INTRODUCTION

This article covers common gastroenterological presenting complaints seen in primary care. Presentations covered are: dyspepsia, diarrhoea, PR bleeding, constipation and deranged LFTs.

DYSPEPSIA

Definition

Spectrum of upper GI symptoms including epigastric pain and heartburn and acid reflux.
Can be categorised into functional causes vs. structural causes (e.g. GORD, PUD, GI malignancies)

Overview of causes

• Functional
• Gastritis or oesophagitis – secondary to EtOH, Helicobacter pylori (H.pylori), candida 
• Gastro-oesophageal reflux disease (GORD)
• Peptic ulcer disease (PUD) – gastric or duodenal ulcers
• Upper GI malignancies – oesophageal, gastric
• Achalasia
• Pharyngeal pouch
• Medications e.g. steroids, bisphosphonates, SSRIs

Management of dyspepsia in primary care

Check for red flag symptoms and if present – REFER 2 week wait!

If no red flag symptoms then try lifestyle advice with antacids +/- alginates e.g. Gaviscon

Lifestyle advice

• Smoking cessation
• Avoid trigger foods – coffee, fatty or spicy foods, tomatoes
• Eat small meals and eat evening meal 3-4 hours before bedtime
• Reduce alcohol intakeWeight loss if BMI >25
• Stress management

Review medications: common precipitants

• Selective serotonin reuptake inhibiters (SSRIs)
• Non-steroidal anti-inflammatory drugs (NSAIDS)
• Steroids
• Bisphosphonates
• Nitrates
• Calcium-channel blockers

Consider stopping or reducing dose of such medications if appropriate.

Test for Helicobacter Pylori  (H. pylori)
If positive – then treat, see section below for full management of H.pylori

If negative for H. pylori then trial proton pump inhibitors (PPI) or histamine (H2)-receptor antagonist (H2RA) for 1 month

• First trial low dose e.g. omeprazole 20 mg or lansoprazole 15 mg OD
• If response – then titrate to lowest dose that controls symptoms
• If no response – trial HIGH dose PPI for 4 weeks e.g. omeprazole 40 mg BD or lansoprazole 30 mg BD

• If failure of PPI then refer for OP OGD

Consider Gastro referral (non-urgent) if:

• H. pylori with unsuccessful second-line eradiation
• Frequent vomiting associated with dyspepsia
• Persistent regurgitation of food
• Gastroparesis suspected [e.g. if background of DM or scleroderma]
• Failure to respond to PPI with negative OGD – may need specialist investigations:
  • Barium swallow or meal
  • Gastric scintigraphy to assess for delayed gastric emptying
  • Hydrogen breath tests to detect small intestinal bacterial overgrowth  

Approach to PPI use

• Empiric PPI trials should be brief (e.g. 2-4 weeks). There is no need to test PPI efficacy over longer period e.g. months.
• Maximal acid suppression occurs within 2-5d
• Avoid high-dose PPI at first line
• Once symptoms controlled, trial the LOWEST effective dose used periodically
• Upon stopping PPI– risk of PPI-induced rebound acid hypersecretion  
  • Occurs as hypoacidity from acid suppression induces hypergastrinemia resulting in increase in parietal cell mass
• Other PPI adverse effects:
  • Increased risk of osteoporotic fractures
  • Hypomagnesaemia
  • Hyponatraemia
  • C. difficile infection

Common condition managed in primary care: Helicobacter Pylori

Presentation

• Dyspepsia
• Nausea
• Loss of appetite
• Bloating
• Burping and regurgitation

Investigations

• Carbon-13 urea breath test OR stool antigen test
• Ensure no PPI in the past two weeks or antibiotic use in the past four weeks

Management of H.pylori

• If POSITIVE – then triple therapy for 7 days and review response
• 1st line eradication = PPI + amoxicillin 1g BD + clarithromycin 500 mg BD OR metronidazole 400 mg BD
• If penicillin allergic then PPI + clarithromycin + metronidazole

