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ENGLISH FOR HEALTH SCIENCES

Digestive System

Digestive System

Table of Contents

HOW IT WORKS ...... 4 ...... 5 and ...... 5 Oesophagus ...... 5 ...... 6 , and ...... 6 Intestines ...... 7 COMMON GASTROINTESTINAL CONDITIONS ...... 8 Mouth ...... 8 Oesophagus ...... 8 Stomach ...... 9 Liver, pancreas and gallbladder ...... 9 Intestines ...... 9 SERIOUS ...... 10 Deadly habits ...... 10 Tests and Diagnoses ...... 12 AND PROCEDURES ...... 13 Surgical Excision ...... 13 Surgical Repairs ...... 13 Suturing ...... 14 ...... 14 GLOSSARY ...... 16 Terms and Abbreviations ...... 16 CASES ...... 18 Diarrhoea ...... 18 Abdominal ...... 19 ...... 21 ...... 22

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Digestive System

Digestive System English for Health Sciences

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Digestive System

The Digestive System

HOW IT WORKS The gastrointestinal system, also called the alimentary or digestive tract, provides a tube-like passage through a maze of organs and body cavities. It begins at the mouth where the food enters the body, and ends at the , where solid waste material exits the body.

This system and its organs perform three primary functions:

Carrying food for Preparing it for absorption Transporting waste products for elimination

Digestion begins with our help. Food is put in the mouth. It has to be broken down and digested both mechanically and chemically, as it makes its way through the . Digestive help speed up the chemical reaction and assist in the breakdown or digestion of complex nutrients from the food.

During the digestive process, proteins break down to amino acids, complicated sugars reduce to simple sugars, such as glucose, and large fat molecules are broken down into fatty acids and .

Absorption takes place when the digested food is absorbed into the blood-stream, by going through the walls of the . By this process, nutrients like sugar and amino acids travel to all cells in the body. Fatty acids and triglycerides are also absorbed through the wall of the small intestine, but enter lymphatic vessels rather than blood vessels.

The third stage is elimination of solid waste materials that cannot be absorbed into the bloodstream. This solid waste, called faeces, collects in the large bowel and finally exits the body you know where.

You can follow the route taken through the various passages and organs that make up the digestive system by watching the following video with subtitles.

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ANATOMY Mouth and Pharynx The digestive tract begins with the oral cavity or the mouth. In the mouth, the extends from the floor of the mouth and is attached by muscles to the lower jawbone. It moves food around during chewing (mastication) and (deglutition). The tongue is covered with tiny projections called papillae, which contain buds.

During the chewing process, the teeth break down food into smaller pieces to make the swallowing process easier. Around the oral cavity are three pairs of salivary .

Food passes from the mouth to the pharynx (throat). It acts as the passageway for air from the nasal cavity to the (voice box) but also as a food passageway going from the mouth to the oesophagus. A flap of called the epiglottis covers the opening to the larynx and prevents food from going into the (windpipe) when swallowing occurs.

Did you know...? The salivary glands are made up of the parotid , the , and the , on each side of the mouth. These glands produce , which contains digestive enzymes. Narrow salivary ducts carry the saliva into the oral cavity.

The provide the opening and the form the walls. The hard is the roof of the mouth, and the muscular lies behind it, horizontally separating the mouth from the nasopharynx, or posterior nasal cavity. Then everything blends in together. The mouth, or oropharynx, shades subtly into the hypopharynx, or the back of the mouth/top of the throat, and then the pharynx proper, or upper throat, which then becomes the oesophagus.

Oesophagus The oesophagus is a 9–10-inch muscular tube from the pharynx to the stomach. It aides in swallowing and propelling the food toward the stomach. is the involuntary process of wave-like contractions in the oesophagus that helps the food reach its next destination. This process actually takes place throughout the entire gastrointestinal tract, helping to propel food through the system.

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Stomach Food passes from the oesophagus into the stomach. The openings into and from the stomach are controlled by rings of muscles called . The oesophageal (or cardiac) relaxes and contracts, moving food from the oesophagus into the stomach, and the pyloric sphincter allows food to leave the stomach when it has been sufficiently broken down.

