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Gastroenterology for GPs: Your Essential Guide

From gut feelings to solid diagnoses — because every rumble tells a story

🥧 Tea-Friendly Learning 🥨 For GP Trainees Short on Time 🥩 Red Flag Focused

Last Updated: March 2026

Executive Summary

Key Statistics

IBD Prevalence

540,000

people in UK

UC: 0.44%, Crohn's: 0.31%

Bowel Cancer

3rd

most common cancer in UK

FIT threshold: 80 μg/g (Jan 2026)

MASLD (NAFLD)

~25%

of adults affected

Most common liver disease in UK

Downloads & Resources

Essential resources for ongoing learning and patient support

📁 Downloads

path: GASTROENTEROLOGY

🌐 Web Resources

🧮

MDCalc FIB-4 Calculator

Calculate fibrosis risk in NAFLD/MASLD. Use at every fatty liver diagnosis and annual review.

📋 Pathways & Algorithms

🩸 Barnsley BEST — Iron Deficiency Anaemia Pathway Clear IDA investigation and referral pathway, including when to suspect GI malignancy.

🔥 Barnsley BEST — Dyspepsia Pathway Very practical history, alarm features and investigation algorithm for dyspepsia in GP.

💊 Nottinghamshire — Dyspepsia & GORD Guideline Step-by-step PPI and reflux management algorithm for general practice.

🔬 Faecal Calprotectin Care Pathway (NICE-aligned) Clear primary-care pathway for IBS vs IBD, including thresholds and when to refer.

🫀 Liver Disease

📊 RUH Bath — LFT Guide for GPs Extremely practical guide for interpreting abnormal LFT patterns and investigating in primary care.

📈 BSG/BASL — Abnormal Liver Blood Tests Guidelines One of the most practical algorithms for interpreting LFTs in primary care.

🫀 British Liver Trust — Primary Care Toolkit Excellent one-stop GP toolkit for liver disease, including testing, pathways and audit tools.

🌀 IBS & Lower GI

💊 Derbyshire — Primary Care IBS Management One of the best step-by-step IBS management guides for primary care.

🏥 Primary Care Focused

🏥 Primary Care Sheffield — Gastroenterology Resources Real-world primary care advice and referral guidance from GP specialists.

🩺 Primary Care Society for Gastroenterology (PCSG) Primary-care-focused organisation with practical education and GP-relevant gastroenterology updates.

🎓 CPD & Exam Preparation

📚 BMJ Learning — Gastroenterology Modules Short evidence-based modules on IBS, IBD and dyspepsia — useful for CPD.

🎓 RCGP Curriculum — Gastroenterology Defines what GPs should know and manage in GI medicine — useful for teaching and exam preparation.

👤 Patient Education

💚 Guts UK — Digestive Health Charity High-quality patient information on IBS, IBD, reflux etc. — useful for patient education and leaflets.

Quick Navigation

GP Role Red Flags IDA Investigations Abnormal LFTs FIT Test Upper GI Lower GI IBD GI Cancers & 2WW Fatty Liver Other Liver

🧠 Brainy Bites

Quick-fire clinical pearls and mnemonics for busy GPs

ALARMS — Upper GI Red Flags

Use this mnemonic when seeing anyone with dyspepsia or upper GI symptoms

A — Anaemia (iron deficiency)
L — Loss of weight (unintentional)
A — Anorexia
R — Recent onset of progressive symptoms
M — Melaena / haematemesis
S — Swallowing difficulty (dysphagia)

Rome IV Criteria for IBS

Recurrent abdominal pain, ≥1 day/week for the last 3 months, related to 2 or more of:

Related to defecation
Change in frequency of stool
Change in form (appearance) of stool

Symptoms must have started ≥6 months ago. Always exclude red flags first.

🧠 Tip: Think "3-3-2" — 3 months, 3 criteria listed, need 2 to qualify.

1️⃣ Role of the GP in Gastroenterology

Your scope of practice — from first contact to specialist referral

Diagnosis

Recognise common GI presentations
Differentiate functional from organic disease
Identify red flag symptoms requiring urgent referral
Arrange appropriate first-line investigations

Management

Initiate treatment for common conditions (GORD, IBS, constipation)
Prescribe safely (PPIs, laxatives, antispasmodics)
Provide lifestyle and dietary advice
Monitor chronic conditions (IBD, coeliac disease)

Emergencies

Recognise acute abdomen requiring emergency admission
Identify GI bleeding and assess severity
Manage acute presentations (bowel obstruction, perforation)
Initiate resuscitation and arrange urgent transfer

Coordination

Refer appropriately to gastroenterology/surgery
Coordinate care between primary and secondary care
Manage post-discharge follow-up
Liaise with dietitians, IBD nurses, stoma nurses

Prevention

Promote bowel cancer screening uptake
Advise on alcohol reduction and healthy diet
Identify and manage risk factors (obesity, smoking)
Provide H. pylori eradication where indicated

2️⃣ Red Flag Symptoms & Emergencies

Recognise these immediately — they require urgent action

Upper GI Red Flags

Dysphagia (progressive or persistent)
Unintentional weight loss (>5% in 6 months)
Persistent vomiting
Iron deficiency anaemia
Haematemesis or melaena
Epigastric mass

Lower GI Red Flags

Rectal bleeding (especially if >50 years)
Change in bowel habit (>6 weeks, >50 years)
Abdominal mass
Unexplained iron deficiency anaemia
Positive FIT test (≥80 μg/g)

Acute Abdomen

Severe abdominal pain with peritonism
Absolute constipation (no flatus or stool)
Distended, tympanic abdomen
Haemodynamic instability
Sepsis (fever, tachycardia, hypotension)

🩸 Iron Deficiency Anaemia — The Golden Rule

In adults, IDA = GI blood loss until proven otherwise. Do not assume diet.

🔑 The One Rule You Must Remember

Iron deficiency anaemia in an adult = bleeding from somewhere, until proven otherwise.

Why this matters — even if the patient says:

❌ "I don't eat much red meat" — doesn't matter
❌ "I'm vegetarian" — doesn't matter
❌ "My diet isn't great" — doesn't matter

You must exclude occult GI bleeding before attributing IDA to diet alone. Colorectal and gastric cancer are the key concerns.

⚡ Who needs urgent investigation? (NICE NG12)

Group	How cautious?	Action
Men (any age)	🔴 High priority	FIT test + 2WW referral
Post-menopausal women	🔴 High priority	FIT test + 2WW referral
Menstruating women <50	🟡 Assess carefully	Often menstrual/dietary — but still exclude coeliac and upper GI causes; consider GI investigation if no menstrual source found

Typical GP Work-up for IDA

1. Confirm true iron deficiency: ferritin (low), MCV (low), serum iron (low), TIBC (high)
2. FIT test — remember: does NOT exclude anal/rectal cancer → PR exam still needed
3. Coeliac screen (tTG IgA + total IgA) — common cause, often missed
4. 2WW referral if criteria met (men or post-menopausal women)
5. Consider upper GI pathology (OGD) and menstrual loss in younger women

What to say to patients:

"Iron deficiency in adults often comes from slow bleeding from the stomach or bowel — bleeding you might not even notice. It doesn't mean you have cancer, but we always check carefully to make sure."

For menstruating women (if unclear cause):

"Heavy periods can cause iron deficiency, but we still like to check your bowel health too — especially your food pipe and stomach — because these are common causes as well."

