Gastrointestinal Hot Topics for SCA Revision

From all of us at SCA Prep, here is a list of topics to make sure you have covered from gastroenterology.

You can print this quick summary and ensure you have practiced these common cases from the curriculum. You can generate specific cases on our SCA cases page or even practice them with our specialised and UK guidelines trained AI Actors.

Gastro-Oesophageal Reflux Disease (GORD) and Dyspepsia

GORD refers to endoscopically determined oesophagitis or endoscopy-negative reflux disease. Patients with uninvestigated “reflux-like” symptoms should be managed as patients with uninvestigated dyspepsia. Distinguish between GORD and functional dyspepsia based on symptom characteristics.

Lifestyle modifications should be first-line for all patients: reduce weight if overweight, avoid trigger foods, reduce alcohol and caffeine, eat smaller meals, avoid eating close to bedtime. Review medications that may contribute – calcium antagonists, nitrates, theophylline, and bisphosphonates should be stopped if possible.

Treatment pathway:

• Step 1: Full-dose PPI for 1-2 months (omeprazole 20mg or lansoprazole 30mg once daily)
• If response: offer low-dose PPI or on-as-required basis with limited repeat prescriptions
• If no response: proceed to Step 2
• Step 2: If still ongoing symptoms despite PPI, check for H Pylori and eradicate this if positive. If symptoms still recurrent and H pylori negative, consider the need for OGD and also review lifestyle advice.
• Step 3: For endoscopy-negative reflux disease or persistent symptoms despite double-dose PPI: try H2-receptor antagonist at night or switch PPI

H. pylori eradication is NOT indicated for GORD alone without confirmed H Pylori. Review long-term PPI use annually – discuss medication and symptoms, consider stepping down or discontinuing if symptoms controlled.

Alarm features requiring 2-week referral: Dysphagia, odynophagia, persistent vomiting, evidence of GI bleeding, weight loss, iron deficiency anaemia, or palpable mass.

Peptic Ulcer Disease and Helicobacter pylori Infection

H. pylori is the most common cause of peptic ulcer disease. Eradication therapy should be offered to all patients with proven H. pylori infection and active or past ulceration.

Test for H. pylori if:

• Active ulcer on endoscopy
• History of ulcer disease
• Functional dyspepsia (in some cases)
• Gastric MALT lymphoma
• Early gastric cancer

Diagnostic tests: Urea breath test, stool antigen test, or serology. In patients <55 years without alarm features, a non-invasive test and treat strategy is appropriate. Serology has higher sensitivity but cannot distinguish past from current infection.

First-line H. pylori eradication therapy (7 days):

• PPI (high-dose) + Clarithromycin 250mg twice daily + Amoxicillin 1g twice daily
• For penicillin allergy: PPI + Clarithromycin + Metronidazole 400mg twice daily

First-line for regions with high clarithromycin resistance (14 days):

• PPI + Bismuth + Tetracycline 500mg twice daily + Metronidazole 400mg twice daily

All patients treated for H. pylori must be tested for eradication at least 4 weeks after completing therapy using urea breath test or stool antigen test. Do NOT use serology for test of cure.

NSAID-induced ulcers: If continuing NSAIDs, co-prescribe PPI. For aspirin users, continue low-dose aspirin and add PPI. If stopping NSAID, PPI therapy for 4-8 weeks.

Upper Gastrointestinal Bleeding

Prioritise assessment of severity: perform basic observations, secure IV access, obtain FBC, clotting studies, group and cross-match. Contact gastroenterology for urgent advice and referral.

Initial stabilisation: Maintain airway, breathing, circulation. Two large-bore IVs for rapid fluid resuscitation. Consider proton pump inhibitor bolus (omeprazole 80mg IV) while awaiting endoscopy.

Most common causes: peptic ulcer disease (most frequent), oesophageal varices in those with liver disease, Mallory-Weiss tear, and gastritis.

Red flags requiring immediate admission: Haemodynamic instability, significant bleeding (haematemesis), syncope, severe co-morbidities.

Safety net: Advise patient to seek immediate medical attention if bleeding continues or recurs, or if they develop haemodynamic symptoms.

Stomach Cancer: Red Flag Symptoms

Gastric cancer often presents late in the UK, with only 15% diagnosed at stage 1. Red flag symptoms require urgent investigation.

Alarm features warranting 2-week referral pathway (or urgent FIT in primary care):

• Dysphagia (difficulty swallowing) – particularly concerning if progressive
• Persistent indigestion/dyspepsia for >3 weeks unresponsive to treatment
• Unexplained weight loss >3kg
• Persistent vomiting
• Iron deficiency anaemia without other obvious cause
• Palpable abdominal mass
• Persistent upper abdominal pain

Additional concerning symptoms (consider urgent CXR or further investigation):

• Early satiety (feeling full quickly)
• Loss of appetite
• Nausea or feeling unwell
• Dark/tarry stools (melaena)
• Recurrent heartburn despite treatment

Patient age >60 with new onset dyspepsia or dysphagia warrants investigation. Consider family history of gastric cancer.

