Presentations

Coeliac disease This is a condition characterised by T cell-mediated damage of the small bowel villi due to gluten exposure, which leads to malabsorption. Gluten is found in wheat and grains and causes reduced mucosal absorption in the distal duodenum +/- proximal jejunum. It is associated with HLA-DQ2 and HLA-DQ8, and onset has a bimodal prevalence pattern, presenting in childhood and again between 50–60 years. If untreated, it can lead to T cell lymphoma of the small intestine.   Symptoms Diarrhoea, bloating, abdominal pain Steatorrhea, weight loss Fatigue and failure to thrive Hyposplenism Anaemia secondary to iron, folate and vitamin

These conditions usually present with epigastric pain. When dealing with stomach conditions you should be aware of the 5 alarm symptoms or age>55years, which require urgent upper GI endoscopy: Anaemia Loss of weight Anorexia Recent onset symptoms Malaena/hematemesis   Acute gastritis This refers acute inflammation of the stomach mucosa, which occurs due to anvimbalance between mucus defence and acid. The stomach is usually lined by bicarbonate ions, prostaglandins and a mucus barrier,vwhich protects against stomach acid. The acid damage results in superficial inflammation and can cause erosions (loss ofvsuperficial layer), which may progress to ulcer development (loss of mucosal layer).

Pancreatic cancer This refers to a metastatic proliferation of pancreatic cells. It is usually an adenocarcinoma which arises from the head of the pancreas. It is seen in older patients and usually presents late with established metastases.    Risk factors Smoking, Alcohol Diabetes Chronic pancreatitis Hereditary non-polyposis colorectal carcinoma Multiple endocrine neoplasia Symptoms Painless obstructive jaundice, as the tumour compresses the common bile duct Epigastric pain which may radiate to the back, weight loss, decreased appetite Palpable gallbladder on examination (Courvoisier’s law states that patients with painless jaundice and a palpable gallbladder often have a malignant CBD obstruction)   Complications

Pancreatic cancer This refers to a metastatic proliferation of pancreatic cells. It is usually an adenocarcinoma which arises from the head of the pancreas. It is seen in older patients and usually presents late with established metastases.    Risk factors Smoking, Alcohol Diabetes Chronic pancreatitis Hereditary non-polyposis colorectal carcinoma Multiple endocrine neoplasia Symptoms Painless obstructive jaundice, as the tumour compresses the common bile duct Epigastric pain which may radiate to the back, weight loss, decreased appetite Palpable gallbladder on examination (Courvoisier’s law states that patients with painless jaundice and a palpable gallbladder often have a malignant CBD obstruction)   Complications

Oesophageal web This is the protrusion of oesophageal mucosa, usually in the upper oesophagus. It is a risk factor for the development of oesophageal squamous cell carcinoma. It is associated with Plummer-Vinson syndrome, a triad of dysphagia, iron deficiency anaemia and oesophageal web.   Symptoms Dysphagia (to solids more than liquids) Can increase risk of aspiration and nasopharyngeal reflux   Management Endoscopic dilation of the oesophagus   Pharyngeal pouch (Zenker diverticulum) This is a pouch at the back of the throat, thought to be due to over-tightening of the cricopharyngeus muscle, causing the pharyngeal mucosa above it to pouch out.

Acute Liver Failure This term is used to describe an acute decrease in hepatocyte dysfunction.   Causes Drugs, e.g., paracetamol overdose, excess alcohol consumption, medicine reaction Infections, e.g., hepatitis A/B Trauma Symptoms Jaundice due to hyperbilirubinaemia Coagulopathy due to decreased hepatocyte synthetic function Oedema Hepatic encephalopathy   Key tests Liver function tests are not as indicative of the level of hepatic impairment It is more useful to measure albumin levels and prothrombin time (this provides a better assessment of the synthetic function of the liver)   Management Correct underlying cause, e.g., if paracetamol, the antidote is N-acetylcysteine Medical management involves