Immediate Actions

2-Week Wait Referral: Men (any age) + post-menopausal women with unexplained IDA

FIT Test: Threshold ≥80 μg/g since January 2026 — but remember: does NOT exclude anal cancer (PR exam required)

Coeliac Screen: tTG IgA + total IgA — always do this in IDA

Iron Replacement: Start orally while investigating (do not wait for results)

💊 Oral Iron Replacement

Drug	Dose	Frequency	Duration / Notes
Ferrous sulfate (1st line)	200mg	Once to twice daily (OD–BD)	Until Hb normalises + 3 months to replenish stores. OD gives fewer side effects with similar efficacy (NICE).
Ferrous fumarate (alt)	210mg	BD–TDS	Alternative if GI side effects with sulfate
Ferrous gluconate (alt)	300mg	OD	Gentler — lower elemental iron content per dose. NICE CKS recommends once daily.

Take on empty stomach (better absorbed); if GI intolerance, take with food. Alternate-day dosing (every other day) has better absorption due to hepcidin suppression. Check Hb at 4 weeks — expect rise of ~20g/L.

🎓 AKT Pearl: Ferritin is an acute phase reactant — it can be normal or raised in inflammation even with true iron deficiency. If in doubt, check serum iron and TIBC (transferrin saturation <20% = iron deficiency).

🔬 Investigations & Screening

First-line tests and screening programmes in gastroenterology

Blood Tests

FBC

Anaemia (IDA, B12/folate deficiency)
Macrocytosis (alcohol, B12/folate deficiency)
Thrombocytopenia (cirrhosis, hypersplenism)

LFTs

ALT/AST (hepatocellular damage)
ALP/GGT (cholestasis)
Bilirubin (jaundice), Albumin (synthetic function)

Inflammatory Markers

CRP/ESR — IBD flare, infection, malignancy

Coeliac Serology

tTG IgA + total IgA (always request together)

Stool Tests

🔴 FIT (Faecal Immunochemical Test)

Detects occult blood in stool from the GI tract
Threshold: ≥80 μg/g (January 2026)
⚠️ Does NOT exclude anal/rectal cancer — always perform PR exam alongside FIT
Use for: suspected colorectal cancer, IDA, screening programme

🟡 Faecal Calprotectin

🧠 One-liner: FIT → rules out cancer | Calprotectin → rules out IBD. Both work mainly because of their very high Negative Predictive Value (NPV).

Marker of intestinal inflammation (neutrophil-derived protein)
Main use in primary care: differentiate IBD from IBS — and monitor IBD activity
Normal: <50 μg/g

📊 Faecal Calprotectin — Performance in Plain Numbers

Test Performance (threshold ~50 μg/g)

Sensitivity~85–95%Detects most IBD

Specificity~75–85%Some false positives

NPV (Negative Predictive Value)~95–98%Negative test strongly rules out IBD

PPV (Positive Predictive Value)~35–55%Many positives are NOT IBD

What does this mean in real life?

🟢 Negative Test (normal calprotectin)

Out of 100 people with symptoms and a normal test: 95–98 truly do NOT have IBD. Only 2–5 might still have IBD. Very reassuring.

🟡 Positive Test (raised calprotectin)

Out of 100 people with a raised result: only 35–55 have IBD. The rest have something else causing bowel inflammation.

⚠️ False Positives Occur With:

Infection, NSAIDs, diverticular disease, colorectal cancer, polyps, coeliac disease

💬 How to Explain to Patients

🟢 Normal Result:

"A normal calprotectin makes inflammatory bowel disease very unlikely — about 95–98 out of 100 people with a normal test don't have it. This is reassuring."

🟡 Raised Result:

"A raised calprotectin suggests there may be some inflammation in the bowel, but it doesn't necessarily mean inflammatory bowel disease. We would usually arrange further tests to find out more."

🎓 Teaching Pearl — FIT vs Calprotectin

FIT detects blood → rules out bowel cancer (high NPV for cancer) | Calprotectin detects inflammation → rules out IBD (high NPV for IBD)
Both are screening/exclusion tools, not diagnostic. A positive result needs further investigation.

Stool Culture (MC&S)

Bacterial pathogens (Campylobacter, Salmonella, Shigella, E. coli)
Ova, cysts, parasites — if recent travel
C. difficile toxin — if recent antibiotics or hospitalisation

Imaging

Ultrasound Abdomen (First-line)

Liver disease, gallstones, biliary obstruction
Assess liver texture (cirrhosis, fatty liver, masses)

CT Abdomen/Pelvis

Acute abdomen, suspected perforation or obstruction
Staging colorectal cancer

Endoscopy

OGD (gastroscopy): dysphagia, GORD, PUD, upper GI bleeding
Colonoscopy: positive FIT, lower GI symptoms, IBD, screening, surveillance

Fibroscan (Transient Elastography)

Non-invasive assessment of liver fibrosis — used in hepatology for MASLD and chronic liver disease

📊 Managing Abnormal LFTs

Systematic approach to elevated liver enzymes

Raised ALT (Alanine Transaminase)

⚡ GP Action Guide — ALT Thresholds

ALT Level	Action	Notes
< 3× ULN	Bloods + Liver USS	If MASLD: annual recall
3–5× ULN	Hepatology eCONSULT + Bloods + USS	Do not watch and wait
> 5× ULN	Same-day call to Gastro oncall	Urgent hepatology referral

🔬 Full Investigation Panel for Raised ALT

Standard Bloods

FBC, U&E, HbA1c, Lipid screen, LFTs (including AST), TFTs, Ferritin

Liver-Specific

GGT, Coagulation screen (INR/PT)

Viral Hepatitis Screen

HBsAg (Hep B surface antigen), Anti-HCV (Hep C antibody)

Autoimmune Panel

ANA, SMA, LKM1, GPC antibody, Immunoglobulins (IgG, IgM, IgA)

Other Causes

Coeliac screen (anti-tTG IgA + total IgA), Ceruloplasmin (Wilson's disease — especially <40 yrs)

Imaging

Liver USS (first-line)

Common Causes

MASLD / fatty liver disease (most common)
Alcohol excess
Viral hepatitis (A, B, C)
Medications (statins, paracetamol, antibiotics)
Autoimmune hepatitis
Haemochromatosis, Wilson's disease

Refer to Hepatology if:

ALT >3× ULN persistently OR >5× ULN (same-day urgent call), cirrhosis, or diagnostic uncertainty

Raised ALP (Alkaline Phosphatase)

Hepatic Causes

Cholestasis (bile duct obstruction)
Primary biliary cholangitis (PBC)
Primary sclerosing cholangitis (PSC)
Infiltrative disease (sarcoidosis, amyloidosis)

Non-Hepatic Causes

Bone disease (Paget's, osteomalacia, fractures)
Pregnancy (physiological)
Malignancy (bone metastases)

Key Investigation

Check GGT — if raised, source is hepatic; if normal, likely bone
Ultrasound abdomen (bile ducts)
AMA (anti-mitochondrial antibody) for PBC

Refer to Hepatology if:

Persistent elevation with raised GGT, cholestasis, or cirrhosis

Raised AST (Aspartate Transaminase)

The Ratio Rule — Very Useful in Practice

AST:ALT >2:1 → Strongly suggests alcohol-related liver disease (DeRitis ratio)
AST:ALT <1 → Suggests MASLD or viral hepatitis
Both very high (>10× ULN) → Think acute hepatitis, ischaemia, drugs

Non-Hepatic Causes (AST is not liver-specific!)

