The role of the GP in gastroinestinal health
As a GP, your role is to:
- diagnose, investigate, and manage digestive symptoms using history, examination, monitoring and referral where appropriate. Take into account how digestive symptoms can often be multiple and imprecise
- communicate effectively and consider the psychosocial impact of digestive problems, including the potential difficulties for some patients in discussing digestive symptoms due to embarrassment and/or social stigma
- intervene urgently when patients are present with emergencies related to digestive health
- coordinate care and collaborate with other organisations and members of the multidisciplinary team, leading to effective and appropriate acute and chronic digestive disease management
- offer advice and support to patients, relatives and carers regarding prevention, prescribing, monitoring and self-management (such as lifestyle interventions including diet, healthy weight, alcohol and drugs, stress reduction and primary cancer and liver disease prevention).
Knowledge and skills guide
For each problem or disease, consider the following areas within the general context of primary care:
- the natural history of the condition, including whether acute or chronic
- the incidence and prevalence, including in different demographic groups
- typical and atypical presentations
- recognition of normal variations throughout life
- risk factors, including lifestyle, socio-economic and genetic factors
- diagnostic features and differential diagnosis
- recognition of ‘alarm’ or ‘red flag’ features
- appropriate and relevant investigations
- interpretation of test results
- management, including initial and continuing care, chronic disease monitoring and emergency care
- patient and carer information and education prognosis.
Symptoms and signs
Many gastrointestinal (GI) conditions are often asymptomatic in their early stages. Symptoms and signs include:
- abdominal masses and swellings, including ascites and organ enlargement such as splenomegaly and hepatomegaly
- abdominal pain, including the differential diagnoses from non-gastrointestinal causes (such as gynaecological, or urological)
- bloating
- bowel issues, including constipation, diarrhoea, changes in habit, tenesmus and faecal incontinence
- chest pain
- cough
- disturbance of smell and taste
- dyspepsia
- dysphagia
- hiccups
- inflammation (for example, in eyes, joints)
- jaundice
- mouth ulceration, erythroplakia, leukoplakia, salivary problems
- nausea and vomiting, including non-gastrointestinal causes
- pruritus
- rectal bleeding, including melaena
- regurgitation
- vomiting, including haematemesis
- unexplained weight loss and anorexia
- weight gain, including obesity.
Common and important conditions
- Dyspepsia and gastro-oesophageal reflux disease (GORD) affect a significant proportion of the population
- Chronic abdominal conditions: inflammatory bowel disease, diverticular disease, coeliac disease and irritable bowel syndrome
- Acute abdominal conditions: appendicitis, acute obstruction and perforation, diverticulitis, Meckel’s diverticulum, ischaemia, volvulus, intussusception, gastric and duodenal ulcer, pancreatitis, cholecystitis, biliary colic, empyema and renal colic
- Medication effects: analgesics (codeine, non-steroidal anti-inflammatory drugs (NSAIDs), paracetamol), antibiotics (nausea, risk of Clostridium difficile (C. diff)), proton pump inhibitors (potential masking of symptoms)
- Post-operative complications
- Hernias: inguinal, femoral, diaphragmatic, hiatus, incisional
Upper GI conditions
- Gastrointestinal haemorrhage, including oesophageal varices, Mallory–Weiss syndrome, telangiectasia, angiodysplasia, Peutz–Jeghers syndrome
- GORD, non-ulcer dyspepsia, peptic ulcer disease, Helicobacter pylori (H. pylori), hiatus hernia
- Oesophageal conditions, including achalasia, malignancy, benign stricture, Barrett’s oesophagus, globus
- Gastrointestinal malignancies including oesophageal, gastric, pancreatic
Lower GI conditions
- Constipation: primary and secondary to other systemic diseases such as hypothyroidism, drug-induced, hypercalcaemia
- Diarrhoea
- Gastrointestinal infection, including:
- toxins such as C. diff and Escherichia coli (E. coli)
- bacterial causes such as salmonella, campylobacter, amoebic dysentery
- viral causes such as rotavirus, norovirus
- parasitic causes such as Giardia lamblia
- Note: sexually transmitted infections can also cause symptoms
- Gastrointestinal malignancies, including colorectal, carcinoid, lymphoma
- Inflammatory bowel disease such as Crohn’s disease, ulcerative colitis
- Malabsorption, including coeliac disease, lactose intolerance, secondary to pancreatic insufficiency (such as chronic pancreatitis, cystic fibrosis, bacterial overgrowth)
- Rectal problems, including anal fissure, haemorrhoids, perianal haematoma, ischiorectal abscesses, fistulae, prolapse, polyps, malignancy
Liver, gallbladder and pancreatic disease
- Liver disease:
- drug-induced: alcohol
- medications (paracetamol, antibiotics), chemicals
- infection: viral hepatitis, leptospirosis, hydatid disease
- malignancy: primary and metastatic
- cirrhosis (for example, from alcohol, fatty liver or non-alcoholic fatty liver disease NAFLD))
- primary biliary cirrhosis, chronic active hepatitis, haemolysis
- alpha-1 antitrypsin deficiency, haemochromatosis, Wilson’s disease
- Secondary effects of liver diseases such as ascites, portal hypertension, hepatic failure
- Gallbladder disease: gallstones, cholecystitis, cholangitis, biliary colic, empyema, malignancy
- Pancreatic disease: acute pancreatitis, chronic pancreatitis, malabsorption, malignancy including islet cell tumours
Nutrition
- Dietary management of disease, inadequate or excessive intake
- Impact of diet on health (such as risk of cancer from high red meat intake) and dietary approaches to healthy living and prevention of disease
- Disorders of weight: obesity and weight loss including non-nutritional causes such as cancer, thyroid disease and other endocrine conditions
- Nutritional problems: vitamin and mineral deficiencies or excess, supplementary nutrition such as dietary, percutaneous endoscopic gastrostomy (PEG) and parenteral feeding
- Complications and management of stomas
Examinations and procedures
The nature of GI symptoms and examinations can be sensitive. It is important to put your patient at ease and provide an environment where abdominal and rectal examinations are performed with dignity and, where appropriate, under chaperoned conditions.
