ileal Crohn’s disease and those under 40. Diagnosis of IBD involves endoscopy and biopsy. Approximately 25% of people with IBD will have extra-intestinal manifestations of the disease, involving skin, eyes, joints or the liver. There is an increased risk of colorectal cancer in patients with ulcerative colitis.

Constipation is the most common childhood gastroenterological  problem, affecting 5-30% of children. Up to a third of these children will develop chronic constipation. The signs and symptoms of constipation in children are seldom clear and there is frequently a delay in seeking help in either a primary or secondary care setting. Patients and their parents often express concern that healthcare professionals do not take the problem seriously and the advice given is sometimes contradictory. Chronic constipation and soiling can have a massive impact on all aspects of a child's life, and that of their family, causing social, educational and psychological problems. [With external links to the evidence base]