The function of the stomach is to prepare food chemically to be received in the small intestine for further digestion and absorption into the bloodstream. Food is churned and mixed with gastric juices to make a semi-liquid called . Food does not enter the bloodstream through the walls of the stomach. The stomach controls passage of food into the first part of the small intestine, so it proceeds only when it is chemically ready and in small amounts.

Did you know...? The stomach is made up of 3 parts: the fundus (top portion), body (middle portion), and antrum (lower portion). The lining of the stomach consists of folds called rugae, which allow the stomach to stretch when food enters.

Liver, Pancreas and Gallbladder The liver, gallbladder, and pancreas are accessory organs of the digestive system. Food doesn’t pass through these organs, but each plays a role in the proper digestion and absorption of nutrients.

The liver produces greenish fluid called that contains , a fat substance, bile acids, and several bile pigments.

Bile is continuously released from the liver and travels down the hepatic duct to the . The cystic duct leads to the gallbladder, which stores and concentrates the bile for later use.

After meals, the gallbladder contracts, forcing bile into the common joining with the pancreatic duct, just before the entrance of the . The duodenum receives a mixture of bile and pancreatic juices.

The pancreas produces juices filled with enzymes, and , to digest food. These pass into the duodenum through the pancreatic duct. An , the pancreas also secretes . This is needed to help regulate levels of glucose in the blood.

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The gallbladder is a sac-like structure 3–4 inches long tucked under the right lobe of the liver. It is part of the (hepatic, cystic, and common bile ducts). It stores bile until needed in the duodenum to aid digestion.

Did you know...? You can live without a gallbladder. If inflamed or containing stones (a calcified pebble formed in the gallbladder), it is surgically removed. Bile can find another home in the biliary ducts, allowing the biliary process to function.

Intestines The small intestine, or small bowel, extends from the pyloric sphincter to the first part of the . It is 21 feet (6.4m) long, 1 inch (2.5cm) in diameter, and has three parts. The duodenum, a foot in length, receives the chyme from the stomach, as well as bile from the liver and gallbladder and pancreatic juices from the pancreas.

Enzymes and bile help digest food before it passes into the second part of the small intestine, the . The jejunum is about 8 feet (2.4m) long and connects to the third portion, the , which is 11 feet (3.35m) long. Most of the absorption process takes place in the ileum. In the wall of the small intestine are millions of tiny microscopic villi, finger-like projections. Through tiny in the villi, digested nutrients pass through to enter the bloodstream and lymph vessels. At the lower end of the ileum is the , the joining point of the small intestine to the large intestine.

The large intestine, or large bowel, extends from the end of the ileum to the anus. It is made up of four parts: the , colon, , and . It is five feet (1.5m) long and about 2½ inches (6.35cm) in diameter. The cecum is a pouch that is connected to the ileum by the ileocecal valve.

The hangs from the cecum. The appendix has no known function, which is why it’s not a huge loss to your body if it must be removed. The colon has three divisions: the ascending, transverse, and . The sigmoid colon is S-shaped, at the end of the descending colon that leads into the rectum. The rectum terminates at the lower opening of the gastrointestinal tract at the anus. The entire large intestine receives fluid waste products of digestion that cannot be absorbed into the bloodstream and stores it until it is released from the body.

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COMMON GASTROINTESTINAL CONDITIONS Because the gastrointestinal system is made of many parts, it shouldn’t be a surprise that it can be prone to all sorts of ailments and maladies.

Mouth Mouth conditions are some of the most obvious to the naked eye. Thankfully, professionals can help find to maladies of the mouth that affect mastication (chewing).

An orthodontist who specialises in the correction of deformed or maloccluded (crooked or misaligned) teeth. The periodontist specialises in diseases of the tissue around the teeth. The dentist, who takes care of dental issues; and the oral and maxillofacial who deal with dental and facial to repair things like cleft and dental trauma.

