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Ростовский Государственный Медицинский Университет
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Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2899_Библиотеки_им_академика_М_И_Перельмана

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History
Dyspepsiasymptoms:
Recurrentepigastricpain/discomfort Acidreflux/heartburn Theabove-mentionedsymptomsmaybeaccompaniedbynausea,vomiting,orbloating GORDmayalso presentwithachroniccough,hoarseness,and‘water brash’whereacidreflux mixeswithexcessivelyproducedsalivainthethroat PatientswithahiatusherniaaremorelikelytodevelopGORD.
Examination
Involvesassessmentoftheunderlyingcauseofdyspepsia:
Cachexia Conjunctivalpallor Epigastric/upperabdominaltenderness Melaena.
Investigations
Bloods
FBC,U&E,LFT,andcoagulationprofile.
H.pyloritesting
TherearemultipletestsavailableforH.pylori.OptionsarelistedinTable30.1.
Table30.1OptionsforH.pyloritesting
Demonstratesactiveinfection Unabletodistinguishbetweenactiveand
pastinfection
Invasivetests OGDwithCLO(Campylobacter-likeorganismor
rapidurease)test OGDwithgastricbiopsies(forhistology)
Non-invasive tests
Carbon-13(C13)ureabreathtest Stoolantigentest
H.pyloriserology
PatientsonPPIs should havea 2-weekwashoutperiodprior toH.pylori testing withstool antigen,breathtest,orCLOtesttopreventfalse-negativeresults.
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Uppergastrointestinalendoscopy
Identifiespresenceofpepticulcerdisease,GORD,oesophagitis,andBarrett’soesophagus Performwithin2weeksif:
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DysphagiaOR Age≥55withweightlossANDupperabdominalpainORrefluxORdyspepsia
If dyspepsia is accompanied by significant upper GI tract bleeding, refer the same day for urgentendoscopy.
Performnon-urgentlyif≥55yearswith:
TreatmentresistantdyspepsiaOR DyspepsiawithraisedplateletcountOR Dyspepsiawithnausea/vomiting.
OesophagealpHmonitoring±manometry
Confirms diagnosis in patients with refractory symptoms despite treatment and patients without evidenceofrefluxonendoscopydespiteclassicalsymptomsofGORD
Management
Step-wise approach as laid out in the followingsections. Patients with classical GORD symptomswithoutsymptoms/signsmayonlyrequirelifestyleinterventionsandashort 4-week course of acid suppression therapy. If symptoms resolve following this, no furtherinvestigationisrequired.
Patienteducation
Encouragethepatienttoidentifytriggersthatprovoketheirsymptoms.
Lifestyleandsimpleinterventions
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Weightloss Reductioninalcoholconsumption Smokingcessation Avoidspecificfoodtriggers,e.g.spicyfood Avoidlargemealsforafewhoursbeforegoingtobed Elevateheadofbed.
Pharmacologicalmanagement
Stopculpritmedications(ifpossible)
NSAIDs,steroids,andbisphosphonatesincreaseriskofdamagingupperGItractmucosa Nitratesandcalciumchannel blockers andanticholinergics reduceloweroesophageal sphincter pressure.
Symptomaticrelief
Antacids/alginatescanbeusedasshort-termtreatmentforsymptomaticrelief.
Acidsuppressiontherapy
UninvestigateddyspepsiaorGORD
Offer full-dose PPI for 4 weeks if dyspepsia is not investigated or 4–8 weeks if GORD is diagnosed,e.g.omeprazole20mgODorlansoprazole30mgOD OfferlowesttolerateddoseofPPIforsymptomrecurrencefollowinginitialtreatment IfthereisinadequateresponsetoPPI,offerahistamine-2receptorantagonist.
Pepticulcerdisease(withoutH.pyloriinfection)
Offer full-dose PPI for 4–8 weeks, e.g. omeprazole 20mg OD or lansoprazole 30mg OD, or a histamine-2receptorantagonist,e.g.ranitidine150mgBD.