This refers to chronic, relapsing inflammation of the bowel, which is thought to be associated with an abnormal immune response to gut flora. It classically presents in the younger population with two key symptoms: bloody diarrhoea and abdominal pain. It is subdivided into two disorders which share similar symptoms.   Ulcerative colitis (UC) This disease is associated with recurrent inflammation of the colon which involves part or all the colon and rectum. The involvement is continuous, rather than in patches and never proximal to the ileocecal valve. Inflammation leads to bleeding mucosa, pseudopolyp formation and ulcers which extend into the

A hernia is the abnormal protrusion of tissue through an opening, which can occur in many different locations. They usually present as a visible lump, with an expansible cough impulse   Risk factors These increase intra-abdominal pressure or weaken the abdominal wall Heavy lifting                            Previous abdominal surgery Constipation                           Obesity   Symptoms Visible lump, with expansible cough impulse They are usually soft, painless, and reducible Complications  Irreducibility/incarceration – this means the contents cannot be pushed back into their original position Obstruction – this refers to hernia containing bowel;

This is a viral infection of the hepatocytes which leads to inflammation. It can cause acute and chronic symptoms   Acute This refers to inflammation of the liver which usually resolves within 6 months. It causes jaundice (mixed conjugated and unconjugated bilirubin) with dark urine. Also causes fever, tender hepatomegaly, nausea and weight loss. Blood tests show very elevated LFTs (ALT > AST). However, it can be asymptomatic with elevated LFTs.   Chronic This is characterised by elevated LFTs for > 6 months. It may be initially clinically silent, but usually progresses to liver cirrhosis.   Hepatitis A This is

Biliary Colic This is writhing right upper quadrant pain which occurs due to the gallbladder contracting to clear a stone stuck in the cystic duct or gallbladder neck. Pain usually occurs after a fatty meal when the gallbladder contracts to release bile. If left untreated this can lead to inflammation causing acute cholecystitis.   Symptoms Right upper quadrant pain (can radiate to the right shoulder and scapula) Nausea and vomiting No fever or jaundice Key tests Ultrasound to detect stone LFTs are usually within normal limits   Management Small stones can pass spontaneously with resolution of the symptoms If persistent,

Coeliac disease This is a condition characterised by T cell-mediated damage of the small bowel villi due to gluten exposure, which leads to malabsorption. Gluten is found in wheat and grains and causes reduced mucosal absorption in the distal duodenum +/- proximal jejunum. It is associated with HLA-DQ2 and HLA-DQ8, and onset has a bimodal prevalence pattern, presenting in childhood and again between 50–60 years. If untreated, it can lead to T cell lymphoma of the small intestine.   Symptoms Diarrhoea, bloating, abdominal pain Steatorrhea, weight loss Fatigue and failure to thrive Hyposplenism Anaemia secondary to iron, folate and vitamin

Biliary Colic This is writhing right upper quadrant pain which occurs due to the gallbladder contracting to clear a stone stuck in the cystic duct or gallbladder neck. Pain usually occurs after a fatty meal when the gallbladder contracts to release bile. If left untreated this can lead to inflammation causing acute cholecystitis.   Symptoms Right upper quadrant pain (can radiate to the right shoulder and scapula) Nausea and vomiting No fever or jaundice Key tests Ultrasound to detect stone LFTs are usually within normal limits   Management Small stones can pass spontaneously with resolution of the symptoms If persistent,

Biliary Colic This is writhing right upper quadrant pain which occurs due to the gallbladder contracting to clear a stone stuck in the cystic duct or gallbladder neck. Pain usually occurs after a fatty meal when the gallbladder contracts to release bile. If left untreated this can lead to inflammation causing acute cholecystitis.   Symptoms Right upper quadrant pain (can radiate to the right shoulder and scapula) Nausea and vomiting No fever or jaundice Key tests Ultrasound to detect stone LFTs are usually within normal limits   Management Small stones can pass spontaneously with resolution of the symptoms If persistent,