Now, take a closer look at some of the conditions these specialists treat:

Aphthous stomatitis: Canker sores in mouth Bruxism: Grinding teeth involuntarily, often while sleeping Cleft palate: Congenital split in the roof of the mouth or upper Dental caries: Cavities in the teeth (caries means “decay”) Dysphasia: Difficulty speaking Edentulous: Without teeth Gingivitis: of Halitosis: Herpes simplex: Cold sore or blister on lip or nose due to herpes virus : White plaques or patches of mouth mucosa Sublingual: Under the tongue

Oesophagus The oesophagus is the next stop on your tour of gastrointestinal conditions. Many of the following conditions result in discomfort both in swallowing (deglutition) and in the digestion process:

Aphagia: Inability to swallow Dysphagia: Difficulty swallowing : Just like varicose in the legs; boggy veins with inefficient valves that allow venous backflow, resulting in stagnant blood in bulging veins Oesophagitis: Inflammation of the oesophagus : Burning sensation caused by reflux or flowing back of acid from the stomach into oesophagus

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Stomach Next is the stomach, an area full of possibility when it comes to conditions. is the study of the stomach and intestines, and a gastroenterologist is the who treats conditions of stomach and intestine.

Many of the conditions that eventually affect the oesophagus or intestine start in the stomach. So, have your ready for these:

Dyspepsia: Difficult digestion Eructation: Act of belching or raising gas from stomach Gastric : Lesion on wall of stomach. Also known as ulcer : Inflammation of the stomach Gastrodynia: Pain in the stomach : of blood Hiatal : Protrusion of part of the stomach through the oesophageal opening into diaphragm Hyperemesis: Excessive vomiting Nasogastric: Pertaining to nose and stomach : Urge to vomit Regurgitation: Return of solids and fluids to mouth from stomach Ulcer: Sore or lesion of or Vomit: Also known as emesis; stomach contents expelled through mouth

Liver, pancreas and gallbladder The liver, pancreas, and gallbladder all experience their own specific conditions, the most common of which is good, old-fashioned, often-painful .

Calculus (plural is calculi): Stones Cholelithiasis: Condition of having gallstones Duodenal ulcer: Ulcer in the duodenum Gallstones: Hard collections of bile that form in gallbladder and bile ducts : Enlargement of liver Hepatoma: Tumour of liver

Intestines All the twists and turns of both the large and small intestines can make for some interesting and often complicated conditions. The sheer length of these organs makes diagnosis and treatment difficult.

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Ascites: Abnormal accumulation of fluid in caused by , tumours, and Borborygmus: Rumbling, gurgling sound made by move of gas in intestine Cathartic: Strong Colonic polyposis: Polyps, small growths protrude from mucous membrane of colon : Difficult or delayed caused by low peristalsis movement, over- absorption of water as contents sit too long in the intestine, or by : Frequent discharge of liquid stool () Diverticula: Abnormal side pockets in hollow structure, such as intestine, sigmoid colon, and duodenum Flatus: Gas expelled through the anus : Swollen or twisted veins either outside or just inside the anus Hernia: A protrusion of an or part through the wall of the cavity that contains it : Intestinal obstruction that can be caused by failure of peristalsis following surgery, hernia, tumour, adhesions, and often by : A small loop of bowel protruding through a weak place in the inguinal ring, an opening in the lower , which allows blood vessels to pass into the Intussusception: Telescoping of the intestine; common in children Laxative: encouraging movement of feces : Black stool; feces containing blood Polyposis: Condition of polyps in the intestinal wall : Intense itching of the anal area : Excessive fat in feces : Twisting of intestine upon itself

SERIOUS DISEASES Deadly eating habits Sadly, some diseases are the result of more serious mental and psychotic disorders, and they can be deadly. If you or someone you know shows any signs of these disorders, please seek medical help immediately. No amount of weight loss is worth losing one’s life. Here are the most serious disorders of this type:

Anorexia: Psychiatric condition involving self-deprivation of food, lack of appetite, and pathological weight loss Anorexia nervosa: Psychiatric disorder; an abnormal fear of becoming obese Bulimia: Gorging with food and then purging, most commonly by inducing vomiting or use of intense exercise or / Cachexia: Generalized poor nutrition (adjective: cachectic)