Functionaldyspepsia
Uselow-dosePPI,e.g.omeprazole10mgODorlansoprazole15mgOD.
Severeoesophagitis
Providefull-dosePPIfor8weeksandconsiderlong-termmaintenancetherapy Iftreatmentfailure,considerswitchingPPIorescalatingtoahighdose,e.g.omeprazole40mgBD, lansoprazole30mgBD.
H.pylorieradicationtherapy
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Consultwithlocalantibioticprotocolsiftheseareavailable.Ifunavailable,recommended regimensareasfollows:
Firstline:
7daysofPPI,e.g.omeprazole20–40mgBD
PLUSamoxicillin1gBD ANDEITHERclarithromycin500mgBDORmetronidazole400mgBD
Secondline:
Repeat first-line course but switch clarithromycin or metronidazole to the alternative, whicheverwasnotusedfirstline If previouslyexposed tobothclarithromycin andmetronidazole, switch toaquinolone,e.g. levofloxacin250mgBDORtetracycline500mgQDS
Penicillinallergy:
Firstline:
7daysofPPI,e.g.omeprazole20–40mgBD
PLUSclarithromycin500mgBD ANDmetronidazole400mgBD
Secondline:
Switchclarithromycintolevofloxacin250mgBD ORifpreviouslyexposedtoaquinolone, switchclarithromycintotetracycline500mg QDSANDbismuth240mgBD
Ifpenicillinallergyandpreviousclarithromycinexposure:
7daysofPPI,e.g.omeprazole20–40mgBD
PLUSmetronidazole400mgBD ANDtetracycline500mgQDS ANDbismuth240mgBD.
Surgicalmanagement
Fundoplication may be considered in patients with severe symptoms or ongoing oesophageal insult (oesophagitis, stricture, or Barrett’s metaplasia) despite maximal medical therapy. This procedure involves ‘tightening’ the lower oesophageal sphincter leadingto↑loweroesophagealsphincterpressurewhichreducesacidreflux.
Complications
Barrett’soesophagus Severeerosiveoesophagitis Oesophagealstricture.
Monitoringandfollow-up
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None if symptoms respond to lifestyle interventions or pharmacological management. Consider repeattestingforH.pyloriifongoingsymptomsdespiteeradicationtherapyusingC13ureabreath test Repeatendoscopyin6–8weekstoensurehealingifsevereoesophagitisorgastriculcer Regular follow-up endoscopy may be required if Barrett’s oesophagus has been diagnosed (to monitorformalignantchanges).
Specialconsiderations
Referraltospecialistservicesshouldbeconsideredin:
Refractorysymptoms ofGORDunresponsivetomaximalmedicaltherapyorifthesymptomsare unexplained RefractoryH.pyloriinfection(resistanttosecond-linetreatment) ForsurgicalmanagementofGORD.
Furtherreading
1. Wilkinson IB, Raine T, Wiles K et al. (2017). Dyspepsia and peptic ulcer disease. In: Oxford HandbookofClinicalMedicine,10thed(pp.252–3).Oxford:OxfordUniversityPress.Availableat:
https://doi.org/10.1093/med/9780199689903.003.0006
2.WilkinsonIB,RaineT,WilesKetal.(2017).Gastro-oesophagealrefluxdisease(GORD).In:Oxford HandbookofClinicalMedicine,10thed.(p.254–5).Oxford:OxfordUniversityPress.Availableat:
https://doi.org/10.1093/med/9780199689903.003.0006
3.BloomS,WebsterG,MarksD(2011).Dyspepsiaandgastro-oesophagealreflux.In:OxfordHandbook ofGastroenterologyandHepatology,2nded(pp.52–8).Oxford:OxfordUniversityPress.Available at:https://doi.org/10.1093/med/9780199584079.003.0012
1Suspectedcancer:recognitionandreferral,NICENG12;https://www.nice.org.uk/guidance/ng12
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Chapter31
Irritablebowelsyndrome
Guideline: NICE CG61 (Irritable bowel syndrome in adults: diagnosis and
management):https://www.nice.org.uk/guidance/cg61
OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.