Do not reassure on persistent dyspepsia symptoms alone – if symptoms persist despite 2-4 weeks of treatment, refer for endoscopy. Success of anti-reflux treatment should not delay investigation of alarm features.

In general, have a low threshold for requesting a FIT test if you even think of malignancy.

Oesophageal Cancer: Red Flag Recognition

Oesophageal cancer is relatively rare in UK (around 25 new cases daily nationally) but has poor prognosis if diagnosed late. Early recognition is crucial.

Key alarm features requiring 2-week referral:

• Progressive dysphagia (difficulty swallowing), particularly solid food progressing to liquids
• Painful swallowing (odynophagia)
• Persistent heartburn for >3 weeks on PPI therapy
• Unexplained weight loss
• Persistent vomiting or regurgitation
• Food sticking in throat or chest

Additional features to investigate urgently:

• Hoarseness lasting >3 weeks
• Cough with eating (aspiration risk)
• Dark or tarry stools
• Vomiting blood (haematemesis)

Any patient with heartburn on most days for >3 weeks should be encouraged to see GP even if OTC medication helps. Patients aged >60 with new-onset dysphagia warrant urgent referral regardless of other features.

Barrett’s oesophagus (endoscopically confirmed) requires surveillance but chronic reflux alone without proven Barrett’s does not automatically require endoscopy – reassess if symptoms recur.

Inflammatory Bowel Disease: Crohn’s Disease and Ulcerative Colitis

IBD comprises Crohn’s disease and ulcerative colitis (UC), characterised by chronic inflammation of the GI tract.

Key differences:

• Ulcerative colitis: Limited to colon and rectum, continuous inflammation, affects only innermost lining
• Crohn’s disease: Can affect any part GI tract mouth-to-anus, patchy inflammation with healthy areas between, affects all layers of the bowel wall

Classic presentation:

• Diarrhoea with blood/mucus
• Abdominal pain and cramping
• Urgency and tenesmus
• Weight loss and fatigue
• Fever (particularly in Crohn’s)

Extraintestinal manifestations: Arthralgia/arthritis (especially knees, ankles), erythema nodosum, pyoderma gangrenosum, uveitis, hepatitis, primary sclerosing cholangitis (especially UC).

Diagnosis requires clinical assessment, blood tests (FBC, U&Es, LFTs, CRP/ESR), faecal calprotectin testing, and endoscopy with biopsy. Faecal calprotectin >250 micrograms/g is highly suggestive of IBD.

Do NOT use FIT for IBD patients – this is for colorectal cancer screening only. However, don’t feel that you can’t also request a FIT test if you are also requesting calprotectin at the same time, if you are worried about malignancy.

Refer urgently if:

• Severe bloody diarrhoea with systemic symptoms (fever, tachycardia, anaemia)
• Suspected toxic megacolon (severe colitis with abdominal distension, fever)
• Suspected perforation (acute peritonitis)

Initial management in primary care aims to control symptoms and monitor for complications. Specialist management determines specific therapies including aminosalicylates, corticosteroids, immunosuppressants, or biologics.

Irritable Bowel Syndrome (IBS)

IBS is a functional disorder affecting up to 15% of UK population. Diagnosis is positive and based on specific criteria. Rome IV criteria: Recurrent abdominal pain/discomfort on at least 1 day per week for ≥3 months, with at least 2 of: altered stool passage, bloating/distension, symptoms worse after eating.

IBS subtypes:

• IBS-D: Diarrhoea predominant
• IBS-C: Constipation predominant
• IBS-M: Mixed
• IBS-U: Unspecified

Red flags requiring 2WW referral to secondary care:

• Unintentional/unexplained weight loss
• Rectal bleeding (especially if age >50)
• Family history of bowel cancer or ovarian cancer
• Change in bowel habit to looser/more frequent stools lasting >6 weeks in those aged >60
• Iron deficiency anaemia
• Abdominal or rectal mass
• Abnormal FIT test
• Inflammatory markers elevated

For women aged ≥50 with new-onset IBS symptoms, consider measuring CA125 serum level to screen for ovarian cancer.

Primary care management:

• Lifestyle advice: regular exercise, adequate hydration (6-8 glasses daily), stress management, consider FODMAPs diet
• First-line pharmacotherapy based on predominant symptom:
  • Pain/mixed: Antispasmodics (mebeverine, dicyclomine) or low-dose TCAs (amitriptyline 5-10mg nocte)
  • Diarrhoea: Loperamide as needed
  • Constipation: Regular fibre, osmotic laxatives (polyethylene glycol), consider linaclotide if loperamide/antispasmodics/TCAs unsuccessful
• Psychological therapies: Cognitive behavioural therapy (CBT) or gut-focused hypnotherapy effective

Faecal calprotectin testing is useful to help differentiate IBS from IBD in patients with recent-onset symptoms, if cancer not suspected and age-appropriate.