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The gastrointestinal system can also play host to even more pathological diseases. Many of these involve inflammation of the various system components, which can cause major disruption to the work the system performs, as well as major discomfort. Here’s a look at inflammation-related diseases:

Cholecystitis: Inflammation of the gallbladder Crohn’s : Inflammation and ulceration of the intestinal tract of terminal or end portion of ileum : Inflammation of diverticula : Inflammation of the intestine : Inflammation of stomach and intestine A: Acute inflammation of the liver, spread by fecal-oral contact. : Inflammation of the liver due to a virus transmitted by blood and body fluids : Virus affecting the liver spread through blood and body fluids. Like other forms of hepatitis, this can cause , a yellowish discoloration of the skin Hepatitis: Inflammation of the liver caused by virus or damage to the liver : Inflammation of pancreas Periodontal disease: Inflammation and degeneration of gums, teeth, and surrounding Ulcerative : Chronic inflammation of colon with ulcers

As you can see, inflammation is a huge issue with the gastrointestinal system. Here are some other common diseases that can put a halt to this system’s daily functions:

Anal : This is an abnormal tube-like passageway near the anus communicating with rectum. Celiac disease: Also known as syndrome, this disease is thought to be precipitated by gluten-containing foods. The hair-like pro-jections (villi) degenerate (or actually flatten) so they lose their absorption function. The disease can be hereditary and is common in people of Irish origin. Those with the disease must follow a gluten-free diet to control abdominal pain and diarrhea. Also known as gluten or nontropical sprue. Cirrhosis: scarring of the liver parenchyma, or tissue, due to damage from , , and viruses like hepatitis. GERD: means gastroesophageal reflux disease. It refers to the backward flow of gastrointestinal contents into the . IBS: is a group of symptoms including diarrhea, abdominal , cramping, and constipation associated with stress and tension (also known as spastic colon).

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Tests and Diagnoses There are three primary ways diagnose digestive diseases and conditions: X-rays, ultrasounds, and blood tests.

Abdominal ultrasound: Most common method to determine the presence of stones in gallbladder, can detect liver cysts, abscesses, gall-stones, enlarged pancreas (lower GI series): Series of X-rays taken of large intestine after barium enema injected Cholangiogram: X-ray film of bile duct, contrast medium is injected to outline the ducts Cholecystogram: X-ray of the gallbladder Upper GI series: Series of X-rays taken of stomach and duodenum after barium swallow or meal has been taken

The blood can tell a million stories about what is going on inside the body. A wide variety of blood tests can be done to diagnose gastrointestinal conditions and diseases, all of which look for varying levels of enzymes, proteins, and other blood elements. Some of the most common ones are as follows:

Alkaline phosphatase Elevated results indicate Amylase Pancreatic levels elevated in disease of pancreas Bilirubin levels Present in liver and (Complete blood count): Measures types and levels of white CBC blood cells (indicators of infection), red blood cells (measures of anaemia), and platelets, or clotting factors (Complete metabolic profile): Damaged organs release certain enzymes from their damaged tissue, and these elevated enzyme levels show up in the blood; non- CMP functioning organ cannot clean waste products out of the blood the way they’re supposed to, and elevated levels of these products also show up in the blood; CMP in particular looks at electrolytes, liver function, and function Blood test to determine presence of H. pylori organisms, pylori that can be found in stomach lining, causing test duodenal ulcer Test to detect occult (hidden) blood in feces; also called Occult blood test Hema-Check and Colo-Rec Elevated in liver disease

Some diagnostic procedures are a bit more invasive, such as an abdominocentesis (also called ), a surgical puncture to remove fluid from . Most of the other invasive procedures involve the use of an endoscope, an instrument used to visually examine internal organs and body parts. Almost every part of the digestive system can be viewed with the

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endoscope. The fibreoptic endoscope has glass fibre in a flexible tube that allows light to be transmitted back to the examiner. The endoscope can be inserted into a body opening (mouth or anus) or through a small skin incision to view internal organs.

