Gastrointestinal and Liver Diagnoses

  • Gastro-Oesophageal Reflux Disease

    This describes a situation in which stomach contents run back into the oesophagus (gullet), because what is supposed to be a one-way valve only allowing food downwards, does not work properly. The commonest resulting symptom is Heartburn. It is a problem which many people have to a minor extent, but it sometimes becomes more major and occasionally causes significant complications. If there are no worrying features it can be treated without an endoscopic examination, although such an examination is often useful to assess severity or complications. Treatment usually consists of using Proton Pump Inhibitor drugs, which substantially reduce acid production in the stomach. Some patients need these intermittently and some patients need to take them continuously, which is broadly a safe thing to do. Occasionally it is suggested that an operation is performed to make the valve work more efficiently, an operation which is now usually done by a keyhole method. Before considering an operation, with any difficulty in diagnosis, or if standard treatment is not completely effective, a series of tests known as Oesophageal Function Tests can be performed to define the exact nature and extent of the problem.

  • Gastric and Duodenal Ulcers

    Before the 1970’s it caused a great deal of problem and distress, but the advent of tablets to suppress acid and more recently the discovery that most ulcers are linked to Helicobacter infection which can now treated, it has very substantially reduced the degree of problems and distress caused by ulcers. If a patient has ulcer-type symptoms, it is usually reasonable to look for Helicobacter first of all and then treat it if it is present. If the symptoms disappear, then upper GI endoscopy may not be needed. However the presence of associated alarm symptoms (difficulty in swallowing, vomiting, weight loss) or the failure of Helicobacter treatment to help, requires an endoscopic examination. Surgery for ulcers, which used to be common, is now rarely performed.

  • Oesophago-gastric Cancer

    This refers to a cancer arising in the oesophagus (gullet) and stomach. It is relatively common in the western world but unusual at a young age. Symptoms include progressive difficulty in swallowing, new or persistent dyspepsia and frank upper abdominal pain. Weight loss is usually present and vomiting can also occur. The diagnosis is usually made at upper GI endoscopy, with biopsy. Treatment often involves an operation and may also include both Chemotherapy and Radiotherapy. As with most cancers, the overall outlook is improved if the diagnosis is made early on in the disease process.

  • Pancreatic Cancer

    This is also a relatively common cancer in the western world. One classic presentation is when the developing cancer begins to obstruct the bile duct joining the liver to the bowel and the back-pressure on the liver causes jaundice, which is often painless. It is also unusual at a young age. There may also be upper abdominal pain, which may radiate through to the back. Pancreatic cancer can also present with a more general range of symptoms, including isolated weight loss, and more non-specific abdominal symptoms. The diagnosis is usually made by CT scanning. Treatments can include surgery as well as both Chemotherapy and Radiotherapy. As with most cancers, the outlook is improved by early diagnosis.

  • Coeliac Disease

    Coeliac Disease is genetically-based. As such, it may present at a very young age, but sometimes does not show itself until much later in life. It is caused by an “allergy” of the mucosal tissue lining the small bowel to the gluten fraction of wheat and other cereals. The mucosa becomes inflamed and less efficient at absorbing nutrients. The classic symptoms are of diarrhoea and weight loss. Now that it can be diagnosed by blood tests, it is recognised in a wide variety of less severe clinical situations as causing vague abdominal pain, bloating, bowel disturbance, and also a range of symptoms outside the abdomen including joint discomfort, rashes and sometimes psychological changes. The initial screening test is a blood test, but if suspected, Coeliac Disease is confirmed by taking a biopsy from the upper small bowel at an upper GI endoscopy. Treatment involves going onto a diet that is completely and strictly free of Gluten, for which advice from a Dietician is essential. A strict Gluten-free diet, which needs to be lifelong, almost always resolves the symptoms and problems.

  • Irritable Bowel Syndrome

    As with any condition involving the word “Syndrome”, the Irritable Bowel Syndrome is a collection of symptoms which seem to occur very regularly but for which an exact and single cause has not been defined. The key symptoms of the Irritable Bowel Syndrome include abdominal pain, abdominal bloating and a change in bowel pattern. There should be no “alarm” symptoms, in particular no vomiting, no weight loss and no rectal bleeding. There is no specific test for the Irritable Bowel Syndrome, and tests are done to exclude other and more specific problems. It is important to emphasise that the Irritable Bowel Syndrome is a real condition with genuine symptoms, and although there is often a psychological element, symptoms are not imagined. Approaches to treatment include some level of medication, dietary alteration, various psychological approaches, and often more alternative approaches. Although there is no simple cure, in many patients, an accurate diagnosis and a simple explanation of the condition makes it much more bearable.