Myocardial infarction
Muscle injury / rhabdomyolysis
Haemolysis

🧠 Tip: If AST is raised but ALT is normal, think heart/muscle, not liver. Check CK and troponin.

Refer to Hepatology if:

AST >2× ULN persistently, or evidence of cirrhosis/decompensation

🧪 FIT Test Performance

Understanding sensitivity, specificity, PR examination, and patient communication

⚠️ FIT Does NOT Exclude Anal or Rectal Cancer — Always Do a PR Examination

FIT detects occult blood in stool from anywhere in the GI tract, but tumours at or very close to the anal margin may not reliably bleed into the stool sample. A PR examination is essential whenever you are worried about colorectal or anal cancer — regardless of the FIT result. Do not let a negative FIT falsely reassure you when symptoms or examination findings suggest anorectal pathology.

Bottom line: FIT + PR examination = complementary tools, not alternatives.

Test Performance Metrics (at 80 μg/g threshold)

Sensitivity:~92%

Specificity:~91%

Positive Predictive Value (PPV):~7–10%

Negative Predictive Value (NPV):~99.8%

💡 What these numbers mean in plain numbers:

If 100 people have a positive FIT: ~7–10 have bowel cancer; ~90–93 do not.

If 100 people have a negative FIT: ~99–100 do not have bowel cancer (but ~1 might still).

True/False Positives & Negatives

True Positive: FIT positive + cancer present ✓

False Positive: FIT positive, no cancer — polyps, haemorrhoids, diverticular, NSAIDs (90–93% of positives)

True Negative: FIT negative + no cancer — very reassuring ✓

False Negative: FIT negative but cancer present (~8% missed — especially proximal colon and anal cancers)

⚠️ Key rule: A negative FIT does NOT rule out cancer if red flags are present. Always use clinical judgement. Consider 2WW even with negative FIT if symptoms are concerning.

💬 How to Explain FIT Results to Patients

These phrases use simple ratios and natural language. They work because they give numbers, avoid false reassurance, and include built-in safety-netting.

🔴 Positive FIT Result

"A positive FIT doesn't mean you have cancer. It just means we've detected a tiny amount of blood in the stool. About 1 in 10 people with a positive test have bowel cancer, so we arrange a colonoscopy to check properly."

✅ Why this works: gives a concrete ratio (1 in 10), avoids catastrophising, explains the next step clearly.

🟢 Negative FIT Result

"A negative FIT is very reassuring — about 99 in 100 people with a negative test do not have bowel cancer. But if your symptoms persist or change, we would reassess and may still arrange further tests."

✅ Why this works: reassures with a number (99 in 100), but includes safety-netting — symptoms can override a negative FIT.

⚠️ Important — Always Say This Too

"I'm also going to do a brief internal examination to check the passage at the back. This is important because the FIT test doesn't check the very end of the bowel in the same way, and it's a key part of making sure we don't miss anything."

✅ Explains the PR exam in simple terms. Never skip the PR because the FIT is negative — anal cancer specifically can be missed by FIT alone.

🎯 Screening Programmes

National screening programmes for early detection

Bowel Cancer Screening (NHS)

Age:50–74 years (England)

Method:FIT (Faecal Immunochemical Test)

Frequency:Every 2 years

Threshold:≥80 μg/g (January 2026)

Positive result:Colonoscopy referral

Note:Screening age changed from 60 to 50 years in England — GPs should encourage uptake, especially in deprived areas

Barrett's Oesophagus Surveillance

Who:Patients with confirmed Barrett's

Method:Endoscopy with biopsies

Frequency:2–5 years (depends on segment length and dysplasia)

Aim:Detect dysplasia / early adenocarcinoma

HCC Surveillance (Hepatocellular Carcinoma)

Who:All cirrhotic patients (any cause) + chronic HBV (even without cirrhosis)

Method:Ultrasound + AFP

Frequency:Every 6 months

Aim:Early detection for curative treatment (resection, ablation, transplant)

3️⃣ Upper GI Conditions

Common presentations from oesophagus to duodenum

Clinical Features

Heartburn (retrosternal burning), acid regurgitation
Worse after meals, lying flat, bending forward
May also cause nocturnal cough, hoarseness, dental erosion

Management

Lifestyle: weight loss, elevate bed head, avoid triggers (alcohol, caffeine, large late meals)
H. pylori test and treat if uninvestigated dyspepsia (urea breath test or stool antigen — not serology)

💊 PPIs (Proton Pump Inhibitors)

Drug	Dose	Frequency	Duration
Omeprazole (1st line)	20mg	Once daily (OD)	4–8 weeks; step-down or lowest effective dose for maintenance
Lansoprazole (alt)	30mg	OD	4–8 weeks
Pantoprazole (alt)	40mg	OD	4–8 weeks

Take 30–60 mins before food. Review long-term use annually — risks include C. diff, hypomagnesaemia, B12 deficiency.

H. pylori Eradication

💊 Triple Therapy (1st line — NICE CKS)

Drug	Dose	Frequency	Duration
Omeprazole	20mg	Twice daily (BD)	7 days
Amoxicillin	1g	Twice daily (BD)	7 days
Clarithromycin	500mg	Twice daily (BD)	7 days

If penicillin allergy: PPI BD + clarithromycin 500mg BD + metronidazole 400mg BD for 7 days. Confirm eradication with urea breath test or stool antigen test 4–6 weeks after completing treatment. Source: NICE CKS Helicobacter pylori.

Barrett's Oesophagus

Develops in 10–15% of patients with chronic GORD — metaplasia of oesophageal mucosa
Increases risk of oesophageal adenocarcinoma (0.3% per year)
Requires endoscopic surveillance (frequency depends on length and dysplasia)

Risk Factors

H. pylori infection (most common cause — present in ~70% of gastric ulcers, ~90% of duodenal ulcers)
NSAIDs/aspirin — directly damage mucosal barrier
Smoking, alcohol, stress (physiological e.g. ICU)

Presentation

Epigastric pain — duodenal: relieved by eating; gastric: worse with eating
Nausea, bloating, waterbrash
Complications: bleeding (haematemesis/melaena), perforation, gastric outlet obstruction

Management

Test and treat H. pylori (urea breath test or stool antigen — not serology for active infection)
Stop NSAIDs if possible; add PPI if essential NSAID use
Urgent endoscopy if red flags or complications

💊 PPI after H. pylori Eradication

Drug	Dose	Frequency	Duration
Omeprazole	20mg	OD	4–8 weeks (gastric ulcer 8 wks; duodenal 4 wks)

Presentation

Diarrhoea, bloating, abdominal pain, weight loss, fatigue
Iron deficiency anaemia, B12/folate deficiency, osteoporosis
Dermatitis herpetiformis (itchy blistering rash on elbows/knees) — pathognomonic
Often asymptomatic — incidental finding on blood tests

Diagnosis

⚠️ Patient must be eating gluten for ≥6 weeks before testing
Serology: tissue transglutaminase (tTG) IgA + total IgA (to exclude IgA deficiency)
Refer to gastroenterology for duodenal biopsy (gold standard)

Management

Lifelong gluten-free diet — the only treatment
Dietitian referral (essential)
Annual review: FBC, ferritin, B12, folate, vitamin D, bone health (DEXA if indicated)
Pneumococcal vaccination (functional hyposplenism in coeliac disease)

🧠 Exam pearl: If total IgA is low, request IgG-based coeliac tests (tTG IgG, DGP IgG) — IgA deficiency is 10× more common in coeliac than the general population.