Investigations
- Stool tests, including culture and faecal calprotectin, faecal immunochemical test (FIT)
- Tests of liver function, including interpretation of immunological results and markers of disease including cirrhosis and malignancy, including scoring tools for NAFLD
- Endoscopy, ultrasound, and other scans (e.g., transient elastography), interpretation of relevant tests such as those for Helicobacter pylori infection, coeliac disease
- Secondary care interventions such as laparoscopic surgery, endoscopic retrograde cholangio pancreatography (ERCP), radiological investigations (including contrast and computed tomography (CT) scans)
- Screening programmes for colorectal cancer such as stool tests (FITs), endoscopy and the evidence base.
Service issues
- High prevalence of GI symptoms in the community and the implications for primary care
- Importance of assessing major risk factors and encouraging early lifestyle interventions to reduce the risk of liver disease
- Availability and appropriate use of direct-access endoscopy and imaging for primary care practitioners
- Community-based services in areas such as drug and alcohol rehabilitation (both of which are implicated in GI and liver disease)
- Increasing demand for weight-loss surgery, and its potential long-term effects
- Public health implications of the national bowel cancer screening programme and the role of primary care in provision and in dealing with symptoms among screening invitees.
Additional important content
- Appropriate tailoring of treatment to cater for the patient’s GI function and preferences
- Side effects of common medicines, including analgesics, antibiotics and proton pump inhibitors
- Drug and alcohol misuse: range of associated Gl and liver problems, complex issues, ways these impact digestive disorders and the management problems they are associated with
- Impact of social and cultural diversity, and the important role of health beliefs relating to diet, nutrition and the presentation of gastrointestinal disorders. Ensure that the practice is not biased against recognising these.
Case discussion
Beverley Adams is a 62-year-old librarian with a history of osteoarthritis in her knees. She has not been eating or sleeping well, and is presented with intermittent constipation, bloating, epigastric discomfort, tiredness and 5kg weight loss in the last six months.
She presented last year with some rectal bleeding, which was attributed to haemorrhoids by another GP. It settled with conservative treatment. She takes NSAID for her arthritis and has a vegetarian diet.
Her marriage has been under strain since her husband lost his job and increased his alcohol consumption. She is stressed at work due to a difficult new supervisor and she would like to retire but cannot be due to their financial situation.
As part of the national screening programme, she has been invited to undertake a second FIT; the first was negative two years ago and she has declined to do another. You do not find anything abnormal on abdominal or rectal examination and you request blood tests, which show mild anemia.
Questions
These questions are provided to prompt you to consider the key points of the case. They can form the basis for a case discussion with your educational supervisor and will assist you in writing reflective entries in your ePortfolio. The questions are examples to trigger reflection and are not intended to be comprehensive.