  • Ulcerative Colitis

    Ulcerative Colitis is one of the Inflammatory Bowel Diseases. The cause is unknown, but probably consists of a genetic tendency for it to occur, and then something that makes it begin. Once it starts, it usually becomes a chronic relapsing and remitting problem. It affects only the large bowel, in which the lining tissue (mucosa) becomes inflamed, causing the main symptom which is diarrhoea containing blood. The segment of large bowel involved starts at the anus and goes for a variable different distance upstream, sometimes just involving a little bit of the bowel near the anus and sometimes involving most of the large bowel. The diagnosis is made by Colonoscopy and biopsy. Treatment initially involves settling down the acute inflammation, either with enema treatment or corticosteroids. Most patients then need long-term maintenance treatment to prevent the disease relapsing. The simplest maintenance treatment is Mesalazine, but some patients need stronger drugs such as immunosuppressives. Very occasionally surgery is needed to remove the large bowel, either in an acute situation or because medical treatment has gradually failed.

  • Crohn’s Disease

    This is the other main Inflammatory Bowel Disease. In contrast to Ulcerative Colitis it can affect any part of the GI tract, but most commonly the section where the small bowel joins the large bowel. It can also involve several sections of the bowel, with normal tissue in between. The cause is unknown, but in a similar way to Ulcerative Colitis there may be a genetic tendency followed by a trigger for it to start. It also tends to be a relapsing and remitting disease. The symptoms depend on the exact position in the bowel of the main area of inflammation, but can include abdominal pain, weight loss and diarrhoea. Problems around the anus can occur. Initial treatment is broadly similar to Ulcerative Colitis, using steroids to settle about inflammation. Recently, Biologic treatment given intermittently can have a dramatically beneficial effect. Some patients need surgery to remove segments of bowel. A very few patients with Crohn’s Disease get a more severely troublesome form of the disease, sometimes needing multiple operations and major nutritional support.

  • Colorectal Cancer

    This phrase describes cancer of the large bowel and rectum (back passage). Colorectal cancer is particularly curable if diagnosed early on in the disease process. If the cancer is near the anus there may well be a change in bowel pattern and persistent rectal bleeding. If the cancer is near the upper end of the large bowel there may be less in the way of bowel symptoms, although the patient may become gradually anaemic from blood slowly lost from the cancer surface, but not enough to see it red in the toilet. The diagnosis is by colonoscopy and biopsy, and sometimes needing CT scanning. Almost all patients need surgery to remove the affected part of the large bowel. Cure rates a very good if the diagnosis is made early in the disease process. Because of this, there is a National Screening Programme for Large Bowel Cancer, partly involving a single endoscopy aged 55 and partly involving regular tests of the stool for traces of blood between the ages of 60 and 75. If the latter is positive, a colonoscopy is advised. Some families can be defined as having a particular tendency to colorectal cancer at a young age, and family members then need an increased level of screening.

  • Gallstones

    The gallbladder lies just below the liver and is attached to the bile duct. It stores up the bile between meals so that more bile is available for digestion. Although the exact cause of gallstones is not known, because bile is both sticky and stationary, it is easy to see that the stones crystallize out of it. It is possibly to live with gallstones for many years without knowing of their existence and without them causing any symptoms. Once symptoms begin they often consist of episodic but quite severe pain, sometimes linked to meals and often accompanied by nausea and vomiting. There may be waves of very severe pain under the right ribs radiating round to the right shoulder. Gallstones tend to run in families and are slightly commoner in women. Diagnosis is by ultrasound scanning. If the stones are confined to the gallbladder then the only useful treatment is a modern keyhole operation to remove the gallbladder with the stones in it. If a stone has escaped into the bile duct, the clinical picture is often different. The stone may need to be removed by a particular kind of upper GI endoscopy known as ERCP. Gallstone symptoms can possibly be controlled by being very careful to avoid any fat in the diet but this is not usually a long-term solution.