4️⃣ Lower GI Conditions

From small bowel to rectum — common presentations and management

Diagnosis (Rome IV)

Recurrent abdominal pain ≥1 day/week for 3 months
Associated with ≥2 of: change in stool frequency, change in stool form, or related to defecation
Always exclude red flags and organic disease first (FBC, CRP, coeliac screen, faecal calprotectin)

Subtypes

IBS-D (diarrhoea predominant) | IBS-C (constipation predominant) | IBS-M (mixed)

Management — Stepwise

Step 1: Reassurance, explanation, lifestyle (regular meals, soluble fibre, avoid sorbitol, limit caffeine/alcohol)
Step 2: Consider low FODMAP diet (with dietitian guidance)

💊 IBS Medications (NICE CKS)

Drug / Class	Drug Example	Dose	Frequency
Antispasmodic (1st line pain)	Mebeverine	135mg	Three times daily (TDS), 20 min before food
Antispasmodic (alt)	Peppermint oil (Colpermin)	1–2 capsules	TDS, before meals
Antispasmodic (alt)	Hyoscine butylbromide (Buscopan)	20mg	Four times daily (QDS) when needed
IBS-D: antimotility	Loperamide	2mg after each loose stool	PRN, max 16mg/day. Start 2mg BD and titrate.
IBS-C: bulk-forming	Ispaghula husk (Fybogel)	1 sachet	BD with plenty of fluid
IBS-C: osmotic	Macrogol (Movicol)	1–3 sachets	OD, adjusted to response
Refractory pain: TCA	Amitriptyline	10mg	Once at night — review at 4–6 weeks; increase to 30mg max if needed
Alt TCA (non-NICE — not listed in NICE CG61)	Nortriptyline	10–30mg	At night. Some local guidelines mention this as an alternative if amitriptyline not tolerated. Not specifically recommended in NICE CKS — use with caution and document rationale.

Note: TCAs in IBS work at low doses via pain modulation, not antidepressant action. Warn patients — not prescribed for depression. Review after 3–4 months.

Causes (Think: MIST)

Medications: opioids (most common drug cause), anticholinergics, iron, calcium channel blockers, antidepressants
Inactivity / low fibre / dehydration
Systemic: hypothyroidism, hypercalcaemia, diabetes, Parkinson's
Tumour / structural: colorectal cancer, strictures — always exclude if new onset >50 yrs

💊 Laxatives — Stepwise (NICE CKS)

Type	Drug	Dose	Frequency / Notes
Bulk-forming (1st line)	Ispaghula husk (Fybogel)	1 sachet (3.5g)	BD with plenty of water — take effect in 1–3 days
Osmotic (1st / 2nd line)	Macrogol (Movicol)	1–3 sachets	OD, adjusted to response. Preferred over lactulose.
Osmotic (alt, cheaper)	Lactulose	15ml	BD — takes 48h to work; can cause bloating
Stimulant (short-term)	Senna	2–4 tablets (15–30mg)	At night. Takes 8–12h to work.
Stimulant (alt)	Bisacodyl	5–10mg oral	At night. For short-term use only.
Rectal: glycerol	Glycerol suppository	4g suppository	PR, once. Lubricant + mild stimulant.

Red Flags — Investigate Urgently

New onset >50 years | rectal bleeding | weight loss | abdominal mass | IDA

Diverticulosis (No Inflammation)

Asymptomatic outpouchings of colonic mucosa — incidental finding
Very common: affects >50% of people over 60 years
Manage with high-fibre diet; avoid NSAIDs

Diverticulitis (Inflammation/Infection)

LLQ pain, fever, change in bowel habit, raised CRP/WCC
Complications: abscess, perforation, fistula, stricture, bleeding

⚠️ NICE: Consider NO antibiotics if systemically well

For uncomplicated diverticulitis in a systemically well patient: offer paracetamol, clear fluids, and advise to re-present if symptoms worsen. Antibiotics are only needed if the patient is systemically unwell, immunosuppressed, or has significant comorbidity.

💊 Antibiotics for Acute Diverticulitis (NICE NG147)

Drug	Dose	Frequency	Duration
Co-amoxiclav (1st line)	500/125mg	TDS	5 days
Cefalexin + Metronidazole (pen allergy / unsuitable)	500mg + 400mg	BD–TDS + TDS	5 days
Trimethoprim + Metronidazole (alt)	200mg + 400mg	BD + TDS	5 days
Ciprofloxacin + Metronidazole	500mg + 400mg	BD + TDS	5 days — only if switching from IV ciprofloxacin with specialist advice

Symptoms

Bloody diarrhoea, abdominal pain, fever. Complication: liver abscess.

Management

Stool microscopy. Metronidazole 800mg TDS for 5 days, followed by diloxanide furoate 500mg TDS for 10 days (to eliminate cysts). Notifiable.

When to Investigate?

✓ Diarrhoea >7 days
✓ Blood in stool
✓ Immunocompromised
✓ Recent travel to tropics
✓ Suspected food poisoning outbreak
✓ Healthcare worker or food handler

Send: Stool culture (MC&S), ova/cysts/parasites if travel history, C. diff toxin if antibiotics/hospitalised.

Red Flags — Admit if:

• Severe dehydration (sunken eyes, dry mucosa, tachycardia, hypotension)

• Unable to tolerate oral fluids

• Altered consciousness

• Suspected sepsis or HUS

• Elderly/frail with significant comorbidities

GP Pearl

Most gastroenteritis is self-limiting — treat with oral rehydration (Dioralyte). Avoid loperamide if bloody diarrhoea or fever. Antibiotics are rarely needed and can cause harm (e.g. E. coli O157 — NEVER give antibiotics). If in doubt, take stool cultures before starting antibiotics.

5️⃣ Inflammatory Bowel Disease

Ulcerative Colitis and Crohn's Disease — diagnosis, management, and monitoring

Ulcerative Colitis (UC)

Features

Continuous mucosal inflammation — starts at rectum, spreads proximally
Bloody diarrhoea, urgency, tenesmus
Mucosa and submucosa only (cf Crohn's = transmural)
Increased colorectal cancer risk — surveillance colonoscopy required

Extra-intestinal Manifestations (EIMs) — "JASPE"

Joints (arthritis), Ankylitis/uveitis, Skin (erythema nodosum, pyoderma gangrenosum), PSC (primary sclerosing cholangitis — especially UC), Eyes (episcleritis, uveitis)

🧠 Remember: Maintenance therapy (e.g. mesalazine — specialist prescribed) is lifelong in UC. As a GP, do NOT stop it without specialist input.