Some endoscopic procedures include the following:

Colonoscopy Visual examination of the colon using an instrument called a colonoscope Also known as an endoscopic retrograde cholangiopancreatography, this ERCP involves an X-ray of bile and pancreatic ducts using contrast medium (like dye) and Visual examination of the stomach using an instrument called a Gastroscopy gastroscope Visual examination of any internal organ or cavity using an instrument called a laparoscope (oesophagogastroduodenoscopy): Visual examination of oesophagus, OGD stomach, and duodenum Visual examination of the rectum using an instrument called a proctoscope Visual examination of the sigmoid colon using an instrument called a sigmoidoscope

SURGERIES AND PROCEDURES Luckily, many parts of the gastrointestinal system can be repaired using surgical methods such as surgical excision, repair, and suturing. You may recognise some of these terms but some will be new to you. Let’s start by taking a look at surgical excisions, or removals. Here are some of the most common:

Surgical Excision

Abdominoperineal resection: Surgical excision of colon and rectum, by both abdominal and perineal approach : Surgical excision of appendix : Surgical excision of gallbladder : Surgical excision of the colon or part of the colon : Surgical excision of stomach : Surgical excision of a Uvulectomy: Surgical excision of uvula

Surgical Repairs Surgical repairs are next on the to-do list of procedures and surgeries. Gastrointestinal surgical repairs include

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Anoplasty: Surgical repair of anus : Surgical connection between two normally distinct structures Choledocholithotomy: Incision into to remove stone : into Palatoplasty: Surgical repair of palate Pyloroplasty: Surgical repair of UPPP (uvulopalatopharyngoplasty): Surgical repair of uvula, palate, and pharynx to correct obstructive sleep apnea : Cutting of certain branches of vagus performed during gastric surgery to reduce amount of

Suturing Finally, surgeons use suturing and the creation of artificial openings to help treat conditions of the gastrointestinal tract. These are some of the most common:

Colostomy: Artificial opening into the colon through abdominal wall Gastrojejunostomy: Artificial opening between stomach and jejunum : Artificial opening into stomach through abdominal wall; this is a feeding method used when swallowing is not possible Herniorrhaphy: Suture of a hernia to repair : Creation of artificial opening into ileum through abdominal wall for passage of feces (used for Crohn’s disease, , or ) : Creation of artificial opening in the jejunum

MEDICINES Antacids are one of the most common and useful over-the-counter remedies for what ails your digestive tract. And most of them provide an added boost of calcium as well. Antacids with simethicone also relieve excess .

Another great over-the-counter remedy is the laxative. This medication relieves constipation. Conversely, antidiarrheals relieve or stop diarrhoea, and stool softeners allow fat and water in the stool to mix in order to soften hard stool.

A doctor may prescribe stronger :

Activated charcoal: Used for its absorption powers; often used via naso-gastric tube to assist with stomach pumping ( overdose) : To treat , , ulcerative colitis, and Crohn’s exacerbations, and traveller’s diarrhoea : To treat spasms of the GI system such as IBD, divericulitis, and even ulcers; effectively slow down peristalsis with a calming effect

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Antiemetics: Control nausea and vomiting. Often prescribed when or radiation is administered Bowel preparations and : Bowel cleansers taken before barium enema or bowel surgery Emetics: Used to induce vomiting; especially useful in cases of or ingested H2 blockers: Used to treat gastric ulcers

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GLOSSARY Terms and Abbreviations A lot of parts work together in the gastrointestinal tract. The good news, with regard to word building, is that the list of prefixes and suffixes is a lot less complicated than those of other large systems. The prefixes and suffixes listed in the PDF file will help you keep all of the body parts, ailments, and procedures straight.

Food In, Food Out: Gastro Prefixes and Suffixes Prefix What It Means Re- Back Retro- Backward, back

Suffix What It Means -ase Enzyme -flux Flow -iasis Abnormal condition -lithiasis or stone -lytic Destruction or breakdown -pepsia Digestion -prandial Meal -orrhaphy Surgical fixation or suturing -ostomy Creation of an artificial opening -tresia Opening -tripsy Crushing

Now, in 2, it’s time to find out what comes in between these word parts. Consider the combining forms and root words as you would the stomach - they break the word down into its most useful component. That root will, in turn, provide the nutritive content that gives the word its meaning.