  • Chronic Liver Disease

    The particular feature of Chronic Liver Disease as an entity is that for the duration of Chronic Liver Disease in most people, there are very few symptoms. It is often hard for a patient to understand that there can be a serious and progressive liver disease, which may shorten life, and yet not really have any symptoms at all. When they do occur, symptoms may include jaundice, itching, and abdominal swelling, but these are often late-stage. Therefore, within the field of Chronic Liver Disease, the emphasis is on prevention and early detection. People often equate “Chronic Liver Disease” with “Cirrhosis”. The word Cirrhosis defines a situation where the liver is completely and irreversibly scarred and is an end-point of many of the Chronic Liver Diseases. If the Chronic Liver Disease can be prevented or stopped before it reaches Cirrhosis, the outlook for the person can be very good. Once Cirrhosis occurs, even if the cause is removed, the Cirrhosis itself can be slowly progressive and can eventually cause major problems. The three commonest causes of Chronic Liver Disease in the UK are excess alcohol, Fatty Liver disease, and Viral Hepatitis. There are also rarer liver diseases.

  • Fatty Liver Disease

    This describes the situation in which the liver is infiltrated with excess fat. It tends to occur in patients who are either overweight, have significant cholesterol problem, or who are diabetic, or any combination of these three. If all three of these factors are present, then the patient is said to have the Metabolic Syndrome, which carries particular risk for Fatty Liver Disease. Most patients with Fatty Liver Disease may have abnormal liver blood tests but may not progress to more serious forms of liver disease. A small proportion of patients do progress to significant liver scarring and Cirrhosis, but it is difficult to predict in which patients this will occur. There are no useful treatments to prevent the progress of fatty liver disease other than good control of weight, cholesterol and Diabetes. Excess alcohol can also cause fat to accumulate in the liver and the process may be additive to other causes.

  • Viral Hepatitis

    There is quite a wide range of viruses which can cause liver problems. Most of them have the word “Hepatitis” in their name, followed by a letter of the alphabet. Hepatitis A and Hepatitis E only cause acute liver diseases and never go on to Chronic Liver Disease. Hepatitis D is an unusual infection that can only occur in patients who already carry Hepatitis B. Hepatitis B and Hepatitis C have the potential to go on and cause Chronic Liver Disease. Most patients who carry Hepatitis B do not have Chronic Liver Disease at all and may never develop it, whereas most patients who carry Hepatitis C will eventually develop some degree of Chronic Liver Disease. Hepatitis B is mainly contracted either mother-to-baby at birth, sexually, or by infected blood and needles. The transmission of Hepatitis C is mainly by infected blood and needles, although there can be sexual transmission and transmission from mother-to-baby. Worldwide these are extremely common infections, but less so in the UK. There is a vaccination against Hepatitis B but not yet against Hepatitis C. Any patient found to be carrying these viruses needs an assessment of whether they have liver disease or not. If they do have liver disease, both viruses have treatment. Hepatitis B is usually treated with continuous treatment to suppress it. There are newer Hepatitis C treatments in being launched, which seem to give the potential to cure the infection in most people.

  • Alcohol-related Liver Disease

    Anybody who drinks regularly above the nationally recommended limits is risking the development of Alcohol-related Liver Disease. The limit is 14 units of alcohol per week for men and women. The risk of liver disease is measurable but not that much increased if these limits are doubled. Above that level, there is a very noticeable risk of developing Alcohol-related Liver Disease. Women are more sensitive to alcohol, and they tend to develop liver disease quicker. In the early stages of alcohol-related liver disease, the liver may just be inflamed with some excess fat, although asymptomatic. As indicated above, once Cirrhosis develops, the liver can deteriorate quickly if drinking continues. The only overall treatment for Alcohol-related Liver Disease is to stop drinking completely and permanently. If the person is an habitual drinker but not an addictive drinker, this can be relatively easy. If they not only are an excessive drinker but also an addictive drinker, giving up alcohol can be much more difficult. All localities in the UK have a range of service that can help people with alcohol-related problems.

  • Rarer Liver Diseases

    Between 5 and 10% of all Chronic Liver Disease in the UK is represented by rarer liver diseases. Most of these either have an autoimmune or genetic basis. As for other liver diseases, there is usually a long period in which they are asymptomatic and they may be discovered by a chance finding of abnormal Liver Function Tests. Some of these diseases have good treatments to control them, whereas others do not.