Hi Everyone!

Have you been eating well today? I know during my preparation for exams I gained over 5kg in weight from eating whatever I wanted. Chips and chocolates were my go-to foods. While I thought it felt great to lay my usual restrictions aside, I know that these foods were not great for my mood or my brain. If you have no time to cook during these times then seek out a healthy alternative: pay a family member/friend to cook for you, purchase prepared meals from businesses such as Lite n’Easy (not sponsored) or choose frozen meals that are low in salt. You are important! Nourish your body and your brain will flourish.

This article is about Gastroenterology.

My first consultation as a GP registrar was with a real ole country bloke whose opening line was to complain about his “a**hole doctor” (excuse the language). A short period of confusion and directed questioning later revealed that he was talking about his gastroenterologist who had been reviewing him for his severe ulcerative colitis. This started my journey with him through the storms of inflammatory bowel disease, DMARDs and a 100+ day hospital admission following a partial colectomy. And of course, lots of opportunities to learn along the way for me.

One of the most common presentations in the GP setting for gastrointestinal medicine comes in the form of a request for a medical certificate. Patients present during or following a bout of gastroenteritis – quite often with the queasy look on their face or the vomit bag in hand. When dealing with a patient with gastroenteritis, after establishing they aren’t dying,  it is vital to provide education about hydration and transmission. Thorough and regular washing with soapy water, should prevent the condition spreading around the community – the importance of this is not to be discounted – I’ve seen nursing homes and schools put in lock down after an epidemic of viral gastroenteritis. It’s not hard to write a medical certificate to encourage them to stay away from their work place for 24-48hours after resolution of their symptoms to prevent spread.

You’ll soon notice in general practice that nearly everyone you see is taking a proton pump inhibitor for GORD. These are drugs that, like paracetamol, have been dished out like candy over the years. Don’t be afraid to take the step to trial de-prescribing this medication, particularly if the patient has been symptom-free for many years. Coupled with some counselling about avoiding triggers, and some empowerment towards weight loss, it is possible to control this condition without medication. In saying that, don’t be complacent when it comes to new onset of symptoms of dyspepsia in an older person. This is a red flag.

Be kind to yourself, and give your body nourishment in the week ahead!

Dr Andrew Harris
Director of Amadeus Education.

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Important conditions:

These are the common conditions that should be reviewed for this topic:

Topics	Important reading
Disorders of the mouth	– Dry mouth: Xerostomia and salivary gland hypofunction. AFP, July 2016. (https://bit.ly/2TVO3fJ) – Solving dental problems in general practice. AFP, April 2009. (https://bit.ly/2TWYPlB) – Management of dental infections by medical practitioners. AFP, May 2014. (https://bit.ly/2GR4YfK) – Management of dental trauma by general practitioners. AFP, December 2015. (https://bit.ly/2S7qiiY)
Stomach/oesophagus abnormalities – including GORD, Peptic ulcer disease/h. Pylori	– Helicobacter pylori eradication – an update on the latest therapies. AFP, May 2014. (https://bit.ly/2GR3cLC) – Proton pump inhibitors: Uncommon adverse effects. AFP, September 2011. (https://bit.ly/2BHrqUS) – GORD. AFP, December 2009. (https://bit.ly/2T1gtHD) – Peptic ulcer disease and non-steroidal anti-inflammatory drugs (https://bit.ly/3KWyHmm)
Bowel disease – including inflammatory bowel disease, coeliac disease, diverticular disease, appendicitis, gastroenteritis	– Coeliac disease: where are we in 2014? AFP, October 2014. (https://bit.ly/2GCFELd) – Update on inflammatory bowel disease. AFP, December 2009. (https://bit.ly/2IlExRv) – Diverticular disease practice points. AFP, November 2017. (https://bit.ly/2T0UQaA) – Inflammatory Bowel Disease. Gastroenterological Society of Australia, 2018. (https://bit.ly/3KZkOUn) – Gastroenteritis. RCH. (https://bit.ly/2XqBgnl)
Bowel dysfunction – including constipation, diarrhoea, irritable bowel disease	– A challenging care of chronic diarrhoea. AFP, January/February 2015. (https://bit.ly/2K0DxhG) – Wind: Problems with intestinal gas. AFP, May 2013. (https://bit.ly/2TVrtUq) – Irritable bowel syndrome: The role of complementary medicines in treatment. AFP, December 2009. (https://bit.ly/2IokUbH) – IBS or intolerance? AFP, December 2009. (https://bit.ly/2IlDXmN)
Liver disease – including Hepatitis, fatty liver disease	– Fatty liver disease: A practical guide for GPs. AFP, July 2013. (https://bit.ly/2GQU7lQ) – Hepatitis B serology. AFP, April 2012. (https://bit.ly/2Im1Qe3) – Australian consensus statement for the management of hepatitis B (https://bit.ly/3x4VvKX) – Hepatitis C clinical guidelines. 2018. (https://bit.ly/2T21GN3) – Alcoholic liver disease: Assessment and management. AFP, August 2011. (https://bit.ly/2IqkdhY) – Liver function tests. AFP, March 2011. (https://bit.ly/2BHrzaS)
Pancreatitis	– Chronic pancreatitis: Negotiating the complexities of diagnosis and management. AFP, October 2015. (https://bit.ly/2XcC8w6)
Anorectal disorders – including haemorrhoids, pruritis ani	– Pruritis ani. AFP, June 2010. (https://bit.ly/2TVp9g7) – Perianal problems. AFP, June 2010. (https://bit.ly/2V4ss4D) – Anorectal pain, bleeding and lumps. AFP, June 2010. (https://bit.ly/2T332aq)
Cancer of the GIT – including oesophageal, colon, stomach, pancreatic, liver	– Clinical practice guidelines for the prevention, early detection and management of colorectal cancer. Cancer Council. (https://bit.ly/2NdXg0a) – Diagnosing colorectal polyps and masses: The use of CT colonography. AFP, March 2011. (https://bit.ly/2tqnAeB) – Bowel cancer screening: A role for general practice. AFP, April 2009. (https://bit.ly/2GQGHq7)
Intestinal parasites	– Intestinal parasites. RCH. (https://bit.ly/2tGiGtK)
Gall bladder disease	– Biliary pain: Work-up and management in general practice. AFP, July 2013. (https://bit.ly/2TffRP2)

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Medication doses:

These are the medications and doses that should be learned for the exam:

Condition	Medication
Nausea	Metoclopramide 10mg orally TDS PRN Ondansetron 4-8mg orally TDS PRN
GORD	Ranitidine 150mg daily orally Esomeprazole 20mg daily orally
H.Pylori infection	Triple therapy (ACE) for 7 days: Amoxycillin 1g orally BD Clarithryomycin 500mg orally Esomeprazole 20mg orally BD
Diarrhoea	Loperamide 2mg, 1-4 times daily PRN
Constipation	Movicol 13.12g sachet, use 1-2 daily Docusate+senna 50+8mg 1-2 nocte

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CHECKS:

Here are the list of recommended Checks that would be useful in your study for GP exams (accessed via subscription from http://gplearning.racgp.org.au):

• Gastroenteritis, May 2014
• Chronic viral hepatitis, March 2013
• Abdominal pain, December 2012

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Focus on clinical skills:

Here is a brief focus on some OSCE preparation materials related to this topic:

• Gastrointestinal examination playlist by GP Synergy: https://bit.ly/2SWfMMt
• Interpersonal relationships for patients with irritable bowel syndrome: A qualitative study of GPs’ perceptions. AFP, November 2013. (https://bit.ly/2TT5s8A)

Copyright © 2021 Andrew Harris