Gastroenterology

NICE CG61 · BSG 2022 · ACG 2022 · EASL 2022

11%
Global IBS prevalence
40%
Adults have GERD symptoms
5.6%
Lifetime risk of peptic ulcer
354M
Chronic HBV infections

Gastroenterology in Primary Care — What Every GP Must Know

GI complaints account for 10–15% of all GP consultations. IBS affects 1 in 10 patients; GERD is one of the most common presentations; H. pylori eradication prevents ulcer recurrence and reduces gastric cancer risk. Viral hepatitis — especially HBV and HCV — remains underdiagnosed in Pakistan. Modern DAAs now cure Hepatitis C in >95% of patients.

H. pylori eradication reduces PUD recurrence by 90%HCV cure rate >95% with DAAsLow-FODMAP reduces IBS symptoms in 70%Barrett's surveillance prevents oesophageal cancer

Rome IV Diagnostic Criteria

Recurrent abdominal pain ≥1 day/week in last 3 months, onset >6 months prior, associated with ≥2 of:

Related to defecation
Associated with change in stool frequency
Associated with change in stool form/appearance

⚠ Alarm features must be absent: rectal bleeding, unintentional weight loss, nocturnal symptoms, family history of colorectal cancer/IBD, age >50 (new onset), iron deficiency anaemia

IBS Subtypes (Bristol Stool Scale)

IBS-C

Constipation-predominant

  • • >25% hard stools
  • • <25% loose stools
  • • Bloating prominent

IBS-D

Diarrhoea-predominant

  • • >25% loose stools
  • • <25% hard stools
  • • Urgency common

IBS-M

Mixed pattern

  • • >25% hard AND
  • • >25% loose stools
  • • Variable pattern

IBS-U

Unsubtyped

  • • Cannot be categorised
  • • Insufficient data
  • • Reassess later

Recommended Investigations

FBC + CRP/ESR— Exclude anaemia, infection, IBD
Anti-TTG IgA + total IgA— Exclude coeliac disease
TFTs— Exclude thyroid dysfunction
Faecal calprotectin— Distinguish IBS from IBD (cut-off <50 μg/g)
Stool M/C/S (once)— If recent travel or infection suspected

Red Flags → Urgent Referral

Rectal bleeding / melaena
Unintentional weight loss (>5% in 3 months)
Nocturnal diarrhoea waking patient
Progressive dysphagia
Palpable abdominal or rectal mass
Onset age >50 (especially new symptoms)
FH of colorectal cancer or ovarian cancer
Iron deficiency anaemia

Stepwise Management

Step 1Lifestyle & Dietary Modification
Low-FODMAP diet (supervised dietitian — 4–8 weeks trial)
Regular meals, avoid skipping
Reduce insoluble fibre, caffeine, alcohol, sorbitol
Adequate hydration (1.5–2L/day)
Regular moderate exercise (30 min, 5×/week)
Stress management & sleep hygiene
Step 2Symptom-Targeted Pharmacotherapy
IBS-C: Ispaghula husk (Fybogel) 1 sachet BD, Laxatives (PEG/macrogol)
IBS-D: Loperamide 2mg PRN (max 16mg/day), Colestyramine
Bloating/Pain: Mebeverine 135mg TDS (antispasmodic), Peppermint oil 0.2mL TDS
Antispasmodics: Dicyclomine 10–20mg TDS, Hyoscine 10mg TDS
Step 3Second-line & Adjunct Therapy
Low-dose TCAs: Amitriptyline 10–25mg nocte (IBS-D, pain)
SSRIs (if anxiety/IBS-C): Fluoxetine 20mg OD (improves transit)
Rifaximin 550mg TDS × 14 days (non-constipation IBS post-SIBO)
Probiotics: VSL#3, Lactobacillus — limited evidence but safe
Step 4Psychological & Specialist Referral
Gut-directed hypnotherapy (strong evidence base)
CBT — especially for anxiety-driven IBS
Gastroenterology referral if refractory or diagnostic uncertainty
Dietitian referral for supervised FODMAP reintroduction
Based on NICE CG61, BSG IBS Guidelines 2021, ACG Monograph 2021. Always individualise treatment. FODMAP requires dietitian supervision.

Hypertension

BP management module

Diabetes

In-depth DM module

Lab Reference

LFTs, hepatitis serology

Drug Database

Full dosing reference

Based on NICE CG61, BSG IBS/GERD Guidelines, ACG 2022, EASL HBV/HCV Guidelines 2022. Always individualise management. Refer complex or alarm-feature cases.