Gastrointestinal Disease Diagnosis and Management
1. Haematemesis Management and Differentials
Differential Diagnoses:
- Oesophageal variceal bleeding secondary to chronic alcohol use
- Mallory-Weiss tear
- Boerhaave syndrome
- Peptic ulcer disease
Investigations
- Bedside: Full set of basic observations, A-E assessment, and ECG.
- Bloods: FBC, baseline U&Es, LFTs, coagulation screen, and group and save.
- Imaging: Endoscopy.
Management
- A-E assessment: Stabilise the patient.
- Keep nil by mouth (NBM).
- Oxygen and IV fluids.
- Group and save.
- IV terlipressin and antibiotics.
- Stop NSAIDs.
- Escalate to the Oesophago-Gastro-Duodenoscopy (OGD) team.
- If haemodynamically unstable: Urgent endoscopy and band ligation.
- If uncontrolled bleeding: Sengstaken-Blakemore tube.
2. Oesophageal Cancer and Dysphagia
Symptoms: Dysphagia, unintentional weight loss, progressive difficulty with solids then liquids, sore throat, and cough.
Differential Diagnoses
- Oesophageal cancer
- Achalasia: Presents with regurgitation of undigested food (solids and liquids start at the same time) and chest pain.
- GORD: Does not typically present with systemic symptoms.
- Oesophageal stricture: Mostly occurs in patients with GORD or chronic heartburn.
Investigations
- Bedside: Full set of vital signs, weight, and BMI for nutritional status; calculate the Malnutrition Universal Screening Tool (MUST) score.
- Bloods: FBC, baseline U&Es, LFTs, CRP/ESR, clotting profile, group and save, and nutritional bloods (albumin and vitamin deficiencies if dysphagia is long-standing).
- Imaging: Endoscopy (OGD) is the gold standard. If a tumour is identified, perform a CT Chest, Abdomen, and Pelvis (CAP) and PET-CT for metastasis. If aspiration is suspected, perform a Chest X-ray for aspiration pneumonia.
Management
- Two-week wait (2WW) referral (cancer pathway).
- Endoscopy and barium swallow.
- Once diagnosis is confirmed:
- Surgery: Alongside preoperative chemotherapy or radiotherapy to shrink the tumour.
- Palliative care: Stenting to relieve dysphagia if the cancer is advanced and not curable.
- Psychological support for a distressing diagnosis.
3. Pancreatic Cancer Presentation and Care
Symptoms: Central abdominal pain, unintentional weight loss, jaundice, loose stools, and loss of appetite.
Differential Diagnoses
- Chronic pancreatitis
- Gastric ulcer
- Gallstones
Investigations
- Bedside: Full set of vital signs.
- Bloods: FBC, U&Es, LFTs, CRP/ESR, amylase/lipase, clotting screen, bone profile (to check for hypercalcaemia), HbA1c (if new-onset diabetes), and CA19-9 (tumour marker).
- Imaging: CT abdomen (gold standard), MRCP, and ERCP (if MRCP is positive, to relieve obstructive jaundice).
Management
- Explanation and reassurance.
- Two-week wait (2WW) referral.
- Carry out necessary investigations while waiting for a specialist appointment.
- Supportive care: Analgesics for pain and anti-emetics if vomiting.
- Psychosocial support for the distress of a cancer diagnosis.
4. Colorectal Cancer and Rectal Bleeding
Symptoms: Abdominal pain, unintentional weight loss, rectal bleeding, and tenesmus.
Differential Diagnoses
- Colorectal cancer
- Inflammatory Bowel Disease (IBD)
- Irritable Bowel Syndrome (IBS)
- Diverticular disease
Investigations
- Bedside: Full set of vital signs, Digital Rectal Examination (DRE), and FIT test for occult blood.
- Bloods: FBC, U&Es, LFTs, clotting profile, group and save, CRP/ESR, Faecal calprotectin, and CEA (tumour marker).
- Imaging: Colonoscopy with biopsy (gold standard). If rectal cancer is suspected, perform an MRI pelvis. If bowel obstruction is suspected, perform an abdominal X-ray.
5. Ulcerative Colitis and IBD
Patient Profile: 30-year-old woman with lower abdominal pain, weight loss, and occasional bloody diarrhoea.
Differential Diagnoses
- Ulcerative Colitis (UC)
- Crohn’s Disease: Bloody diarrhoea is less common.
- IBS: Often stress-related.
- Colorectal cancer: Should always be a differential if blood is present in stools.
Investigations
- Bedside: Full set of vital signs, DRE, and stool MC&S.
- Bloods: FBC, U&Es, LFTs, clotting profile, CRP/ESR, Faecal calprotectin, albumin, iron studies, B12, and folate.
- Imaging: In an active flare-up, perform a sigmoidoscopy. When stable, perform a colonoscopy with biopsy (for colorectal cancer surveillance). If severe disease is present, perform an abdominal X-ray to look for signs of toxic megacolon.
Management
- Non-pharmacological: Lifestyle measures such as diet, exercise, and smoking cessation.
- Pharmacological:
- Mild to moderate: Rectal or oral aminosalicylates (typically mesalazine).
- Moderate to severe: Add corticosteroids.
- Acute flare-up: May require hospital admission with IV steroids and IV fluids.
- Regular monitoring and colonoscopy, as UC increases the risk of colorectal cancer.