• After treatment no need for routine re-testing unless there are specific clinical circumstances as per below.
  • There has been poor compliance to first-line eradication therapy, or the initial test was performed within 2 weeks of proton pump inhibitor (PPI) or 4 weeks of antibiotic therapy.
  • Aspirin or an NSAID is indicated, especially if there is a history of peptic ulcer disease.
  • There is a family history of gastric malignancy.
  • There are severe, persistent, or recurrent symptoms.
  • The person requests re-testing (for example if there is anxiety about whether H. pylori has been eradicated)

Retesting

• Must be at least 4 weeks after initial eradication therapy
• If re-testing is positive then second-line H.pylori eradication (exact regimen varies as per Trust guidelines)
• PPI + amoxicillin + either clarithromycin or metronidazole (whichever was NOT used first-line)
• If previous exposure to clarithromycin and metronidazole then 7-10 days with PPI + amoxicillin + either quinolone e.g. levofloxacin or tetracycline hydrochloride
• If penicillin allergy then 7-10 day PPI + metronidazole + levofloxacin

DIARRHOEA

Definition

Defined according to NICE as passage of 3 or more loose or liquid stools per day (or more frequently than is normal for the individual)

• Acute: less than 14 days
• Persistent: more than 14 days
• Chronic: more than 4 weeks

Overview of possible causes

• Gastroenteritis/infectious colitis: bacterial, viral, parasitic
  • Amoebae, giardia, cryptosporidium can be cause of persistent (>14d) diarrhoea
• Drug-induced: PPIs, antibiotics, laxative abuse
• Functional – irritable bowel syndrome, acute anxiety-related diarrhoea
• Coeliac disease
• Lactose intolerance
• Inflammatory bowel disease (IBD)
• Acute dietary cause: e.g. over-consumption of alcohol, spicy foods, caffeine, sorbitol
• Appendicitis
• Colorectal malignancies
• Microscopic colitis
• Diverticulitis
• Ischemic colitis
• Overflow diarrhoea (suspect if recent history of constipation)
• Bile acid malabsorption (suspect if history of cholecystectomy or ileal resection)
• Small intestinal bacterial overgrowth
• Hyperthyroidism

Management of diarrhoea in primary care

History

• Onset/duration – acute vs chronic
• Frequency
• Presence of pus/blood
• Consistency – steatorrhea points towards malabsorptive cause
• Associated symptoms – vomiting, fevers, abdominal pain, weight loss)
• Symptoms pointing towards other diseases as a cause (e.g. hyperthyroidism: tremor, palpitations, weight loss
• Recent constipation – think overflow diarrhoea
• Travel
• Unwell contacts
• Recent takeaway/outside foods
• Recent hospitalisation
• Recent exposure to possible sources of enteric infection e.g. recent farm or petting zoo visits
• Stress/anxiety
• Diet – Worsened by dairy? Recent alcohol or caffeine excess?
• Medication use – laxatives, PPI, recent antibiotics (C.difficile)
• Risk factors for immunosuppression – HIV, long-term steroids or immunosuppressive medication use, chemotherapy
• Past medical history – endocrine diseases e.g. hyperthyroidism
• Previous abdominal surgery – bile acid diarrhoea more likely if history of ileal surgery or cholecystectomy
• Family history e.g. IBD, coeliac disease, thyroid disease

Examination

• Assess for complications e.g. dehydration (high heart rate, dry mucous membranes, delayed capillary refill time, hypotension, reduced skin turgor
• Abdominal exam – look out for pain, distension, mass, organomegaly
• Rectal examination – assess for bleeding, presence of stool and consistency (helps guide need for suppository +/- enema), faecal leakage, anal pain.

Blood tests

The following applies in the chronic setting – if bloods are needed in the acute setting then patients are referred to hospital for further assessment.

