Question 1

What is the first-line H. pylori eradication regimen and how long should it be given?

Accepted Answer

First-line H. pylori eradication (NICE NG 2022 / ACG 2022): Triple therapy for 14 days — Omeprazole 20 mg twice daily + Amoxicillin 1 g twice daily + Clarithromycin 500 mg twice daily (OAC). Use Metronidazole 400 mg twice daily instead of Amoxicillin if penicillin-allergic (OMC). 14-day courses achieve significantly higher eradication rates than 7-day courses (~85–90% vs ~75%). Second-line (if first-line fails): Bismuth quadruple therapy — Omeprazole + Bismuth subcitrate + Tetracycline + Metronidazole for 10–14 days. Confirm eradication with urea breath test or stool antigen at least 4 weeks after completing antibiotics and 2 weeks after stopping PPI. Eradication reduces peptic ulcer recurrence by 90% and reduces gastric cancer risk long-term.

Question 2

When should a GP urgently refer a patient with upper GI bleeding?

Accepted Answer

Immediate (999 / emergency admission) for haemodynamic compromise: systolic BP <100 mmHg, pulse >100 bpm, active haematemesis, or melaena with shock. Use the Glasgow-Blatchford Score (GBS) to stratify: GBS 0 = very low risk (can manage outpatient); GBS ≥1 = requires inpatient endoscopy; GBS ≥6 = high risk, needs urgent intervention. Red flags mandating same-day or urgent referral: haematemesis (fresh or coffee-ground), melaena, syncope with GI symptoms, dysphagia, unexplained iron-deficiency anaemia, weight loss, palpable abdominal mass, or age >55 with new-onset dyspepsia. For suspected upper GI cancer (2-week wait pathway, NICE NG12): refer if age ≥55 with weight loss plus any of — upper abdominal pain, reflux, or dyspepsia; OR dysphagia at any age; OR haematemesis at any age.

Question 3

What is the difference between IBS and IBD?

Accepted Answer

IBS (Irritable Bowel Syndrome) is a functional gut disorder — there is no structural or inflammatory bowel pathology. It is diagnosed by Rome IV criteria: recurrent abdominal pain ≥1 day/week for 3 months, associated with ≥2 of: related to defecation, change in stool frequency, or change in stool form. Normal investigations (bloods, CRP, faecal calprotectin, colonoscopy). Management: low-FODMAP diet, antispasmodics (mebeverine, hyoscine), loperamide for diarrhoea-predominant, laxatives for constipation-predominant. IBD (Inflammatory Bowel Disease) — Crohn's disease and Ulcerative Colitis — involves chronic intestinal inflammation confirmed on endoscopy and histology. IBD features NOT seen in IBS: elevated CRP/ESR, raised faecal calprotectin (>200 µg/g strongly suggests IBD), rectal bleeding, nocturnal symptoms, weight loss, fever. Key rule: Faecal calprotectin is the pivotal GP test — a normal result (<50 µg/g) effectively excludes IBD and supports IBS diagnosis, avoiding unnecessary colonoscopy.

Question 4

What are the Rome IV criteria for diagnosing IBS in primary care?

Accepted Answer

Rome IV criteria for IBS (2016): Recurrent abdominal pain on average ≥1 day per week in the last 3 months, associated with ≥2 of the following: (1) related to defecation; (2) associated with a change in frequency of stool; (3) associated with a change in form (appearance) of stool. Subtypes: IBS-D (diarrhoea-predominant, >25% loose stools), IBS-C (constipation-predominant, >25% hard stools), IBS-M (mixed), IBS-U (unclassified). Positive diagnosis requires: absence of alarm features (rectal bleeding, weight loss, nocturnal symptoms, anaemia, family history of colorectal cancer or IBD, age >50 with new symptoms) and normal faecal calprotectin, CRP, FBC, and coeliac serology (TTG IgA). A positive diagnosis with investigations avoids unnecessary colonoscopy and reassures the patient.

Question 5

What is the first-line treatment for GERD (gastro-oesophageal reflux disease) in primary care?

Accepted Answer

First-line GERD management (NICE CG184 / ACG 2022): (1) Lifestyle: elevate head of bed 15–20 cm, avoid triggers (fatty food, caffeine, alcohol, chocolate, late meals), lose weight if BMI >25, stop smoking. (2) Step-up pharmacotherapy: start with a full-dose PPI for 4–8 weeks (Omeprazole 20 mg OD, Lansoprazole 30 mg OD, or Pantoprazole 40 mg OD) — taken 30 minutes before breakfast. (3) On-demand or maintenance PPI: for recurrent/chronic GERD use the lowest effective dose. H2 blockers (famotidine) are an alternative if PPI is not tolerated. Refer for endoscopy if: alarm features (dysphagia, weight loss, haematemesis, iron-deficiency anaemia), age >55 with new-onset symptoms, inadequate PPI response after 4 weeks, or symptoms requiring long-term PPI >4 weeks. Barrett's oesophagus (columnar metaplasia) found on OGD requires surveillance endoscopy every 2–5 years depending on grade.

Question 6

When should a GP test for and treat hepatitis C, and what is the current treatment?

Accepted Answer

Test for Hepatitis C (anti-HCV antibody) in: people who inject or have ever injected drugs (highest risk group), recipients of blood products before 1992 (pre-screening era), HIV-positive patients, those born in high-prevalence countries (Pakistan, Egypt, Central Asia, sub-Saharan Africa), unexplained elevated ALT, or household/sexual contact of confirmed HCV. If anti-HCV positive, confirm active infection with HCV RNA (PCR) — a positive RNA means current infection requiring treatment. Current treatment (EASL 2022): Direct-Acting Antivirals (DAAs) achieve >95% sustained virological response (SVR = cure) in 8–12 weeks. Pan-genotypic regimens: Sofosbuvir/Velpatasvir (Epclusa) 12 weeks, or Glecaprevir/Pibrentasvir (Mavyret) 8 weeks for treatment-naive non-cirrhotic patients. SVR12 (undetectable HCV RNA 12 weeks after completing treatment) = cure. Cured patients no longer transmit the virus. Refer all confirmed HCV RNA-positive cases to hepatology or a DAA-prescribing GP with special interest.

Gastroenterology

Gastroenterology in Primary Care — What Every GP Must Know

Rome IV Diagnostic Criteria

IBS Subtypes (Bristol Stool Scale)

Recommended Investigations

Red Flags → Urgent Referral

Stepwise Management