Overview
Irritablebowelsyndrome(IBS)isaconditionofunclearaetiologywhichpresentswitha combinationofabdominalsymptoms.Ithasafemalepredominanceandusuallyoccursin arelapsing–remittingpattern.
Diagnosis
ThekeytoapproachinganddiagnosingIBSisaclearhistoryandtheabsenceofpositive examination findings and investigations. Based on the patient’s symptoms, IBS can be divided into categories of diarrhoea predominant, constipation predominant, or mixed IBSsymptoms.
History/diagnosticcriteria
Aminimumof6months’historyofAbdominalpain,Bloating,orChangingbowelhabit (diarrhoea, constipation, oralternatingbetween both) should prompt a consideration of IBS.Theabdominalpaindoesnotusuallyhaveafixedsite.
Diagnosing IBS requires the presence of abdominal pain/discomfort which improves
with defecation or occurs alongside a change in bowel frequency or stool consistency.
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Thesesymptomsshouldcoexistwithtwoormoreofthefollowingsymptoms:
Symptomsworsewitheating Bloatingordistensionoftheabdomen Passingmucusperrectum Changeinstoolpassage(feelingofincompleteevacuation,urgencyorstraining).
Othercommonsymptomsinclude:
Lethargy Nausea Backpain Symptomsrelatedtothebladder(urinaryurgency,nocturia) Faecalincontinence(askspecifically,aspatientsmaynotdisclosethisvoluntarily).
Examination
Inmostcases,thereisnoabnormality Generaltendernessmaybeelicitedonpalpationoftheabdomen Ifrequired,basedonsymptoms,carryoutarectalexaminationtoruleoutotherpathology Features of weight loss, aphthous ulcers, abdominal mass, rectal bleeding, or pallor if elicited shouldpromptconsiderationofotherdiagnoses.
Investigations
Theaimofinvestigationsistoexcludeotherdisorders.
Bloods
FBC ESR CRP Tissuetransglutaminase(toexcludecoeliacdisease, especiallyinpatientswithmixedsymptoms orpredominanceofdiarrhoea).
Other
Abdominal ultrasound, endoscopy, barium enema, TFT, hydrogen breath test, faecal ova/parasitetesting,andfaecaloccultbloodareNOTrecommendedtodiagnoseIBS.
Management
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Patienteducation
Empower patients with IBS to manage their condition by providing information leaflets which illustratethesignificanceofself-help Increaseamountofphysicalactivityandrelaxation Supportgroups:
The IBS Network—national charity with website providing information for self-help and networkingwithlocalsupportgroups.
Lifestyleandsimpleinterventions
Eatregularly(avoidskippingmeals)andwithoutrushing Reduceintakeoffibre(especiallyinsolublefibresuchasbran)andresistantstarches,e.g.pulses, reheatedpotato Increasefluidintake (aimfor8 cupsa dayatleast)butreduceconsumptionofcaffeine,alcohol, andfizzydrinks Maximumthreeportionsoffreshfruitperday Forsymptomsofbloating,oatsandlinseedsmayhelp Ifpatientswouldliketotryprobiotics,aminimumtrialperiodof4weeksisrecommendedwhilst monitoringsymptoms Iftheabove-listeddietaryinterventionshavenothelpedsymptoms,patientsshouldreceivedietetic advice,includingadviceonexclusiondietssuchasalow-‘FODMAP’diet(Box31.1).