Crohn's Disease

Features

Skip lesions — patchy inflammation anywhere from mouth to anus
Transmural inflammation — leads to strictures, fistulae, abscesses
Diarrhoea (often non-bloody), abdominal pain, weight loss
Perianal disease — fissures, fistulae, skin tags, abscesses

UC vs Crohn's — Quick Comparison

	UC	Crohn's
Distribution	Colon only, continuous	Anywhere, skip lesions
Depth	Mucosal	Transmural
Bleeding	Very common	Less common
Fistulae	Rare	Common
CRC risk	High	Moderate

GP Role in IBD Monitoring

Annual Review

FBC, U&E, LFTs, CRP, ESR
Vitamin B12, folate, vitamin D, ferritin
Bone health (DEXA if on long-term steroids)
Flu vaccine annually; pneumococcal vaccine (once)
Review medications — check TPMT before azathioprine (specialist)

Flare Recognition — Contact IBD Team Early

Increased stool frequency, more blood, urgency, fever, weight loss
Send: FBC, CRP, faecal calprotectin — then contact IBD nurse/team
⚠️ Do NOT prescribe steroids without IBD team guidance unless emergency

Acute Flare Management

⚠️ Key rule: Always liaise with the IBD team before starting or changing treatment. Exclude infection (C. diff, CMV) before escalating steroids. Send stool cultures and check CRP/faecal calprotectin first.

Assessing Severity First

Mild — managed in primary care with liaison
Moderate — usually requires specialist input; may initiate steroids with IBD guidance
Severe (Truelove & Witts criteria: ≥6 bloody stools/day + systemic features) — admit to hospital, IV steroids

Acute Flare Treatment — UC

Mild-moderate proctitis/left-sided: topical aminosalicylate (mesalazine enema/suppository) — specialist-prescribed
Moderate-severe: oral corticosteroids — if initiating in primary care, contact IBD team first

💊 Prednisolone for IBD Flare (NICE NG130 / BSG guidelines)

Drug	Dose	Frequency	Duration / Taper
Prednisolone (moderate-severe UC or Crohn's flare)	40mg	OD (morning)	Taper by 5mg per week → 8-week course total. Do NOT stop abruptly. Co-prescribe calcium + vitamin D.

Source: BSG guidelines / NICE NG130. Shorter courses risk early relapse; starting doses ≤15mg/day are ineffective. Always co-prescribe calcium and vitamin D supplementation. ⚠️ Do NOT use corticosteroids for IBD maintenance — they are for flares only.

Acute Flare Treatment — Crohn's

Mild-moderate ileal/ileocaecal Crohn's: budesonide 9mg OD — specialist-initiated — preferred over prednisolone (fewer systemic effects)
Moderate-severe Crohn's: prednisolone 40mg OD as above; contact IBD team
Severe flare: hospital admission, IV steroids, exclude C. diff and CMV

Maintenance Therapy (all specialist-prescribed)

UC: mesalazine (5-ASA) long-term — do NOT stop without specialist input
Crohn's: azathioprine or mercaptopurine (steroid-sparing; check TPMT before starting)
Both (refractory): biologics — anti-TNF agents (infliximab, adalimumab), JAK inhibitors, ustekinumab
⚠️ Avoid live vaccines in patients on immunosuppressants/biologics

IBD Complications

Intestinal Complications

Toxic megacolon (UC): colonic dilatation >6cm + systemic toxicity — emergency admission
Perforation (both): surgical emergency
Strictures (Crohn's): bowel obstruction — may require surgery
Fistulas (Crohn's): perianal, enterocutaneous, enterovesical (urine from bowel)
Colorectal cancer (UC): risk rises after 8–10 years of extensive disease — surveillance colonoscopy essential

Extraintestinal Manifestations — "JASPE" (same as before)

Joints: peripheral arthritis (large joints, correlates with bowel activity) | axial (ankylosing spondylitis — independent of bowel)
Skin: erythema nodosum (tender red nodules, shins — correlates with flare) | pyoderma gangrenosum (ulcerating, may be independent)
Eyes: uveitis (painful, vision-threatening — urgent referral), episcleritis (milder)
Liver: primary sclerosing cholangitis (PSC) — particularly in UC; risk of cholangiocarcinoma
VTE: significantly increased risk, especially during flares — thromboprophylaxis in hospital

Nutritional Complications (especially Crohn's)

Malabsorption (Crohn's, especially terminal ileum) — B12, fat-soluble vitamins, zinc
Vitamin B12 deficiency — terminal ileum disease or resection (intrinsic factor/B12 absorption site)
Iron deficiency anaemia — chronic blood loss
Osteoporosis — chronic steroid use + calcium/vitamin D malabsorption; DEXA scan if on long-term steroids

🎓 AKT Pearl: Pyoderma gangrenosum and axial arthritis can be independent of bowel disease activity — treating the IBD flare may not resolve them. Uveitis is urgent — same-day ophthalmology if suspected.

UC vs Crohn's Disease — Side-by-Side

The most common exam comparison question in IBD. Learn the key differences.

Feature	Ulcerative Colitis	Crohn's Disease
Location	Colon only (rectum → proximal). Always starts at rectum.	Anywhere — mouth to anus. Skip lesions (patchy). Terminal ileum most common.
Inflammation depth	Continuous, superficial — mucosa and submucosa only	Transmural — all layers → strictures, fistulas, abscesses
Key symptom	Bloody diarrhoea, urgency, tenesmus	Abdominal pain, diarrhoea (often non-bloody), weight loss
Rectal bleeding	Very common (hallmark feature)	Less common (unless colonic Crohn's)
Smoking	Protective (paradoxically — ex-smokers at higher risk)	Risk factor (worsens disease)
Perianal disease	Rare	Common — fissures, fistulas, abscesses, skin tags
PSC association	Strongly associated (5–8%)	Less common
CRC risk	High — after 8–10 years extensive UC; surveillance colonoscopy	Moderate — colonic Crohn's only
Complications	Toxic megacolon, colorectal cancer, anaemia	Strictures, fistulas, abscesses, malabsorption, B12 deficiency
Surgery	Potentially curative (total colectomy)	Not curative — high recurrence after resection
Maintenance treatment	Mesalazine (5-ASA) — lifelong	Azathioprine / mercaptopurine / biologics

🧠 Memory trick: UC = Ulcer Colitis = Continuous, Curable. Crohn's = Criss-Crossing skip lesions, Complicated, Cannot cure with surgery. Smoking: UC hates quitting, Crohn's hates smoking.

🎗️ GI Cancers & 2-Week-Wait Referral

Recognition, red flags and referral criteria — based on NICE NG12 (last updated January 2026)

⚠️ Two Different FIT Thresholds — Don't Confuse Them

🚨 Suspected Cancer (2WW) Pathway

Threshold: ≥ 10 μg Hb/g faeces

Per NICE NG12 (updated August 2023). Used in symptomatic patients.

🔬 NHS Bowel Cancer Screening Programme

Threshold: ≥ 80 μg Hb/g faeces (reduced from 120 μg/g, January 2026)

For asymptomatic population screening (50–74 years). Different context entirely.

🧠 Memory rule: Symptomatic 2WW = 10 μg/g | Screening = 80 μg/g. Never swap these.