Table 2 The Meaty Part: Gastrointestinal Root Words Root Word What It Means An/o Anus Appendic/o Appendix Bucc/o (facial) Cec/o Cecum

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Celi/o Belly Cheiol/o Saliva Chol/e, bil/i Gall, bile Cholecyst/o Gallbladder Choledoch/o Common bile duct Col/o, colon/o Colon Dent/o, odont/o Teeth Duoden/o Duodenum Enter/o Small intestine Oesophag/o Oesophagus Gastr/o Stomach Gingiv/o Gums Gluc/o, glyc/o Sugar Hepat/o Liver Ile/o Ileum Jejun/o Jejunum Labi/o Lips Lingu/o, gloss/o Tongue Lip/o Fat,lipids Or/o Mouth, oral Palat/o Palate Pancreat/o Pancreas Peritone/o Pharyng/o Pharynx Proct/o Anus, rectum Pylor/o Pylorus Rect/o Rectum Sigmoid/o Sigmoid colon Splen/o Submaxill/o Lower Tonsill/o Tonsil Uvul/o Uvula

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CASES Diarrhoea History

An 8-month-old baby with diarrhoea is brought to her GP by her mother. Since a holiday visit to Turkey 1 month previously, the baby has had up to four watery loose stools a day. Her mother has also observed that the stools are smellier and paler than usual. Before their holiday she was having one or two soft bowel a day. The child is otherwise well and growing normally. She has a healthy appetite and enjoys her food and is active and happy. She was -fed up until 6 months of age. She lives with her parents and two older siblings aged 5 years and 7 years in a well- maintained three-bedroom semi-detached house. Her mother works as a part-time teaching assistant in the local primary school and her father is a real-estate agent. The two older children are at school during the day and the baby attends a nursery when her mother is working. The rest of the family are well and have not had diarrhoea; there is no recent history of gastroenteritis in the family or in the nursery.

Examination

A recent growth check shows that she has maintained her weight and length on the 25th centile. On examination there is nothing abnormal to find; in particular her abdomen is soft, non-tender and no masses are felt.

Questions

What is the diagnosis?

Which investigations would you order?

What advice do you give to mother about the child’s dietary needs?

Answer

This baby has toddler’s diarrhoea. The diagnosis of toddler’s diarrhoea can be made in a child that is well, grows and plays normally, and is not bothered by the diarrhoea. It is thought that an excess of undigested sugars in the large bowel causes an increase in the water content of the large bowel, resulting in watery motions. As the child grows bigger, the large bowel is thought to become more efficient and the problem resolves. Stool cultures should be taken – two or three samples on different occasions. The recent travel history makes it necessary to exclude bowel so an examination for ova, cysts and parasites is included.

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The mother should be advised about the ‘four Fs’:

Fat: toddler’s diarrhoea is more common in children that eat a low-fat diet. The diet of pre- school children should contain 35–40 per cent fat. Choose full-fat in preference to skimmed milk, yoghurts, cheese, milk puddings and other dairy products. Fluid and Fruit juice: some children drink only fruit juices or squashes to quench their . Mothers should be advised that water is preferable. Fruit juice contains that are not digested or absorbed before the passage into the large bowel. Clear apple juice seems to be the worst in this situation. The sugar in the drinks can spoil a child’s appetite leading to a tendency to eat less fat and fibre at normal meal times. Fibre: children should have plenty of fibre such as fruit, wholemeal bread and vegetables. Fibre absorbs surplus water in the bowel, making stools more bulky and less runny.

Key Points

Children differ from adults in their dietary needs.

Healthy eating advice for children needs to be tailored to their age.

Reassurance is an important tool in the GP’s arsenal.