Constipation: Diagnosis and Management

Constipation affects 14% of UK population. Diagnosis based on Rome IV criteria: At least 25% of bowel movements with hard stools (Bristol Stool Form Scale 1-2) and <25% loose stools (Type 6-7), for ≥3 months.

Alarm features requiring urgent referral or investigation:

• Unintentional weight loss
• Iron deficiency anaemia (suggests blood loss)
• Recent onset of constipation (>60 years)
• Rectal bleeding with positive FIT test
• Palpable abdominal or rectal mass
• Family history of colorectal cancer

If alarm features present, perform FIT test prior to urgent referral. Don’t delay investigation with empiric therapy.

Secondary causes to exclude:

• Medications: opioids, anticholinergics, iron supplements
• Hypothyroidism, hypercalcaemia, diabetes
• Neurological: Parkinson’s, spinal cord injury, multiple sclerosis
• Structural: strictures, adhesions, bowel cancer

Primary care management:

• Lifestyle modifications: increased fibre (25-30g daily from whole grains, fruits, vegetables), adequate fluid intake (6-8 glasses/day), regular exercise, avoid caffeine excess
• Regular toileting after breakfast (sit 10 minutes on toilet with feet supported on footstool)
• Review medications for constipating effects

Pharmacotherapy (first-line):

• Osmotic laxatives: polyethylene glycol (MiraLAX) – safest, most effective
• Stimulant laxatives: senna, bisacodyl – use as backup, risk of dependence
• Stool softeners: docusate – limited evidence
• Fibre supplements: psyllium, methylcellulose – less effective than osmotic laxatives

Second-line: Prucalopride (prokinetic) or linaclotide for IBS-C if first-line inadequate.

Refer to secondary care if constipation severe, refractory to treatment of unclear aetiology, or functional defecation disorder suspected.

Diarrhoea: Acute and Chronic

Acute diarrhoea (usually self-limiting) versus chronic diarrhoea (>4 weeks duration). Most acute cases are viral/infectious and managed supportively.

Initial assessment of acute diarrhoea:

• Assess hydration status, severity (frequency, consistency, blood/mucus)
• Identify red flags: bloody stools, severe dehydration, systemically unwell, immunocompromised
• Travel history, antibiotic use (C. difficile risk), food history

Red flags requiring urgent referral/investigation:

• Bloody diarrhoea with systemic symptoms
• Severe dehydration or shock
• Immunocompromised patient
• Recent antibiotic use + severe bloody diarrhoea (suspect C. difficile)

Chronic diarrhoea assessment requires:

• Detailed history: onset, duration, frequency, stool consistency (Bristol scale), blood/mucus, weight loss
• Examine for signs of malabsorption: weight loss, oedema (hypoalbuminaemia), dermatitis, glossitis, neuropathy
• Initial investigations: FBC (anaemia suggests malabsorption/IBD), U&Es, LFTs, CRP/ESR, tissue transglutaminase serology (coeliac disease), stool culture/C. difficile PCR
• Stool form patterns guide diagnosis:
  • Fatty/floating stools suggest malabsorption (pancreatic insufficiency, small bowel disease)
  • Bloody diarrhoea with urgency suggests colitis (IBD, infectious)
  • Watery diarrhoea with urgency overnight suggests osmotic diarrhoea (diet, medication)

Faecal calprotectin >250 micrograms/g suggests colonic inflammation (IBD, infection). Levels <40 make IBD unlikely.

Refer for secondary care if: persistent unexplained diarrhoea after first-line investigations, alarm features present, or suspected specific diagnoses requiring specialist intervention (endoscopy, imaging, specific testing).

Coeliac Disease

Coeliac disease is an autoimmune condition affecting approximately 1% of UK population, triggered by gluten ingestion. Many patients remain undiagnosed – maintain high index of suspicion.

Clinical presentation:

• Gastrointestinal: diarrhoea, bloating, abdominal pain, weight loss, constipation
• Extra-intestinal: iron deficiency anaemia (most common in UK), fatigue, headache, depression
• Dermatitis herpetiformis: intensely pruritic rash on extensor surfaces
• Associated conditions: osteoporosis, infertility, recurrent miscarriage, dermatological conditions

High-risk groups: First-degree relatives of coeliac patients, IgA deficiency, type 1 diabetes, autoimmune thyroid disease.

