Prompt diagnosis and treatment will improve outcomes in acute pancreatitis

27 Jul 2022Paid-up subscribers

Any patient presenting with acute abdominal pain should be assessed for a possible diagnosis of acute pancreatitis. A thorough history of the presenting illness is needed to determine the onset, duration, progress and nature of the pain. In acute pancreatitis the pain typically presents as severe epigastric pain radiating to the back and is worsened by movement, and classically leaning forwards alleviates the pain. 

Managing cardiovascular risk key in non-alcoholic fatty liver disease

27 Jul 2022Paid-up subscribers

Most people living with non-alcoholic fatty liver disease (NAFLD) are thought to remain undiagnosed and many are asymptomatic. Obesity, hypertension, type 2 diabetes and hyperlipidaemia are risk factors for NAFLD, and NAFLD is considered to be the liver component of metabolic syndrome. Cardiovascular risk should be stratified for all NAFLD patients and any cardiovascular risk factors managed aggressively. Patients should be given lifestyle advice aimed at weight loss and increased physical activity.

Prevention, diagnosis and treatment of colorectal cancer

26 Jul 2021Paid-up subscribers

Colorectal cancer is the third most common cancer in both women and men and is the second most common cause of cancer death in the UK. The main symptoms patients with colorectal cancer present with are: persistent blood in faeces; persistent change in bowel habit and persistent lower abdominal pain. Less obvious presentations are unexplained weight loss, tiredness for no reason, general malaise and iron deficiency anaemia found on blood testing.

Multidisciplinary care is key in chronic pancreatitis

26 Jul 2021Paid-up subscribers

In chronic pancreatitis chronic inflammation of the pancreas results in irreversible injury and fibrosis. The most common causal factor is excess alcohol consumption. Smoking is an independent risk factor. Gene mutations can lead to hereditary chronic pancreatitis and idiopathic disease, where no clear cause can be identified, accounts for 20-30% of cases. The typical presenting symptom is intermittent or continuous upper abdominal pain which may radiate to the back. The pain is commonly triggered or exacerbated by eating or alcohol consumption.

Early treatment can arrest or reverse cirrhosis

24 Jul 2020Paid-up subscribers

Around 60,000 people in the UK are estimated to have cirrhosis. It is now the third most common cause of premature death. Decompensation represents a watershed moment for patients with cirrhosis, with the median survival falling from > 12 years for compensated cirrhosis to approximately two years. Patients with cirrhosis should undergo six-monthly ultrasound to screen for the early development of primary hepatocellular carcinoma. They should also undergo an initial upper gastrointestinal endoscopy to screen for varices.

Tailor treatment to the patient with gallstone disease

24 Jul 2020Paid-up subscribers

Gallstones affect around 15% of adults in the UK. Between 50 and 70% of patients with gallstones are asymptomatic at diagnosis and only 10-25% of these individuals will go on to develop symptomatic gallstone disease. The vast majority (90-95%) of gallstones are cholesterol stones. Obesity is associated with an increased risk of symptomatic gallstones. Patients with symptoms suggestive of gallstones should be offered liver function tests and an abdominal ultrasound.

Early detection of liver cancer key to improving outcomes

07 Aug 2019

Hepatocellular carcinoma (HCC) accounts for around 90% of liver cancer cases and intrahepatic cholangiocarcinoma (CC) for 9-10%. Most cases of HCC occur in the context of chronic liver disease with cirrhosis, particularly in those with chronic hepatitis B or C. Other major risk factors include excessive alcohol consumption, obesity and aflatoxins. Overall, 10-15% of cirrhotic patients will develop HCC within 20 years. Patients presenting with an upper abdominal mass consistent with an enlarged liver should be referred for an urgent direct access ultrasound scan within two weeks. 

Optimising the treatment of inflammatory bowel disease

07 Aug 2019Paid-up subscribers

Inflammatory bowel disease (IBD) is a chronic inflammatory condition which runs a relapsing and remitting course. Ulcerative colitis (UC) is more common than Crohn’s disease (CD). UC almost always affects the rectum and extends proximally and continuously to the colon to a variable extent. CD most commonly affects the terminal ileum or colon but can affect any part of the gastrointestinal tract from the mouth to the anus. The vast majority (90%) of people with UC report bloody stools compared with less than 50% of those with CD. CD is characterised by a triad of abdominal pain, diarrhoea and weight loss.

Improving outcomes in pancreatic cancer

25 Jul 2018

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.

Diagnosing and managing colorectal cancer

25 Jul 2018

Colorectal cancer is the fourth most common cancer in the UK and is the second most common cause of cancer deaths. Most cancers are thought to develop from colonic adenomas and incidence is strongly related to age. The majority of cancers are left sided and typically present with a change in bowel habit, blood in the stool or colicky abdominal pain. Rectal cancers can present with fresh red bleeding and large tumours can cause tenesmus (the intense and frequent desire to defecate, with little or no stool passed). Right-sided cancers most often present with anaemia. In both right- and left-sided cancers occasionally the patient may notice an abdominal mass or inexplicable weight loss.

Be vigilant for non-alcoholic fatty liver disease in primary care

28 Jul 2017Paid-up subscribers

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.

Chronic pancreatitis may be overlooked and undertreated

28 Jul 2017

The prevalence of chronic pancreatitis is variable, with estimates between 4 and 52.4 per 100,000. A mismatch exists between reported incidence and prevalence in many studies suggesting chronic pancreatitis is under recognised. One cause for this mismatch is that once diagnosed many patients are lost to secondary care follow-up. Therefore, although a GP may only see two new cases during their career they are likely to encounter patients requiring recurrent consultations.