Abdominal Pain History

It is 7 p.m. on a Friday night in January. Evening surgery has finished and you are about to transfer the telephone to the weekend on-call service when a call comes in from the mother of three children, aged 3, 5 and 8 years. They have all had tummy-ache, diarrhoea and vomiting in the last 24 hours. They are normally healthy children, with only minor illnesses in the past. They have not been abroad recently and their mother and father are both well. The mother has already sensibly stopped them eating and has given them just water to drink, plus a dose of paracetamol to help the pain. You know there has been a minor outbreak of winter vomiting disease (Norwalk virus) locally. She is sorry to trouble you, and is merely seeking advice on how best to manage them.

Questions

Do you need to visit the family?

What further questions would help to answer this question?

What advice should you offer to the mother?

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Answer

The decision to make a home visit is the doctor’s responsibility. It is perfectly reasonable, after taking an adequate history, to offer her simple advice (see below), and to ask her to contact the on-call service if any of the children do not improve as expected – perfectly reasonable, but not necessarily comfortable. You may well find yourself worrying about the case over the weekend, probably needlessly. Although homes are not ideal places for clinical examination, and home visits are time-consuming, they remain an essential part of the GP’s duties. The decision to visit remains with the doctor, but we should consider the logistics from the patient’s point of view. Imposing a car journey to an out-of-hours centre on this mother, with three vomiting children, would be contrary to their, and her, best interests, and would not foster that good patient–doctor relationship that we spend all our working lives trying to cultivate. We should learn to recognise our own very feelings of irritation in this situation, and deal with the problem rationally.

You may ask some ‘closed’ questions to elucidate the problem. Is the abdominal pain constant, and does it prevent any of the children from getting up and running around? Are there any associated features, such as a rash, or fever?

Since all three are described as confined to bed you do visit, to find all three children in the parental bed, in various stages of misery. A forehead skin thermometer shows a low-grade fever in all of them. A gentle hand pressing on the abdomen reveals two who giggle, and one (the eldest) who moans. You ask them to try sitting up with their arms folded. You start with the eldest (as the others will copy the action) who cannot do this, while his younger brother and sister manage it easily.

You decide to admit the eldest to , as a potential case of . The other two can be managed with simple fluid replacement. A prescription for flavoured glucose–electrolyte , dissolved in 200ml water and offered after every loose stool, is helpful. As they recover, they can supplement with starchy foods and even moderate amounts of ‘crisps and cola’ (salt and glucose).

A week later, you see all three in the surgery for follow-up. They have obviously recovered, and are ‘bouncing’ around the room. The eldest proudly shows his right iliac , with subcuticular stitch awaiting removal by the practice nurse. Evidently, the hospital agreed with your diagnosis. The transient irritation of that Friday-night call is erased by the satisfaction of a job well done.

This problem highlights the dangers of assuming a diagnosis based on history and local epidemiology. It is safer to say ‘there’s a lot of it about’ after you have examined the patient, rather than before.

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Key points

Home visits remain an essential part of the ’s duties. Do not assume a diagnosis based purely on history and local epidemiology

Abdominal Pain History

You are visited by a 22-year-old ceramics student at the local art college, who has been a patient of your practice since birth. He is a sensitive and studious young man, who lives with his parents and younger sister. His mother is an anxious intellectual, his father teaches at another college, and you have been concerned for some time that his 18-year-old sister might be anorexic. He has been experiencing sharp abdominal , poorly localised to the mid-zone, for some months, with occasional diarrhoea but no vomiting. He has tried antacids and paracetamol without success, and asks whether he should try a wheat- and dairy-free diet. He returned from a trip to Tanzania earlier this year.

Examination

He is a thin, almost asthenic, young man with no specific abnormalities in his abdomen.

Investigations

His urine shows no blood, sugar or protein.

You prescribe mebeverine as an , and see him in a week’s time.

Questions

What are the likely causes of his symptoms?

What investigations would you suggest?

How would you manage this case further?

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Answer

Common things occur commonly. Viral gastroenteritis is still possible, although the recurrent symptoms make this less likely. Don’t forget appendicitis. Irritable bowel syndrome is very common, and could be considered likely in view of his family and personal history of anxiety, but can only be posited after excluding other serious or treatable conditions. All returning travellers should be suspected of malaria or a bowel infection. His exposure to ceramic glazes might hint at lead : does he have a blue line on his gum? Renal or , owing to calculi or infection, are possible. is also a possibility and is often missed as it can present with any number of non-specific symptoms, most people with this disease are of normal weight or even overweight on presentation and it can be easily confused with irritable bowel syndrome.