• FBC
• U&Es
• LFTs including albumin
• Calcium
• Vitamin B2, folate, ferritin
• TFTs
• ESR and CRP
• Coeliac screen – IgA levels, IGA tissue transglutaminase (tTG) or IgA endomysial antibody (EMA) – should be done whilst patient eating gluten
• Consider Ca-125 if suspicious of ovarian cancer (>50 years, bloating, abdominal distension, family history, history of breast cancer)
• Consider HIV tests if immunodeficiency is suspected

Stool investigations

• Microscopy & culture including ova, cysts, parasite (OCP) – esp. if travel history. Send 3 specimen sat least 2 x apart for OCP.
• Clostridium difficile if high suspicion – recent hospitalisation, antibiotic use, PPI use
• Faecal calprotectin (if suspecting IBD)Faecal elastase (if suspicion of pancreatic insufficiency e.g. loose pale, floaty stool)
• Faecal immunochemical test (FIT) – tests for blood, useful in patients with symptoms suggestive of cancer who do not meet cancer referral criteria (see below)

Indications for hospital admission

• Tachycardia
• Hypotension
• Features of severe dehydration or shock
• Acute abdomen
• Vomiting and unable to retain oral fluids
• Severe electrolyte abnormalities as a result of diarrhoea

Examples where hospital admission can be considered

• Older age as greater risk of complications e.g. >60 years
• Social situation – home circumstances, level of support
• Severe bloody diarrhoeaIncreased risk of poor outcome e.g. frailty or coexisting medical conditions – immunodeficiency, renal impairment, cardiac disease
• Grossly elevated inflammatory markers

Criteria for urgent hospital referral on 2 week wait pathway

• >40 with unexpected weight loss and abdominal pain
• >50 with unexplained rectal bleeding
• >60 with iron deficiency anaemia or changes in bowel habit or if tests show occult blood in faeces

Criteria to consider urgent hospital referral on 2 week wait pathway

• Adults with a rectal or abdominal mass.
• Adults aged under 50 with rectal bleeding and any of the following unexplained symptoms or findings:
  • Abdominal pain
  • Change in bowel habit
  • Weight loss
  • Iron-deficiency anaemia

Routine secondary care referrals

• History, examination, blood tests/investigations suggestive of:
  • Coeliac disease
  • IBD
  • Microscopic colitis
  • Bile acid diarrhoea
  • Malabsorptive causes
  • Other systemic diseases that need specialist assessment e.g. hyperthyroidism
• A person less than 40 years of age who does not have typical symptoms of functional bowel disorder and/or has severe symptoms and documented diarrhoea. 
• The diagnosis is uncertain. 
• Nocturnal or continuous diarrhoea or both (suggestive of an organic rather than functional disorder).
• Moderately raised inflammatory markers – may indicate inflammatory bowel disease. (Note if severely raised this would warrant urgent referral for admission)

Situations where public health may need to be notified

• Diarrhoea in high-risk people (for example food handlers, healthcare workers, elderly residents in care homes).
• Suspected food poisoning (for example after a barbeque, restaurant meal, or eating eggs, chicken, or shellfish).
• Outbreaks of diarrhoea in the family or community, when isolating the organism may help pinpoint the source of the outbreak.
• Contacts of people infected with certain organisms, for example, Escherichia coli O157 or C. difficile, where there may be serious clinical sequelae to an infection.
• Close household contacts of a person with Giardia infection

Common condition managed in primary care: Irritable bowel syndrome (IBS)

Diagnosis

• Diagnosis of exclusion based if above investigations for diarrhoea negative
• Formal diagnosis if symptoms for at least 6 months

Investigations

Need to ensure the investigations below are completed to exclude other diagnoses:

• Bloods – FBC, ESR, CRP, TTA/EMA antibodies
• Stool tests – calprotectin, elastase, MC&S
• Do not need to have done flexible sigmoidoscopy/colonoscopy if other tests normal and patient meets IBS criteria