Box31.1Low-FODMAPdiets
FODMAP stands for fermentable oligosaccharides, disaccharides, monosaccharides, and polyols FoodswithhighFODMAPsarethoughttoincreasesymptomsofbloatingandpain,secondaryto poorabsorptioninthesmallintestinewhichleadstobacterialfermentationinthelargeintestine Some patients with IBS are very sensitive to FODMAPs but others are not, so eliminating FODMAPswillnotalwayswork The usual approach is to eliminate high-FODMAP foods for 4–8 weeks before gradually reintroducingdifferentfoodstofindwhicharetheworsttriggers.
Pharmacologicalmanagement
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Mainaimistargetedsymptomrelief,ifdietaryandlifestyleinterventionsareineffective Abdominalpain:
Consider antispasmodic agents such as hyoscine butylbromide (10–20mg TDS–QDS) or mebeverine(200mgBD)
Diarrhoea:
Antimotilityagentsforsymptomsofdiarrhoea(loperamide2mg,maximum16mgaday)isthe firstchoice
Constipation:
Considerlaxativesforconstipation(exceptlactulosewhichcanworsenbloating) Linaclotide(290microgramsOD)canbeconsideredforpatientswhoexperienceatleast12 months ofconstipationdespitetrials ofmultiple laxatives. Review after3 months toassess response.
Second-lineagents
Tricyclicantidepressantscanbeconsiderediftheabovemedicationsfailtoimprovesymptoms Commenceatlowdose(e.g.amitriptyline5–10mgOD)withgradualtitrationandregularreview Selective serotonin reuptake inhibitors (SSRIs) should be considered if TCAs do not provide adequateclinicalresponse,arepoorlytolerated,orarecontraindicated FollowuppatientswhohavebeenstartedonTCAsorSSRIsafter4weeksand6–12months.
Psychologicalinterventions
InpatientswithrefractoryIBS(noimprovementinsymptomsafter12monthsofpharmacological management)considerreferralforpsychologicalinterventions Theseincludecognitivebehaviouraltherapy(CBT),hypnotherapy,orpsychologicaltherapy.
Monitoringandfollow-up
Furtherinvestigationisrequiredifnewsymptomsdevelop.
Furtherreading
1. Bloom S, Webster G, Marks D (2011). Irritable bowel syndrome. In: Oxford Handbook of Gastroenterologyand Hepatology, 2nded (pp. 373–6).Oxford: Oxford University Press.Available
at:https://doi.org/10.1093/med/9780199584079.003.0220
2.TheIBSNetworkwebsite.Availableat:https://www.theibsnetwork.org/
https://t.me/med1917
Chapter32
Ulcerativecolitis
Guidelines:EuropeanCrohn’sandColitisOrganisation,EuropeanSocietyof
Gastrointestinal and Abdominal Radiology (ECCO-ESGAR guideline for diagnosticassessmentinIBDpart1:initialdiagnosis,monitoringofknown IBD, detection of complications): https://academic.oup.com/ecco-
jcc/article/13/2/144/5078195
European Crohn’s and Colitis Organisation, European Society of Gastrointestinal and Abdominal Radiology (ECCO-ESGAR guideline for diagnosticassessment in IBDpart2:IBD scores and generalprinciples and technical aspects): https://academic.oup.com/ecco-
jcc/article/13/3/273/5078200
EuropeanCrohn’sandColitisOrganisation(ThirdEuropeanevidence-based consensusondiagnosisandmanagementofulcerativecolitis.Part2:current management):https://academic.oup.com/ecco-jcc/article/11/7/769/2962457
OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.
Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.
Overview
Ulcerativecolitis(UC)isachronicinflammatoryconditionofunknownaetiologywhich is thought to occur secondary to environmental triggers in genetically susceptible individuals.
UCoccursintherectumandcolon,unlikeCD(seeChapter29)whichcanoccurinany partoftheGItract.UCcanbefurthercategorizedaccordingtothedistributionofcolonic inflammation: proctitis (limited to rectum), left-sided (up to the splenic flexure), and extensivecolitis(proximaltosplenicflexure).
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