Colorectal Cancer This refers to a proliferation of cells arising from the colonic or rectal mucosa. An elderly adult with iron deficiency anaemia is at high risk for colorectal cancer and should be investigated further, if clinically appropriate. It can be sporadic, which is associated with random mutations in APC, but is also associated with a host of genetic syndromes.   Symptoms These can present very insidiously so it is very important to screen for red flag symptoms: Altered bowel habit Tenesmus (urge but inability to defecate) Vague abdominal pain – Red flags symptoms – rectal bleeding, weight loss, abdominal

Acute Appendicitis This refers to inflammation of the appendix. It is the most common cause of abdominal surgery in patients, which can occur at any age. It occurs due to obstruction of the lumen commonly due to lymph hyperplasia (seen in children) or a feacolith (seen in adults). Gut organisms then invade the appendix wall leading to oedema, ischaemia, and necrosis. The inflammation irritates visceral fibres initially but then causes localised peritoneal inflammation in the right iliac fossa (RIF).  Symptoms Migrating Periumbilical pain – right iliac fossa Mild fever (37.5-38ºC) and anorexia Infrequent Vomiting Constipation (but diarrhoea can also occur)

The stomach acts as a reservoir for food, aids in digestion and uses acid to kill pathogens that we eat. – Thousands of gastric glands drain into the stomach, giving daily secretions of 2 litres   These gastric glands are composed of two main subsets of glands which have different functions: – Oxyntic glands – contain parietal cells which produce acid-HCl and intrinsic factor (Binds Vit B12) – Chief cells – these secrete pepsinogens and enzymes needed for digestion.   One of the most important features of the stomach is acid production, which is under the control of several factors

The liver is essential for life and carries out many important functions. It has a specialised arrangement: – It consists of thousands of lobules giving it an organised structure – Blood flows in through the hepatic artery and portal vein inwards towards the hepatic vein via the hepatic sinusoids – Lining the sinusoids are hepatocytes (functional units of the liver) – Between these are bile canaliculi, which help to drain bile outwards. This counter current flow is helpful as it gives a sustained gradient making it easy for cells to secrete substances from the blood to the bile.   The

Oesophagus This is the start of the gut tube, which carries food from the pharynx to the stomach. – Squamous epithelium lines the oesophagus and provides a protective barrier against wear and tear. – At the bottom is circular smooth muscle, the lower oesophageal sphincter, supplied by vagus nerve – The oesophagus has several adaptations to prevent the reflux of acid from the stomach, including an aute entry angle into the stomach (Angle of His), mucus folds and the left crus of the diaphragm   Blood supply: Inferior thyroid artery (top third), aortic branches (middle third), left gastric artery (bottom)

Biliary Colic This is writhing right upper quadrant pain which occurs due to the gallbladder contracting to clear a stone stuck in the cystic duct or gallbladder neck. Pain usually occurs after a fatty meal when the gallbladder contracts to release bile. If left untreated this can lead to inflammation causing acute cholecystitis.   Symptoms Right upper quadrant pain (can radiate to the right shoulder and scapula) Nausea and vomiting No fever or jaundice Key tests Ultrasound to detect stone LFTs are usually within normal limits   Management Small stones can pass spontaneously with resolution of the symptoms If persistent,

Primary Sclerosing Cholangitis (PSC) This is a chronic disease characterised by inflammation and scarring of the intrahepatic and extrahepatic bile ducts. Chronic inflammation leads to “onion-skin” fibrosis narrowing the ducts. This can result in strictures, causing a backlog of bile which results in jaundice. Bile is hepatotoxic and progression of the disease leads to liver cirrhosis. It is classically seen in young men and has a strong association with ulcerative colitis.   Symptoms Acute obstructive jaundice due to stricture formation Pruritus, fatigue and RUQ pain Leads to chronic liver failure Increased risk of cholangiocarcinoma Key tests Liver function tests show