Improving the detection of coeliac disease

01 Aug 2016Registered users

The common presentation of coeliac disease has shifted from the historically classical symptoms of malabsorption in childhood to non-classical symptoms in adulthood such as irritable bowel syndrome-type symptoms, anaemia, chronic fatigue, change in bowel habit, abdominal pain and osteoporosis. A combination of coeliac serology and duodenal biopsy is required to diagnose coeliac disease in adults. A lifelong strict gluten-free diet is the only effective treatment currently available. All patients should be referred to a specialist dietitian for guidance and support.


Diagnosis and treatment of inflammatory bowel disease

01 Aug 2016Registered users

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.

Diagnosis and treatment of gallstone disease

22 Jun 2015Paid-up subscribers

Gallstone disease increases with age. Women have a higher prevalence of gallstones than men, which is attributed to exposure to oestrogen and progesterone. Liver function tests and an abdominal ultrasound should be offered to patients with symptoms suggestive of gallstone disease (e.g. abdominal pain, jaundice, fever). They should also be considered in patients with less typical but chronic abdominal or gastrointestinal symptoms.

Managing irritable bowel syndrome in primary care

22 Jun 2015Paid-up subscribers

The classic symptoms of irritable bowel syndrome (IBS) are abdominal pain, bloating and some form of bowel dysfunction. The abdomen feels flat in the morning and then gradually becomes more bloated as the day progresses reaching a peak by late afternoon or evening. Rectal bleeding, a family history of malignancy and a short history in IBS should always be treated with suspicion. Both pain and bowel dysfunction are often made worse by eating. It is recommended that a coeliac screening test is undertaken to rule out this condition.

Detecting patients with cirrhosis in primary care

25 Jul 2014Paid-up subscribers

Cirrhosis is a condition that arises as a result of chronic liver damage, typically over many years. It is characterised by fibrosis and nodularity of the liver parenchyma. Common causes of chronic liver disease include alcohol, non-alcoholic fatty liver disease and chronic viral hepatitis. Nearly half of patients with cirrhosis are asymptomatic. As a result the condition may only be discovered incidentally as a result of abnormalities in liver function tests or imaging of the abdomen performed for other reasons. Alternatively patients may present with signs and symptoms of the complications of cirrhosis e.g. jaundice, ascites, variceal bleeding, hepatic encephalopathy or hepatocellular carcinoma. The gold standard test for the diagnosis of cirrhosis remains a liver biopsy.

Early endoscopy improves survival in gastric cancer

25 Jul 2014Paid-up subscribers

Gastric cancer often presents late and the mortality ratio remains one of the highest compared with more common cancers. Early diagnosis improves survival in this potentially curable cancer. Dysphagia, weight loss and age over 55 are significant predictors of cancer. All patients presenting with dyspepsia and either alarm features or known conditions that increase the risk of gastric cancer should be referred for urgent endoscopy. Given that the majority of gastric cancer cases occur in people over 55, urgent endoscopy is also recommended in patients in this age group with new uncomplicated dyspepsia prior to treatment, even without alarm symptoms or if the symptoms respond to treatment. [With external links to current evidence base]

Diagnosing and managing inflammatory bowel disease

25 Jul 2013Paid-up subscribers

Inflammatory bowel disease (IBD) has a prevalence of around 400 per 100,000 in the UK. The two major types of IBD are ulcerative colitis and Crohn’s disease. Both are characterised by a relapsing and remitting course.  Inflammatory markers in the blood are not always raised in ulcerative colitis. The diagnosis is confirmed by typical histological features on biopsy.

Improving the detection and treatment of liver cancer

25 Jul 2013Paid-up subscribers

Liver cancer is the sixth most common cancer worldwide. Over the past decade survival in liver cancer has been steadily improving as a result of developments in surgery, transplantation and the introduction of a number of novel local, ablative and molecular targeted therapies. [With external links to current evidence and summaries]

Early diagnosis improves survival in colorectal cancer

26 Jul 2012Paid-up subscribers

Colorectal cancer is the second most common cause of death from cancer in the UK. The UK has one of the lowest survival rates for colorectal cancer in Europe. Collaborative work from cancer registries across Europe has indicated that early symptom recognition and early diagnosis are important factors in improving survival. GPs play an important role in recognising symptoms and supporting patients through the investigation and ongoing management of their disease.  [With external links to current evidence and summaries]

Diagnosing and managing acute diverticulitis

26 Jul 2012Paid-up subscribers

Acute diverticulitis is the most common complication of diverticulosis. Patients should be assessed according to their level of pain and associated systemic features of sepsis. In those in whom the pain is controlled and there are no signs of systemic sepsis and no high-risk features (immunocompromise, transplant patients, systemic immunosuppression) the patient may be treated in primary care but for those with systemic features of sepsis or high-risk features admission to hospital is required.

Upper GI bleeding requires prompt investigation

08 Aug 2011Paid-up subscribers

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.

Diagnosing and managing pancreatic cancer

07 Aug 2011Paid-up subscribers

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.  [With external links to current evidence and summaries]

Be vigilant for patients with coeliac disease

01 Oct 2009Paid-up subscribers

Recent population studies show that coeliac disease is a common condition affecting around 1 in 100 people. The estimated ratio of diagnosed to undiagnosed individuals is 1:8, and the average delay in diagnosis is reported to be 11 years. The presentations are protean and patients are increasingly diagnosed later in life. The contemporary coeliac patient is diagnosed between the ages of 40 and 60, has a normal or even high BMI, and subtle symptoms.