Management

• Dietary modifications
  • Regular meals, fluid intake, reduce alcohol + fizzy drinks, limit high-fibre foods
• Pharmacological therapy. 1^st line = symptom control:
  
  • Antispasmodics for pain.
  • Laxatives (NOT lactulose as can worsen IBS symptoms) for constipation
  • Loperamide for diarrhoea
  • Second-line: trial tricyclic anti-depressants (TCAs)
• Psychological interventions
  
  • E.g. cognitive behavioural therapy (CBT) – refer if no response to pharmacological treatment after 12 months
• Any new ‘red flag’ symptoms (e.g. a symptom implying organic pathology) needs further investigations +/- secondary care referral

RECTAL (PR) BLEEDING

Causes of PR bleeding

Local causes

• Haemorrhoids
• Anal fissure
• Anal malignancy
• Anorectal fistula
• Anal warts – may bleed
• Perianal abscess
• Rectal or anal varices secondary to portal hypertension

Systemic causes

• Mesenteric ischemia
• Ischaemic colitis
• Angiodysplasia
• Gastroenteritis (shigella, amoebae, yersinia)
• Colorectal cancer
• Diverticulitis
• IBD: UC > Crohn’s
• Fast upper GI bleed  
• Perforation
• Post-op bleeding

Management

History

• Onset: acute vs chronic
• Duration of bleeding
• Associated symptoms – anal or abdominal pain, diarrhoea, skin lesions, fever
• History of constipation/straining
• Medication – importance to establish if on anticoagulation as this may need review if significant bleed

Examination

• Abdominal exam – assess for pain, evidence of acute abdomen
• PR exam – masses, haemorrhoids, fissures, fistula, abscess, blood/mucous, stool consistency  

Investigations in primary care

• Consider blood tests depending on suspicion of cause/severity of bleeding: FBC, CRP/ESR
• Stool sample if associated diarrhoea

Indications for hospital admission

• Haemodynamically unstable: hypotension, tachycardic, shock
• Fast acutely persistent bleeding/ high volume bleed
• Acute surgical causes suspected – mesenteric ischemic, post-op, fast GI bleed
• Perianal abscess – for drainage
• Extremely painful, acutely thrombosed external haemorrhoids who present within 72 hours of onset (as reduction or excision can be considered)
• Internal haemorrhoids which have prolapsed and become swollen, incarcerated, and thrombosed (haemorrhoidectomy may be needed).
• Perianal sepsis (a rare but life-threatening complication)
• Suspicion of underlying cause that warrants hospital admission –  e.g. severe IBD flare, acute diverticulitis requiring intravenous antibiotics

Oakland score in acute PR bleed

• Age, sex, previous lower GI bleed admission, PR findings, HR, systolic BP, Hb
• To stratify if outpatient management is suitable in PR bleeding
• Score given between 0 to 35.
  • In general score of less than 8 points indicate that patient can be managed safely without requiring hospital admission. 
• Although scoring system is available – NOT routinely performed by GPs

In stable PR bleeds

• Consider outpatient flexible sigmoidoscopy to investigate cause
• Referral to general surgery or gastroenterology depending on findings/ suspected underlying cause

Further management depending on cause

Haemorrhoids

• Local measures – Anusol, stool softeners, topical GTN
• If these fail or if persistent symptoms or if large haemorrhoids then refer to surgeons for haemorrhoidectomy

IBD flare

• If mild-moderate then can manage with oral or PR steroids/mesalamine as per advice of IBD helpline/nurses and patients’ own established management plan for flares.
• If new IBD presentation suspected –> refer to secondary care

Colorectal cancer

• See cancer referral guidelines under Diarrhoea section above

Anal cancer

• Refer via cancer pathway in patients with unexplained anal mass or anal ulceration

Anal fissure

• Stool softeners, analgesia, topical anaesthetic, GTN
• Referral to surgical team if no response to initial measures in primary care

CONSTIPATION

Definition

• Defecation that is problematic because of infrequent and/or hard stools, difficulty passing stools (often involving straining), or the sensation of incomplete emptying or anorectal blockage.
• The Rome IV diagnostic criteria for constipation include spontaneous bowel movements occurring fewer than three times a week.
• Stools are often dry, hard, or lumpy, and may be abnormally large or small.
• In practice constipation is often defined as passage of stools less frequently than the person’s normal pattern.