This is a viral infection of the hepatocytes which leads to inflammation. It can cause acute and chronic symptoms   Acute This refers to inflammation of the liver which usually resolves within 6 months. It causes jaundice (mixed conjugated and unconjugated bilirubin) with dark urine. Also causes fever, tender hepatomegaly, nausea and weight loss. Blood tests show very elevated LFTs (ALT > AST). However, it can be asymptomatic with elevated LFTs.   Chronic This is characterised by elevated LFTs for > 6 months. It may be initially clinically silent, but usually progresses to liver cirrhosis.   Hepatitis A This is

Acute Liver Failure This term is used to describe an acute decrease in hepatocyte dysfunction.   Causes Drugs, e.g., paracetamol overdose, excess alcohol consumption, medicine reaction Infections, e.g., hepatitis A/B Trauma Symptoms Jaundice due to hyperbilirubinaemia Coagulopathy due to decreased hepatocyte synthetic function Oedema Hepatic encephalopathy   Key tests Liver function tests are not as indicative of the level of hepatic impairment It is more useful to measure albumin levels and prothrombin time (this provides a better assessment of the synthetic function of the liver)   Management Correct underlying cause, e.g., if paracetamol, the antidote is N-acetylcysteine Medical management involves

Pancreatic cancer This refers to a metastatic proliferation of pancreatic cells. It is usually an adenocarcinoma which arises from the head of the pancreas. It is seen in older patients and usually presents late with established metastases.    Risk factors Smoking, Alcohol Diabetes Chronic pancreatitis Hereditary non-polyposis colorectal carcinoma Multiple endocrine neoplasia Symptoms Painless obstructive jaundice, as the tumour compresses the common bile duct Epigastric pain which may radiate to the back, weight loss, decreased appetite Palpable gallbladder on examination (Courvoisier’s law states that patients with painless jaundice and a palpable gallbladder often have a malignant CBD obstruction)   Complications

Colorectal Cancer This refers to a proliferation of cells arising from the colonic or rectal mucosa. An elderly adult with iron deficiency anaemia is at high risk for colorectal cancer and should be investigated further, if clinically appropriate. It can be sporadic, which is associated with random mutations in APC, but is also associated with a host of genetic syndromes.   Symptoms These can present very insidiously so it is very important to screen for red flag symptoms: Altered bowel habit Tenesmus (urge but inability to defecate) Vague abdominal pain – Red flags symptoms – rectal bleeding, weight loss, abdominal

This refers to chronic, relapsing inflammation of the bowel, which is thought to be associated with an abnormal immune response to gut flora. It classically presents in the younger population with two key symptoms: bloody diarrhoea and abdominal pain. It is subdivided into two disorders which share similar symptoms.   Ulcerative colitis (UC) This disease is associated with recurrent inflammation of the colon which involves part or all the colon and rectum. The involvement is continuous, rather than in patches and never proximal to the ileocecal valve. Inflammation leads to bleeding mucosa, pseudopolyp formation and ulcers which extend into the

Acute Appendicitis This refers to inflammation of the appendix. It is the most common cause of abdominal surgery in patients, which can occur at any age. It occurs due to obstruction of the lumen commonly due to lymph hyperplasia (seen in children) or a feacolith (seen in adults). Gut organisms then invade the appendix wall leading to oedema, ischaemia, and necrosis. The inflammation irritates visceral fibres initially but then causes localised peritoneal inflammation in the right iliac fossa (RIF).  Symptoms Migrating Periumbilical pain – right iliac fossa Mild fever (37.5-38ºC) and anorexia Infrequent Vomiting Constipation (but diarrhoea can also occur)