Cancer	Key Red Flag	NICE Trigger
Oesophageal	Dysphagia	Dysphagia ANY age → 2WW
Gastric	Weight loss + dyspepsia	Age ≥55 + weight loss + upper GI symptoms → 2WW
Bowel / Colorectal	FIT ≥10 μg/g or rectal mass	FIT ≥10 μg/g → 2WW
Pancreatic	Jaundice ≥40	Age ≥40 + jaundice → 2WW \| Age ≥60 + weight loss + symptoms → urgent CT
Pancreatic (new DM)	New DM + weight loss ≥60	Age ≥60 + weight loss + new DM → urgent CT
Cholangiocarcinoma	Obstructive jaundice	Unexplained jaundice → urgent 2WW hepatobiliary

Key Symptoms

Progressive difficulty swallowing — food sticking (classic presentation)
Weight loss
Persistent reflux symptoms
Chest or epigastric pain
Persistent vomiting
Hoarse voice — can occur from recurrent laryngeal nerve involvement, but not a primary NICE referral trigger

NICE Referral (2WW) — NICE NG12

Dysphagia at any age → 2WW referral immediately
Age ≥55 with weight loss AND any of: upper abdominal pain, reflux, or dyspepsia → 2WW

Consider Non-Urgent OGD (Direct Access) if age ≥55 with:

Treatment-resistant dyspepsia
Upper abdominal pain with low haemoglobin
Raised platelets with nausea, vomiting, weight loss, reflux, or upper abdominal pain

📈 Prognosis

✓ Caught early (Stage I): ~50–60% 5-year survival after surgery
✗ Caught late (Stage IV): ~5% 5-year survival — most patients present late
! Overall 5-year survival in UK is ~15% because the majority present at advanced stage

🎓 AKT Pearl: Dysphagia = 2WW at any age — no minimum age threshold. Don't wait. Even mild dysphagia to solids in a young patient warrants urgent referral.

Symptoms — Often Vague Early

Persistent dyspepsia or epigastric discomfort — especially new onset in older adults
Early satiety (feeling full quickly)
Nausea, vomiting
Weight loss
Iron deficiency anaemia
Dysphagia (if tumour at cardia or oesophagogastric junction)

NICE Referral (2WW) — NICE NG12

Dysphagia at any age → 2WW
Age ≥55 with weight loss AND any of: upper abdominal pain, reflux, or dyspepsia → 2WW

Consider Non-Urgent OGD (Direct Access) if age ≥55 with:

Treatment-resistant dyspepsia
Raised platelet count with any of: nausea, vomiting, weight loss, reflux, dyspepsia, upper abdominal pain
Upper abdominal pain with low haemoglobin
Iron deficiency anaemia with upper GI symptoms

📈 Prognosis

✓ Caught early (Stage I): ~70–90% 5-year survival (Japan, where early detection is common)
✗ Caught late (Stage IV): ~5% 5-year survival
! UK overall 5-year survival ~20% — most patients present with advanced disease due to vague early symptoms

🎓 AKT Pearl: H. pylori is the main modifiable risk factor for gastric cancer — eradicate it. Vague dyspepsia in a patient aged ≥55 who doesn't respond to PPIs needs an OGD, not another PPI prescription.

Risk Factors

Age >50 years — risk rises sharply after 50
Family history — especially first-degree relative diagnosed <50 years
IBD — ulcerative colitis and Crohn's (risk rises after 8–10 years of extensive disease)
Hereditary syndromes — Lynch syndrome (HNPCC), Familial Adenomatous Polyposis (FAP)
Lifestyle: obesity, smoking, excess alcohol, high red/processed meat, low fibre

Clinical Features

Change in bowel habit persisting >6 weeks — especially looser or more frequent stools
Rectal bleeding — persistent and unexplained (never assume haemorrhoids without investigation)
Unexplained abdominal pain or bloating
Unintentional weight loss
Iron deficiency anaemia — unexplained in adults
Palpable abdominal or rectal mass

When to Offer FIT — NICE NG12 (2023)

Abdominal mass | Change in bowel habit | Iron deficiency anaemia
Age ≥40 with unexplained weight loss AND abdominal pain
Age <50 with rectal bleeding PLUS unexplained abdominal pain OR weight loss
Age ≥50 with unexplained rectal bleeding, abdominal pain, OR weight loss
Age ≥60 with anaemia even without iron deficiency

🚨 Suspected Cancer Pathway Referral (2WW)

→ FIT result ≥10 μg Hb/g faeces → 2WW referral
→ Palpable rectal mass → consider direct 2WW (no FIT required)
→ Unexplained anal mass or anal ulceration → consider 2WW for anal cancer
→ FIT below 10 μg/g but strong clinical concern persists → do not delay referral

⚠️ FIT does NOT exclude anal/rectal cancer — always perform a PR examination.

Screening Programme (NHS England)

Ages 50–74 years, every 2 years — home FIT kit
Threshold: ≥80 μg Hb/g (reduced from 120 μg/g, January 2026)
Positive result → colonoscopy referral

📈 Prognosis

✓ Stage I (caught early): ~90% 5-year survival
✓ Stage II: ~75% 5-year survival
! Stage III: ~50% 5-year survival
✗ Stage IV (metastatic): ~10% 5-year survival
✓ Screening is proven to save lives — bowel cancer caught by screening is almost always Stage I or II

🎓 AKT Pearl: The 2WW FIT threshold (symptomatic) is ≥10 μg/g. Screening threshold is 80 μg/g. Lynch syndrome and FAP need genetics referral and surveillance.

Symptoms — Often Late and Subtle

Painless jaundice — classic presentation of head of pancreas cancer
Unexplained weight loss
Persistent upper abdominal or epigastric pain — may radiate to back
Back pain
New-onset diabetes (see separate box below)
Persistent nausea or vomiting
Diarrhoea or steatorrhoea (pale, floating, offensive stools)
Loss of appetite, unexplained fatigue

Clinical Clues GPs Often Notice First

Persistent epigastric pain radiating to the back — especially if worse lying flat, relieved leaning forward
Jaundice without pain
Unexplained new-onset diabetes in an older adult — especially with weight loss
Weight loss with vague dyspepsia that doesn't respond to PPIs

🚨 NICE Referral Criteria — NICE NG12

Urgent 2-Week-Wait Referral:

→ Age ≥40 with jaundice → 2WW referral

Urgent CT scan within 2 weeks:

→ Age ≥60 with weight loss PLUS any of: abdominal pain, back pain, diarrhoea, nausea/vomiting, constipation, or new-onset diabetes

📈 Prognosis

✓ Caught early (resectable, Stage I–II): ~20–30% 5-year survival with surgery (Whipple procedure)
✗ Caught late (metastatic, Stage IV): ~3% 5-year survival
! Only ~20% of patients are resectable at diagnosis — most present late
! UK overall 5-year survival ~7% — one of the lowest of any cancer

🎓 AKT Pearl: Painless jaundice = pancreatic cancer until proven otherwise. If CA19-9 is raised with obstructive LFTs and weight loss — act fast. Early detection is the only thing that changes survival.

Why This Matters

New-onset type 2 diabetes can occasionally be an early presenting sign of pancreatic cancer
Pancreatic tumours can impair insulin-producing islet cells, causing diabetes
This is rare but important — most new T2DM is not pancreatic cancer, but the pattern below should trigger investigation

When to Be Alert — Red Flags

Age ≥60 with new-onset diabetes
New diabetes occurring alongside unexplained weight loss
Abdominal or back pain with new diabetes
Rapid unexplained deterioration in glycaemic control in a known diabetic
Painless jaundice in a newly diagnosed diabetic

🚨 NICE Trigger — NICE NG12

Age ≥60 + weight loss + new-onset diabetes → urgent CT scan within 2 weeks

🧠 Clinical Pearl — Easy to Remember

"Older patient + weight loss + new diabetes = think pancreas."

Don't just treat the diabetes and move on. Ask: why has this person developed diabetes now? Is there a reason?

🎓 AKT Pearl: This is a favourite exam scenario — an older patient with new T2DM and weight loss who is worked up for diabetes but the GP misses the underlying pancreatic cancer. The NICE trigger is the clue: age ≥60 + weight loss + new DM = urgent CT.