Investigations

• Exclude any underlying secondary cause (drugs, other conditions e.g. hypothyroidism)
• Review medications to identify any causative drug
• PR exam – assess for faecal impaction as may need enemas, suppositories etc.
• Blood tests to rule out possible underlying cause:
  • FBC, TFTs, HbA1c, U&Es, calcium

Management of constipation

Lifestyle advice

• Regular meals
• High fibre intake – whole grains, fruits, vegetables
• Increase fibre intake gradually to minimise bloating: aim 30 g fibre per day as per NICE guidelines
• Adequate fluid intake
• Regular exercise
• Good toileting regimen – regular, unhurried routine, allow time to defecate fully

Medical management

• 1^st line = bulk-forming laxatives e.g. Ispaghula husk
• If stools hard or difficult to pass then add or switch to osmotic laxative
  • E.g. MacrogolIf Macrogol not tolerated –> lactulose (but not if IBS as can worsen this)
• If stools are soft but difficult to pass or if sensation of inadequate emptying then add stimulant laxative e.g. senna or bisacodyl

Refractory constipation

• If at least 2 laxatives from different classes have been tried at the highest tolerated recommended dose for at least 6 months then:
  • Consider treatment with Prucalopride (a prokinetic 5HT4 receptor agonist) that stimulates GI motility.
  • Offer 4 week prescription

Opioid induced constipation

• Do NOT prescribe bulk-forming laxatives
• Offer an osmotic and stimulant laxative

Laxative weaning

• Aim to wean laxatives once symptoms relieved.
• Gradually reduce and stop once producing soft, formed stool without straining at least three times a week
• Do not stop laxatives suddenly
• Rate of dose reduction should be guided by frequency and consistency of stools
• If combination of laxatives used then reduce and stop one laxatives at a time
• May need to continue long-term laxatives for patients with secondary cause of constipation
• Can refer to dietician if support with dietary changes and increasing fibre content needed

Management of faecal loading and/or impaction

• If hard stools – prescribe high dose of oral macrogol
• If soft stools or ongoing hard stools after few days then start/add oral stimulant
• If poor response to first line oral laxatives, consider:
  • Bisacodyl for soft stoolsGlycerol +/- bisacodyl for hard stoolsDocusate (softener and weak stimulant)
  • Sodium citrate (osmotic)
• Ensure patient aware that diarrhoea and faecal overflow may occur before disimpaction is complete
• If still poor response to treatment –> ENEMA
  • E.g. phosphate or arachis oil retention enema
  • For hard stool – give arachis oil enema overnight before giving a phosphate enema or citrate enema the next day
  • May need to repeat enemas several times to clear hard, impacted faeces
• Glycerol suppository can be used to help to soften stool to aid emptying before enema

Referring to secondary care

When to refer acutely to secondary care

• Concerns re. bowel obstruction:
  
  • Not passed flatus
  • Abdominal pain
  • Vomiting
  • Risk factors for obstruction: previous surgeries with adhesions, stricturing diseases e.g. Crohn’s
• Acute abdomen

Other referrals to secondary care (either gastroenterology or colorectal surgery, depending on cause)

• Refer URGENTLY if suspicious of malignancy – new change in bowel habit in >60 year old patient
  • See 2 week wait cancer pathway under ‘Diarrhoea’ topic
• Secondary cause of constipation is suspected which cannot be managed in primary care
• Persistent symptoms or recurrence despite optimal primary care management
• Complex relevant past medical history e.g. previous abdominal surgeries on background of IBD

DERANGED LIVER FUNCTION TESTS (LFTs)

Red flags for urgent referral/admission

Below are scenarios where you would refer a patient urgently to either secondary care as outpatient or for admission depending on the values and how well the patient is.