Coeliac disease This is a condition characterised by T cell-mediated damage of the small bowel villi due to gluten exposure, which leads to malabsorption. Gluten is found in wheat and grains and causes reduced mucosal absorption in the distal duodenum +/- proximal jejunum. It is associated with HLA-DQ2 and HLA-DQ8, and onset has a bimodal prevalence pattern, presenting in childhood and again between 50–60 years. If untreated, it can lead to T cell lymphoma of the small intestine.   Symptoms Diarrhoea, bloating, abdominal pain Steatorrhea, weight loss Fatigue and failure to thrive Hyposplenism Anaemia secondary to iron, folate and vitamin

A hernia is the abnormal protrusion of tissue through an opening, which can occur in many different locations. They usually present as a visible lump, with an expansible cough impulse   Risk factors These increase intra-abdominal pressure or weaken the abdominal wall Heavy lifting                            Previous abdominal surgery Constipation                           Obesity   Symptoms Visible lump, with expansible cough impulse They are usually soft, painless, and reducible Complications  Irreducibility/incarceration – this means the contents cannot be pushed back into their original position Obstruction – this refers to hernia containing bowel;

These conditions usually present with epigastric pain. When dealing with stomach conditions you should be aware of the 5 alarm symptoms or age>55years, which require urgent upper GI endoscopy: Anaemia Loss of weight Anorexia Recent onset symptoms Malaena/hematemesis   Acute gastritis This refers acute inflammation of the stomach mucosa, which occurs due to anvimbalance between mucus defence and acid. The stomach is usually lined by bicarbonate ions, prostaglandins and a mucus barrier,vwhich protects against stomach acid. The acid damage results in superficial inflammation and can cause erosions (loss ofvsuperficial layer), which may progress to ulcer development (loss of mucosal layer).

Oesophageal web This is the protrusion of oesophageal mucosa, usually in the upper oesophagus. It is a risk factor for the development of oesophageal squamous cell carcinoma. It is associated with Plummer-Vinson syndrome, a triad of dysphagia, iron deficiency anaemia and oesophageal web.   Symptoms Dysphagia (to solids more than liquids) Can increase risk of aspiration and nasopharyngeal reflux   Management Endoscopic dilation of the oesophagus   Pharyngeal pouch (Zenker diverticulum) This is a pouch at the back of the throat, thought to be due to over-tightening of the cricopharyngeus muscle, causing the pharyngeal mucosa above it to pouch out.

Aphthous ulcer This is a painful, superficial ulceration of the oral mucosa, which arises spontaneously and heals without scars Whilst they are usually benign, it is essential to biopsy any ulcer not healing after 3 weeks to exclude malignancy   Symptoms Appears like it has a grey base with surrounding erythema. Tender to touch and pain when eating   Management Most self-resolve spontaneously Can use topical anaesthetic or anti-inflammatory gels (Bongela) for symptomatic relief   Mumps This is an infection due to the mumps virus that causes swelling of the parotid glands. The virus is transmitted by respiratory droplets and

Overview Jaundice refers to the yellow complexion that occurs from an elevated bilirubin. Jaundice refers to the characteristic clinical finding of yellow discolouration of body tissue, particularly the skin and sclera. This occurs due to an elevation in bilirubin, which is a breakdown product of red blood cells that are taken to the liver to be modified and excreted in the bile. Any disease process that alters the normal metabolism of bilirubin can lead to elevated levels and jaundice. This may be due to increased production or impaired excretion of bilirubin. Clinically, jaundice is not noticeable until the bilirubin level is

Overview Abdominal pain is a very common presenting symptom. Abdominal pain is a very common presenting complaint. It can be difficult to comprehend due to the shear volume of conditions that can present with this symptom. The job of any junior doctor, physician associate or advanced nurse practitioner is to take a good history, performance a solid examination and then come up with a synthesised list of possible diagnoses (i.e. the differential diagnosis). Two of the most important things to uncover from the history is the ‘timing of onset’ and the ‘location’. This is because these two factors really help narrow