A blood count, liver and renal function tests, serological tests for coeliac disease and an ultrasound scan of his abdomen would be helpful as would some stool samples looking for bacteria, ova, cysts and parasites. You may think of Crohn’s disease or colitis, and suggest a , or barium . In this case all tests were normal apart from raised endomysial pointing to coeliac disease and he was referred to a gastroenterologist for jejunal . He has greatly improved on a gluten-free diet, prescribable on the NHS and he now gets lifelong free prescriptions. Don’t forget to call in his sister; your suspicion of anorexia may need to be revised: and what about his mother and father?

Key points

Non-specific symptoms such as abdominal pain need an organised approach. Consider whether the traditional is indicated here. Many patients find it intrusive and undignified, and it may not add to your clinical knowledge. Coeliac disease is considerably underdiagnosed in general practice so test for it with any patient with anaemia, tiredness or chronic abdominal symptoms.

Dysphagia History

A 56-year-old man attends the emergency at his GP surgery. He received a letter giving him an appointment date for his planned upper gastrointestinal endoscopy in 6 months time. He is distressed and tells the GP that he cannot wait that long. His records show that he has experienced worsening over the last 3 months and that 3 months ago he presented with heartburn that occurred mainly after food and at night. He had had a similar episode 2 years earlier and the GP had arranged a gastroscopy which was normal. At the time he had responded well to a 1-month course of lansoprazole at 30 mg daily. This time his regular GP had started him

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on lansoprazole, but at a lower dose of 15 mg daily. After 3 weeks symptoms were only partially improving and the GP increased the dose back to 30 mg daily. The patient had then returned, reporting an initial improvement followed by a deterioration that included pain with swallowing. Next the GP had referred him routinely to the open access upper gastrointestinal .

Now, on further questioning, the GP at the emergency clinic finds out the patient has developed a feeling of food getting stuck behind his breast bone and, as a result, has changed his diet to soft foods to avoid choking. He denies vomiting any blood or melaena.

Examination

On examination he has lost 3 kg in weight, but he does not look unwell. His is, except for mild epigastric tenderness on of his abdomen, normal.

Questions

What is the ?

How would you manage this patient?

Can you apply the National Institute for Health and Clinical Excellence (NICE) guidelines for patients with dyspepsia here?

Answer Gastro-oesophageal reflux disease might be causing the symptoms and oesophageal stricture is a possible . Oesophageal cancer is a rare disease, sometimes developing slowly, either as a result of chronic epithelial damage (Barrett’s oesophagus) or spontaneously. The patient is distressed and anxious and, related to this, globus hystericus (a feeling of tightness and of food getting stuck) is a possibility but is usually limited to the throat. However, our patient describes food getting stuck behind the breast bone.

The patient is distressed. He needs to be listened to, his worries explored and the referral chased up. A change of referral status is justified because of the changes in the patient’s symptoms that qualify him to be referred under the 2-week rule for suspected cancer. The patient must be informed that the change to an urgent referral status is to investigate him for possible cancer. The real challenge is to communicate the possibility of cancer to the patient without causing undue alarm.

At this stage of the presentation the NICE guidelines can be applied easily. The patient’s problem with swallowing food changes the clinical presentation. At the beginning of the consultation the

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GP will have had problems deciding if the patient’s symptoms were part of a ‘new’ presentation or not, and if the failure to respond to treatment resulted from insufficient dosage of the medication.

Subsequently, the patient is diagnosed with oesophageal cancer. The GP brings this case to the next critical event meeting: could they have done anything differently?

Key points

Guidelines for common presentations in general practice are not always easy to apply. It is not always possible to decide whether the initial patient’s presentation is a recurrence of an existing problem or the development of a new problem. It is important to keep an open mind and react to changes in the clinical symptoms that patients present. Take situations such as this to your clinical meetings in order to share best practice.

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