What Is It?

Cancer arising from the bile ducts — rare but aggressive
Can be intrahepatic (within liver), hilar (at junction — Klatskin tumour), or distal (common bile duct)
Often presents with biliary obstruction
Risk factors: primary sclerosing cholangitis (PSC), biliary stones, liver fluke, IBD (especially UC)

Symptoms and Signs

Jaundice — usually painless and progressive
Pruritus (itching from bile salts)
Pale stools, dark urine
Right upper quadrant pain or discomfort
Weight loss, fatigue
Abnormal LFTs — cholestatic pattern (↑↑ ALP, ↑ bilirubin, ↑ GGT)

The Key Clinical Scenario — When to Suspect

Obstructive jaundice in a patient WITHOUT gallstones on USS
Cholestatic LFTs (↑ ALP + ↑ bilirubin + ↑ GGT) without obvious cause
Progressive jaundice in a patient with PSC or IBD (especially UC)
No gallstones found but biliary obstruction is present on imaging

🚨 Referral

→ Unexplained jaundice — urgent 2WW hepatobiliary referral
→ Cholestatic LFTs without explanation — urgent USS then hepatobiliary referral
→ PSC patient with worsening jaundice or new symptoms — contact hepatology urgently

📈 Prognosis

✓ Caught early (resectable): ~20–40% 5-year survival with surgery
✗ Caught late (unresectable/metastatic): median survival 12 months; <5% 5-year
! Only ~30% are resectable at diagnosis

🎓 AKT Pearl: Any patient with PSC should be under regular hepatology surveillance — they are at high risk of cholangiocarcinoma. If a PSC patient develops worsening jaundice, weight loss, or rising CA19-9, don't wait. UC patients with PSC have an even higher risk.

🫀 Fatty Liver Disease — NAFLD / MASLD

Most common liver disease in the UK (~25% adults). Name changed internationally in 2023 — but NICE still uses NAFLD.

📢 2023 International Consensus

NAFLD has been renamed MASLD internationally — but NICE (NG49) still says NAFLD

For UK GP exams & NICE pathways: use NAFLD

For journals & hepatology: use MASLD

Safe answer in AKT/SCA: "NAFLD has been renamed MASLD internationally, but NICE guidance currently still uses NAFLD (NG49)."

Key name changes:

NAFLD → MASLD (Metabolic dysfunction-Associated Steatotic Liver Disease, "MAA-zuld")

NASH → MASH (Metabolic dysfunction-Associated SteatoHepatitis)

"Steatotic" = fatty. The new names emphasise the metabolic cause, not what it isn't.

🧠 Memory hook: MASLD = "fatty liver WITH metabolic baggage". No metabolic baggage? → Look for another cause (alcohol, drugs, other).

🌳 New Disease Classification — Steatotic Liver Disease (SLD)

SLD is the umbrella term. Everything below it is a subtype.

MASLD Fatty liver + ≥1 metabolic risk factor. Most common (~25% adults). Replaces old NAFLD.

MASH MASLD + inflammation & hepatocyte injury. Replaces NASH. Higher risk of fibrosis progression.

MetALD MASLD criteria plus excess alcohol (>210g/wk men / >140g/wk women). Both drivers present.

ALD Alcohol-Related Liver Disease. Alcohol is the main driver; no metabolic criteria needed.

Other SLD Fatty liver, no metabolic risk factor, no significant alcohol → investigate other causes (see below ↓)

⚠️ Fatty liver but NO metabolic risk factors? → Think "Other SLD"

Re-check metabolic risk factors first (BMI, HbA1c, lipids, BP, waist) — lean people can have metabolic risk.

Then consider: Alcohol (be honest) • Medications (steroids, amiodarone, methotrexate, tamoxifen) • Wilson's disease (ceruloplasmin — esp. <40 yrs) • Haemochromatosis (ferritin + transferrin saturation) • Viral hepatitis • Rapid weight loss / malnutrition

✅ Diagnosing MASLD — The 5-Factor Checklist

Need: hepatic steatosis + ≥1 of these 5 metabolic risk factors

Risk Factor (W-G-B-T-H)	Threshold
W — Waist circumference	≥94 cm (European men) ≥90 cm (South Asian men) ≥80 cm (all women)
G — Glucose	Prediabetes or Type 2 diabetes
B — Blood pressure	≥130/85 or on treatment
T — Triglycerides	≥1.7 mmol/L or on treatment
H — HDL cholesterol	<1.0 mmol/L men / <1.3 mmol/L women

💡 Waist circumference captures "lean MASLD" — someone with a normal BMI but central adiposity can still have MASLD. Normal BMI does not exclude the diagnosis.

🔬 FIB-4 Score — The Most Important Test in MASLD

"We don't worry about the fat — we worry about the fibrosis."

Formula: (Age × AST) ÷ (Platelets × √ALT) → MDCalc Calculator

FIB-4	Interpretation	Action
< 1.30	Low fibrosis risk	Manage in primary care — annual recall
1.30 – 2.67	Indeterminate	Second test: ELF or FibroScan
> 2.67	High fibrosis risk	Refer to hepatology

⚠️ Many patients with fatty liver have normal LFTs but advanced fibrosis. Checking ALT alone is NOT enough — always calculate FIB-4.

💬 What to Tell Patients

"You have fatty liver disease — called NAFLD or MASLD. It's very common, linked to weight and metabolic health, and is often reversible with lifestyle changes. We'll monitor you every year to make sure it doesn't progress."

⚡ GP Action by ALT Level

ALT	Action
<3× ULN	Bloods + USS + FIB-4 → annual recall
3–5× ULN	Hepatology eCONSULT + bloods + USS
>5× ULN	⚠️ Same-day call to Gastro on-call

📅 Annual Recall Template

Alcohol, smoking, weight, BP
FBC, U&E, LFTs (incl. AST), HbA1c*, Lipids
Recalculate FIB-4 — refer if >2.67
Reinforce lifestyle — mylivingwell.co.uk

*Skip if on diabetes recall

🌟 GP Pearl

Weight loss of 7–10% can reverse fatty liver and reduce inflammation — more powerful than any medication. Losing even 5% reduces liver fat. Mediterranean diet + exercise + treat metabolic syndrome = the treatment. No drug is currently licensed for MASLD/NAFLD in the UK (2026).