Diagnosis (patient must be on gluten-containing diet):

• Serology: tissue transglutaminase (tTG) IgA antibodies (first-line). Anti-endomysial antibodies (EMA) highly specific. If IgA deficiency suspected, check IgA-deamidated gliadin peptide (DGP) IgG.
• Duodenal biopsy (gold standard): shows villous atrophy, increased intraepithelial lymphocytes, crypt hyperplasia
• Serology alone cannot diagnose – biopsy essential for vast majority of adults

Management: Strict, lifelong gluten-free diet. Dietitian referral essential for education, nutritional support, and advice on cross-contamination.

At diagnosis, patients require:

• Full blood count, iron studies, vitamin B12, folate levels
• Bone densitometry (DEXA scan) if severe malabsorption or prolonged symptoms
• Assessment for associated conditions (thyroid function, tissue transglutaminase IgA if not done)
• Family screening recommended (HLA typing and serology for first-degree relatives)

Annual follow-up: assess adherence to gluten-free diet, repeat tissue transglutaminase IgA serology (should normalise on diet), monitor nutritional status, dietitian support.

Refractory coeliac disease (symptoms persist despite strict gluten-free diet) requires secondary care assessment and investigation to exclude other diagnoses.

Colorectal Cancer: Red Flags and Screening

Colorectal cancer is the fourth most common cancer in UK. Early detection via screening improves outcomes significantly.

Bowel screening programme: Asymptomatic adults aged 50-74 (or 45-74 in some regions) offered FIT testing. National programme uses FIT threshold of >120 micrograms Hb/g.

In symptomatic patients, different FIT threshold applies: >10 micrograms Hb/g is positive for suspected cancer pathway.

Red flags requiring FIT test or urgent referral:

• Change in bowel habit: looser stools and/or increased frequency lasting >6 weeks (especially age >60)
• Rectal bleeding with abdominal pain or weight loss
• Iron deficiency anaemia without other obvious cause (suggests occult bleeding)
• Unexplained weight loss (>3kg) + abdominal symptoms
• Palpable abdominal mass
• Age >50 with unexplained rectal bleeding
• Age <50 with rectal bleeding + abdominal pain or weight loss

Positive FIT test (≥10 micrograms/g): Refer via urgent suspected cancer (2-week) pathway for colonoscopy.

Negative FIT test: Patients unlikely to have colorectal cancer BUT do not falsely reassure – ensure symptoms resolve and consider other diagnoses (pancreatic cancer, gynaecological pathology, etc). If strong clinical suspicion persists, can still refer via suspected cancer pathway.

Important: Do NOT rely on normal screening FIT in patient with new symptoms – rescind symptomatic FIT test using higher threshold (10 micrograms/g).

Other risk factors increasing colorectal cancer risk: family history (especially first-degree relatives with early-onset cancer), IBD, polyposis syndromes.

Liver Disease and Cirrhosis

Chronic liver disease can progress to cirrhosis and hepatic failure. Early identification and management are crucial to prevent complications.

Common causes in UK:

• Alcohol-related liver disease (most common cause of cirrhosis)
• Viral hepatitis (B and C)
• Non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH)
• Autoimmune hepatitis
• Primary biliary cholangitis
• Haemochromatosis
• Wilson’s disease (rare)

Initial assessment requires:

• Detailed alcohol history (AUDIT-C screening)
• Serology: hepatitis B and C antibodies
• Iron studies (ferritin, transferrin saturation)
• Liver function tests, FBC, PT/INR
• Ultrasound (assesses liver echotexture, signs of cirrhosis, portal hypertension, HCC screening)

Signs of cirrhosis/decompensation:

• Jaundice
• Ascites
• Hepatic encephalopathy (confusion, flapping tremor)
• Variceal bleeding (haematemesis, melaena)
• Portal hypertension stigmata: spider naevi, palmar erythema, splenomegaly

Primary care management of stable cirrhosis:

• Prevention counselling: Complete alcohol abstinence, healthy weight maintenance, adequate nutrition
• Medication review: Avoid NSAIDs, limit paracetamol to 2g/day, avoid benzodiazepines/opioids, proton pump inhibitors only if indicated
• Vaccinations: Annual influenza, pneumococcal (Pneumovax 23), hepatitis A and B if non-immune
• Monitoring: 6-monthly FBC, LFTs, PT/INR, ultrasound screening. Calculate Child-Pugh and MELD scores to assess severity
• Manage causative factors: Treat hepatitis B/C, encourage alcohol cessation, manage weight (weight loss of 10% improves NAFLD histology)

Refer to secondary care (hepatology) if:

• Decompensated cirrhosis (ascites, hepatic encephalopathy, variceal bleeding)
• MELD score ≥15 (consider for transplant evaluation)
• Suspected HCC
• Complications of portal hypertension
• First diagnosis of cirrhosis (specialist assessment and management planning)

Hepatitis B and C: Antiviral therapies can halt/reverse disease progression – refer all newly diagnosed patients for specialist assessment and potential treatment.