Gastroenterology and Hepatology
What this domain tests
Assessment of dyspepsia, change in bowel habit, rectal bleeding and abnormal liver tests, plus the decision to test, treat, refer or reassure.
Core rules
- Dyspepsia: test and treat. In patients under the endoscopy threshold with no alarm features, non-invasive H. pylori testing (stool antigen or urea breath test) and eradication if positive is the standard path. Stop proton pump inhibitors for two weeks and antibiotics for four weeks before testing to avoid false negatives.
- Alarm features - dysphagia, weight loss, iron-deficiency anaemia, vomiting, an epigastric mass, a new onset over the age of 55 - mandate urgent endoscopy rather than empirical acid suppression.
- Coeliac disease. Request anti-tTG IgA with a total IgA level (IgA deficiency causes false negatives). The patient must be eating gluten for testing.
- Iron-deficiency anaemia in a man or postmenopausal woman requires investigation of the gastrointestinal tract, irrespective of symptoms.
- Deranged liver tests. A cholestatic (ALP/GGT) pattern suggests obstruction or drugs; a hepatocellular pattern suggests alcohol, viral hepatitis, fatty liver or drugs. Repeat, then screen for hepatitis B and C, and calculate a fibrosis score.
- Rectal bleeding. Age, family history and persistent change in bowel habit govern referral; the national bowel screening programme uses a FIT-based pathway.
Worked example
A 61-year-old reports two months of intermittent loose stools and one episode of rectal bleeding, with a normal examination. Because of age and persistent change in bowel habit, you refer on the urgent suspected cancer pathway rather than treating as irritable bowel syndrome; you also check FBC and ferritin. The reasoning: new, persistent change over 60 cannot be managed as a symptom.
Traps
- Prescribing a proton pump inhibitor before H. pylori testing.
- Missing total IgA on coeliac serology.
- Attributing rectal bleeding to haemorrhoids without considering the age and bowel habit.
- Dismissing mildly abnormal liver tests that have been abnormal for years.