🎓 AKT/SCA Exam Tips

NICE still says NAFLD; use MASLD in discussions but acknowledge both
FIB-4 >2.67 = refer. Magic number: 2.67
Normal LFTs do NOT exclude advanced fibrosis — always do FIB-4
Waist alone (no obesity) can qualify someone for MASLD — don't be fooled by normal BMI
Indeterminate FIB-4 (1.30–2.67)? → ELF test or FibroScan, not just repeat FIB-4
If fatty liver + NO metabolic risk factors → think drugs, alcohol, Wilson's, haemochromatosis

🔍 Incidental Fatty Liver on USS — What to Do

MASLD Likely (has ≥1 metabolic risk factor)

Full blood screen + FIB-4 (see investigation panel)
FIB-4 <1.3 → annual recall in primary care
FIB-4 1.3–2.67 → ELF test or FibroScan
FIB-4 >2.67 → refer hepatology
Lifestyle advice — mylivingwell.co.uk
Send patient SMS (see templates ↓)

No Clear Metabolic Risk Factors — Other SLD

Re-check W-G-B-T-H (waist, glucose, BP, TG, HDL)
Ask honestly about alcohol
Review medications (steroids, amiodarone, methotrexate)
Repeat LFTs in ~3 weeks if mildly raised
Consider Wilson's (ceruloplasmin), haemochromatosis (ferritin + transferrin sat.)
If no cause found → hepatology eCONSULT

Patient Resources

🌱 MyLivingWell 📄 Patient.info NAFLD 🫀 British Liver Trust 🧮 FIB-4 Calculator

💬 Fatty Liver SMS Patient Messages

Ready-to-send via Patches, AccuRx, SystmOne Communications Annexe or similar

📱 Compatible platforms:

PatchesAccuRxSystmOne Communications AnnexeEMIS Patient Messaging

📩 SMS 1 — Before Ultrasound Done (Abnormal LFTs)

Your liver test is abnormal. You need some further blood tests — please contact reception for an appointment. I have also arranged an ultrasound scan for you (you will get a letter). It is important your weight is in a healthy range. If you want help, please see https://mylivingwell.co.uk/ We can discuss this further once we have all the results — usually takes 2 weeks, so book a routine appointment with your GP at the 3–4 week stage.

📩 SMS 2 — After USS Shows Fatty Liver Only

Your liver test is abnormal. Your ultrasound showed you have Fatty Liver Disease (also called MASLD). Please read this link to understand it more: https://patient.info/healthy-living/alcohol-and-liver-disease/non-alcoholic-fatty-liver-disease It is extremely important you ensure your weight is in a healthy range and that you do not exceed 14 units of alcohol per week. If you would like to discuss this further, please book an appointment with a practice nurse. We will repeat your liver tests every year to check it is stable.

🏥 Other Liver Disease

From fatty liver to cirrhosis — recognition and management in primary care

Spectrum: Fatty Liver → Hepatitis → Cirrhosis

Steatosis (fatty liver) — reversible with alcohol cessation
Alcoholic hepatitis — acute inflammation; can be fatal
Cirrhosis — irreversible fibrosis; risk of HCC

Assessment Clues

AUDIT-C questionnaire for screening
LFTs: raised GGT (sensitive marker), AST:ALT ratio >2:1
FBC: macrocytosis (MCV >100), thrombocytopenia

Management

Alcohol cessation — refer to alcohol services (AUDIT-C ≥5 triggers brief intervention)
Nutritional support — malnutrition common

💊 Thiamine (Vitamin B1) in Alcohol-Related Liver Disease

Situation	Drug	Dose & Route	Duration
Prevention (outpatient, alcohol-dependent)	Thiamine tablets	100mg orally, TDS	Ongoing while drinking; minimum 3 months
High-risk (poor diet, withdrawal, IV glucose)	Pabrinex (IV/IM)	Specialist decision — admit	As directed by specialist

Always give thiamine before glucose/IV fluids in at-risk patients to prevent Wernicke's encephalopathy.

Signs of Cirrhosis (Think: SPLASH)

Spider naevi, Palmar erythema, Leuconychia
Ascites, peripheral oedema
Splenomegaly, hepatomegaly (early then small)
Hormonal: gynaecomastia, testicular atrophy, jaundice

Decompensation — Refer Urgently

Ascites — diuretics (specialist), paracentesis
Variceal bleeding — endoscopy + banding
Hepatic encephalopathy — lactulose (30ml TDS, adjusted to 2–3 loose stools/day), rifaximin (specialist)
Spontaneous bacterial peritonitis (SBP) — IV antibiotics + admit

Monitoring in Primary Care

6-monthly USS + AFP (HCC surveillance)
Endoscopy for varices (secondary care)
LFTs, FBC, clotting, albumin — every 3–6 months

Common Causes (UK)

Paracetamol overdose — most common in UK
Viral hepatitis (A, B, E) | Drug-induced (antibiotics, NSAIDs)
Autoimmune hepatitis | Acute Wilson's disease (young patients)

Features

Jaundice + coagulopathy (INR >1.5) + encephalopathy
Hypoglycaemia, renal failure

Management

⚠️ Emergency admission — blue light if needed
Paracetamol OD: N-acetylcysteine IV (specialist/A&E)

Supportive (acute). Ribavirin for chronic HEV in immunosuppressed (specialist). Reduce immunosuppression if possible.

Prevention

Cook pork/game thoroughly. Good hygiene. Notifiable. ⚠️ Pregnant women with jaundice — always test for HEV.

🎉 You've Got This!

You've covered the essentials of gastroenterology for GP practice. Remember: red flags first, investigate appropriately, use FIT + PR exam together, and don't hesitate to refer when needed. Your patients are in safe hands.

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"The gut is the seat of all feeling. Polluting the gut not only cripples your immune system, but also destroys your sense of empathy." — Suzy Kassem

Gastroenterology for GPs: Your Essential Guide

Executive Summary

Quick Links

Key Statistics

IBD Prevalence

Bowel Cancer

MASLD (NAFLD)

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🧠 Brainy Bites

ALARMS — Upper GI Red Flags

Rome IV Criteria for IBS

1️⃣ Role of the GP in Gastroenterology

Diagnosis

Management

Emergencies

Coordination

Prevention

2️⃣ Red Flag Symptoms & Emergencies

Upper GI Red Flags

Lower GI Red Flags

Acute Abdomen

🩸 Iron Deficiency Anaemia — The Golden Rule

🔑 The One Rule You Must Remember

Why this matters — even if the patient says:

⚡ Who needs urgent investigation? (NICE NG12)

Typical GP Work-up for IDA

What to say to patients:

For menstruating women (if unclear cause):

Immediate Actions

💊 Oral Iron Replacement

🔬 Investigations & Screening

Blood Tests

FBC

LFTs

Inflammatory Markers

Coeliac Serology

Stool Tests

🔴 FIT (Faecal Immunochemical Test)

🟡 Faecal Calprotectin

📊 Faecal Calprotectin — Performance in Plain Numbers

Test Performance (threshold ~50 μg/g)

What does this mean in real life?

🟢 Negative Test (normal calprotectin)

🟡 Positive Test (raised calprotectin)

⚠️ False Positives Occur With:

💬 How to Explain to Patients

🎓 Teaching Pearl — FIT vs Calprotectin

Stool Culture (MC&S)

Imaging

Ultrasound Abdomen (First-line)

CT Abdomen/Pelvis

Endoscopy

Fibroscan (Transient Elastography)

📊 Managing Abnormal LFTs

Raised ALT (Alanine Transaminase)

⚡ GP Action Guide — ALT Thresholds

🔬 Full Investigation Panel for Raised ALT

Common Causes

Refer to Hepatology if:

Raised ALP (Alkaline Phosphatase)

Hepatic Causes

Non-Hepatic Causes

Key Investigation

Refer to Hepatology if:

Raised AST (Aspartate Transaminase)

The Ratio Rule — Very Useful in Practice

Non-Hepatic Causes (AST is not liver-specific!)

Refer to Hepatology if:

🧪 FIT Test Performance

⚠️ FIT Does NOT Exclude Anal or Rectal Cancer — Always Do a PR Examination

Test Performance Metrics (at 80 μg/g threshold)

True/False Positives & Negatives

💬 How to Explain FIT Results to Patients

🔴 Positive FIT Result

🟢 Negative FIT Result

⚠️ Important — Always Say This Too

🎯 Screening Programmes