• Suspected hepatic or biliary malignancy
  • Weight loss, jaundice, marked cholestasis
  • Usually referred to secondary care for urgent imaging
• Signs if liver decompensation
  • Ascites
  • Jaundice
  • Encephalopathy
  • Bleeding
  • Referred for urgent admission
• Evidence of synthetic failure
  • Elevated bilirubin
  • Low albumin
  • Prolonged INR
• LFTs significantly elevated – a rough guide is > 10 x upper limit of normal (ULN) but this can usually be discussed with on-call gastroenterology/medical SpR for advice re. admission
• Biliary duct dilatation or features of malignancy on ultrasound

Causes of deranged LFTs

Isolated raised bilirubin

• Commonly Gilberts syndrome, occurs in <10% population
• Repeat LFTs with FBC, conjugated bilirubin
• If no evidence of anaemia and unconjugated hyperbilirubinemia – then Gilberts confirmed
• If anaemic – then need to rule out haemolysis
  • Request reticulocyte count, haptaglobin and lactate dehydrogenase (LDH)
  • Consider referral to haematology  

Isolated cholestatic liver enzymes – alkaline phosphatase (ALP)

• Repeat LFTs with gamma-glutamyl transferase (GGT) to determine if liver origin
• If ALP rise in isolation – consider bone origin:
  • Vitamin D deficiency
  • Pagets
  • Physiological cause- pregnancy, puberty
• Common liver causes:
  
  • Primary biliary cholangitis (PBC)
  • Primary sclerosing cholangitis (PSC)
  • Biliary obstruction (stones, strictures, neoplasia)
  • Hepatic congestion secondary to right-sided heart failure
  • Drug-induced cholestasis

Hepatic pattern

• Predominantly raised alanine transaminase (ALT) and aspartate aminotransferase (AST)
• Indicates hepatitis/hepatocellular injury
• May be transient – due to intercurrent illness
• Common causes:
  
  • Viral hepatitis
  • Non-alcoholic fatty liver disease (NAFLD) – presence of metabolic syndrome supports this
  • Alcoholic liver disease
  • Autoimmune hepatitis
  • Drug-induced livery injury

Important information to gather in history-taking

Liver related symptoms

• Abdominal pain
• Jaundice
• Pruritus
• Weight loss

Past medical history

• Features of metabolic syndrome (obesity, hypertension, diabetes, dyslipidaemia) – higher risk of NAFLD
• Heart failure
• Autoimmune conditions
• Inflammatory bowel disease
• Malignancy

Family history

• Any genetic liver diseases e.g. Wilsons, A1At deficiency, hemochromatosis
• Autoimmune diseases running in family

Drug history

• Prescribed medications e.g. any antibiotics that can promote cholestasis e.g. flucloxacillin
• Include herbal and over the counter drugs (especially paracetamol)
• Recreational drug use – e.g. IVDU (increased risk of hepatitis B/C)

Social history

• Country of birth – to screen for possible hepatitis B or C risk
• Alcohol – screen for any history of excess
• Travel – e.g. to countries endemic for Hepatitis A, hepatitis E
• Previous blood transfusions

Management of deranged LFTs in primary care

Lifestyle advice

• Reduction in alcohol intake
• If high BMI – encourage weight reduction, healthy diet, exercise

Review medications

• Recent introduction of statins – can cause acute change in liver enzymes
• Recent antibiotic use – some antibiotics are associated with cholestasis. TB drugs associated with hepatitis.
• Consider stopping any drugs known to be associated with drug-induced liver injury (DILI) —> Then repeat LFTs in 1-3 months to assess for resolution
  • If drugs difficult to stop (e.g. anti-epileptics) – refer for specialist advice