| Core capabilities | Questions |
|---|---|
Fitness to practise This is about professionalism and the actions expected to protect people from harm. This includes the awareness of when an individual’s performance, conduct or health, or that of others, might put patients, themselves or their colleagues at risk. | How might my practice be different if I had past experience of a close relative or friend with a similar presentation? How might this influence how I develop a shared management plan with the patient? |
An ethical approach This is about practicing ethically with integrity and respect for equality and diversity. | How would I deal with my concerns about Beverley’s husband? What ethical principles do I know that might help me with this case? How might my approach be different if the patient was a different sex, had a different culture or religion? |
Communicating and consulting This is about communication with patients, the use of recognised consultation techniques, establishing and maintaining patient partnerships, managing challenging consultations, third-party consulting, the use of interpreters and consulting modalities across the range of in-person and remote methods. | How can I acknowledge the wide range of psychosocial issues in history? What techniques would I use to work flexibly and efficiently within the allotted time? How might I explain my examination findings and the investigations to the patient? |
Data gathering and interpretation This is about the gathering, interpretation and use of data for clinical judgement, including information gathered from the history, clinical records, examination and investigations. | What are the differential diagnoses? What investigations might I request? How do I manage the risk of a possible serious illness if the test results were normal? How sensitive and specific are the bowel screening programmes? |
Clinical examination and procedural skills This is about clinical examination and procedural skills. By the end of training, the GP registrar must have demonstrated competence in general and systemic examinations of all the clinical curriculum areas, including the five mandatory examinations and a range of skills relevant to general practice. | What is the significance of a normal abdominal and rectal examination? Do I feel reassured by this? What other elements of the history and examination would I wish to explore in this case? |
Decision-making and diagnosis This is about having a conscious, organised approach to making diagnosis and decisions that are tailored to the particular circumstances in which they are required. | What is my strategy for investigating this combination of symptoms and factual information (such as weight loss, anemia, weakness or fatigue, psychological issues)? How much should the patient’s priorities influence this? How could I encourage a shared decision-making process? |
Clinical management This is about the recognition and a generalist’s management of patients’ problems. | What are my next steps? When should I refer or investigate with a colonoscopy? What advice would I give regarding her medications? |
Medical complexity This is about aspects of care beyond the acute problem, including the management of comorbidity, uncertainty, risk and health promotion. | How will I address Beverley’s current concerns while being diligent in investigating her for serious illness? How can I involve Beverley in thinking about planning the different strands of her care? What are the possible supportive organisations and potential referral routes in this case? |
Team working This is about working effectively with others to ensure good patient care and includes sharing information with colleagues and using the skills of a multiprofessional team. | What are the referral guidelines for two-week suspected cancer referrals? What information should be included in any referral letter? Who else in the multidisciplinary team could support Beverley? How can Beverley’s care be most effectively coordinated? |
Performance, learning and teaching This is about maintaining the performance and effective CPD of oneself and others. The evidence for these activities should be shared in a timely manner within the portfolio. | What can be identified as areas of personal educational need? What sources of information can I identify to ensure I am up to date with the investigation of lower GI symptoms? What areas could be explored further for potential improvement at the practice level? |
Organisation, management and leadership This is about understanding how primary care is organised within the NHS, how teams are managed and the development of clinical leadership skills. | How does my practice record and follow up patients who have not attended the bowel screening programme? What can my practice do to improve the uptake of screening programmes? What is the most appropriate way to record the multiple aspects of this patient’s presenting complaint? |
Holistic practice, health promotion and safeguarding This is about the ability of the doctor to operate in physical, psychological, socio-economic and cultural dimensions. The doctor is able to take into account the patient’s feelings and opinions. The doctor encourages health improvement, self-management, preventative medicine and shared care planning with patients and their carers. The doctor has the skills and knowledge to consider and take appropriate safeguarding actions. | How could Beverley’s wider concerns influence her presentation? What other aspects of her social and cultural background would I like to enquire about? How could I support Beverley with self-management? |
Community health and environmental sustainability This is about the management of the health and social care of the practice population and local community. It incorporates an understanding of the interconnectedness of health of populations and the planet. | How do people respond to invitations for bowel cancer screening? What influences this? What negative influences or barriers might exist in the community that could exacerbate problems for Beverley and her family? What community services might be available to help Beverley and her family? |
How to learn this area of practice
Work-based learning
You should ideally spend time in clinics, in both general and specialised areas – for example, hepatitis management, liver disorder and endoscopy clinics. There is a very broad spectrum of activities in which you could potentially get involved and the opportunities will depend to some extent on what is available locally. You should also take the opportunity to discuss screening programmes with patients in eligible age groups and check their understanding of the screening process and how it relates to symptom-based diagnosis.
Self-directed learning
You will find many case-based discussions within GP specialty training programmes on GI disorders. These cases are often challenging because patients with GI diseases often follow unpredictable diagnostic journeys.
Learning with other healthcare professionals
GP registrars should take the opportunity of discussing GI disorders with practice nurses and nurses in the hospital environment. Some practices have community nurses dealing specifically with stoma care or drug and alcohol problems and it would be helpful to spend time discussing GI disorders in relation to shared care protocols, intravenous drug use and excessive alcohol consumption.
Examples of how this area of practice may be tested in the MRCGP
Applied Knowledge Test (AKT)
- Investigation of rectal bleeding
- Interpretation of liver function tests
- Assessment of abdominal pain
Simulated Consultation Assessment (SCA)
- A man with a raised body mass index (BMI) has a cough that is worse overnight and first thing in the morning
- A young woman complains of recurrent abdominal pain and bloating
- An elderly woman asks for an explanation and advice after a hospital outpatient attendance; the consultant’s letter (provided) gives a diagnosis of diverticular disease
Workplace-based Assessment (WPBA)
- Case-based Discussion (CBD) about a man who continues to have upper abdominal pain following a recent cholecystectomy
- Log entry about a referral for a woman with dysphagia through the urgent cancer pathway
- Quality Improvement Project (QIP) looking at how effective your GP practice is at suggesting suitable interventions to patients who may potentially be at risk of liver disease