If alcohol excess

• AUDIT scoring: >19 = high risk of liver disease
• Refer to alcohol cessation services
• If AUDIT >19 OR drinking >35 units/week (women) or >50 units/week (men) then for fibrosis assessment via ARFI elastrography/Fibroscan or ELF test
  • If evidence of advanced fibrosis or cirrhosis –> Refer to hepatology

Repeating LFTs

Isolated raised bilirubin

• Repeat whenever with fasting LFTs and FBC
• If normalise – likely due to Gilbert’s syndrome

Repeat LFTs in approx 1-3 months if:

• Isolated ALP – repeat with GGT
• Isolated ALT <3 x ULN – repeat with AST and FBC
• Isolated GGT

Repeat more urgently if:

• Isolated ALT >3 x ULN – repeat with AST and FBC

If repeat LFTs still elevated

If repeat LFTs are still elevated then need to request a non-invasive liver screen (NILS). The British Society of Gastroenterology (BSG) recommend the following:

• Ultrasound liver
• Viral screen (hepatitis B surface antigen, hepatitis C antibody)
  • If Hepatitis C antibody positive  request Hepatitis C PCR
• Autoimmune liver screen (ANA, AMA, SMA, LKM-Ab, Immunoglobulins)
• Haemochromatosis screen: Ferritin and transferrin saturation
• HbA1c
• Often in primary care, specialist tests such as caeruloplasmin, Alpha-1 antitrypsin usually not done, often considered in children however may be discussed with specialist first.

If NILS abnormal then need to refer to secondary care for further management.

Non-alcoholic fatty liver disease (NAFLD)

If the liver screen is normal and patient has risk factors for metabolic syndrome then suspect NAFLD. (If no risk factors for metabolic syndrome and no other cause of deranged LFTs suspected then refer to secondary care for further evaluation).

If NAFLD is the likely diagnosis then need to assess for fibrosis.

First line tests for fibrosis

• FIB-4 score – uses age, AST, ALT, platelets
• NAFLD fibrosis score (NFS)

BSG recommends that these tests be incorporated in all primary care computer systems.

If patient has evidence of advanced fibrosis then refer to secondary care (hepatology).

Non-red flag referrals to hepatology

• Evidence of hepatitis C infection (HCV) – Hepatitis C antibody and PCR positive
• Evidence of hepatitis B infection (HBV) – Hepatitis B surface antigen positive
• Evidence of autoimmune hepatitis (AIH) – raised ALT, positive autoantibodies (SMA, ANA, LKM) +/- raised IgG
• Evidence of primary biliary cholangitis (PBC) – raised ALP, positive anti-mitochondrial antibody (AMA)
• Evidence of primary sclerosing cholangitis (PSC)
• Evidence of haemochromatosis – raised ferritin and transferrin saturation, family history
• Anyone with evidence of chronic liver disease (including alcohol-related)
  
  • Ultrasound showing cirrhosis, portal hypertension
  • Splenomegaly
  • Blood markers – low platelets, low albumin or raised bilirubin
  • Fibroscan reading >16 kPa (if available)  – as indicates possible cirrhosis
• Anyone with non-alcoholic fatty liver disease (NAFLD) with evidence of advanced fibrosis
• Adults with abnormal liver blood tests with negative extended liver aetiology screen and NO risk factors for NAFLD or alcohol liver disease – refer for further evaluation

FURTHER READING/REFERENCES

• NICE Guidelines on Dyspepsia
• GP Notebook on PR bleeding
• NICE CKS on Constipation
• BSG Guidelines on managing abnormal LFTs

Article written by Dr Zahra Mohamedali (Internal Medicine Trainee)
Reviewed by Dr Moinuddin Kapadia (GP Partner)