Domain – Gastrointestinal health (case)

Michael, a 55-year-old man, presents for his repeat script for pantoprazole. He mentions that for the last few months he has occasionally noticed some blood in the toilet bowl, and he hopes you can manage that as well.

Communication and consultation

How would you discuss bowel cancer screening with Michael if he was from a culturally and linguistically diverse background? Or if he was an Aboriginal or Torres Strait Islander? How would you sensitively ask about high-risk behaviours that could cause this presentation?

• Culturally and Linguistically Diverse Background:
  • Use simple language and avoid medical jargon.
  • Utilize an interpreter if there are language barriers.
  • Explain the importance of screening in preventing bowel cancer and detecting it early.
  • Provide culturally relevant information and brochures in his language.
• Aboriginal or Torres Strait Islander:
  • Acknowledge and respect cultural beliefs and practices.
  • Discuss the importance of screening in the context of community health.
  • Utilize Indigenous health workers or liaison officers for support.
  • Offer information on services that are culturally appropriate.

Clinical information gathering and interpretation

What other symptoms would it be important to ask Michael about regarding this presentation? What red flags are important to screen for in this case? What questions would you ask Michael to help you review his need for pantoprazole?

Important Symptoms to Ask About:

• Changes in bowel habits (e.g., diarrhea, constipation)
• Abdominal pain or discomfort
• Unintended weight loss
• Fatigue or weakness
• Presence of mucus in the stool

Red Flags to Screen For:

• Persistent or recurrent bleeding
• Significant weight loss
• Severe abdominal pain
• Family history of colorectal cancer or polyps
• Anemia

Questions About Pantoprazole Use:

• How long has he been taking pantoprazole?
• Has he experienced any side effects?
• Does he have any symptoms of gastroesophageal reflux disease (GERD) or peptic ulcer disease?
• Has there been any change in his symptoms since starting the medication?

Pros of Long-term PPI Use

1. Effective Management of Acid-Related Disorders: PPIs are highly effective in treating conditions such as gastroesophageal reflux disease (GERD), peptic ulcers, and Zollinger-Ellison syndrome
2. Prevention of Complications: Long-term use of PPIs can prevent complications such as esophageal strictures and Barrett’s esophagus in patients with chronic GERD

Cons of Long-term PPI Use

1. Nutrient Deficiencies: Long-term PPI use can lead to deficiencies in vitamins and minerals such as vitamin B12, magnesium, and iron due to reduced absorption (Sheen & Triadafilopoulos, 2011)
2. Increased Risk of Infections: Prolonged PPI therapy has been associated with a higher risk of gastrointestinal infections, including Clostridium difficile and pneumonia
3. Bone Fractures: There is evidence suggesting an increased risk of bone fractures, particularly hip fractures, with long-term PPI use due to impaired calcium absorption
4. Kidney Disease: Chronic PPI use has been linked to an increased risk of developing chronic kidney disease and acute interstitial nephritis
5. Potential Cognitive Effects: Some studies suggest a potential link between long-term PPI use and an increased risk of dementia, though the evidence is not yet conclusive

Indications for PPI Use

1. Short-term Use: PPIs are recommended for short-term treatment (4-8 weeks) of gastroesophageal reflux disease (GERD), peptic ulcers, and other acid-related disorders. The goal is to manage symptoms and promote healing of the gastrointestinal mucosa.
2. Long-term Use: Long-term PPI use is indicated for conditions such as Barrett’s esophagus, severe erosive esophagitis, Zollinger-Ellison syndrome, and prevention of gastrointestinal bleeding in high-risk patients on non-steroidal anti-inflammatory drugs (NSAIDs) or antiplatelet therapy (Freedberg, Kim, & Yang, 2017), (Pezeshkian & Conway, 2018).

Deprescribing Guidelines

1. Reevaluation: For patients on long-term PPI therapy, regular reevaluation is recommended to assess the necessity of continued use. If the initial indication for PPI use is resolved, consider deprescribing.
2. Deprescribing Strategies: Gradual dose tapering before discontinuation is preferred to manage potential rebound acid hypersecretion. Switching to as-needed (PRN) use or to an H2 receptor antagonist can also be effective (RACGP, 2024).

Monitoring and Patient Engagement

1. Monitoring: During the deprescribing process, monitor for symptom recurrence and manage accordingly. Patients should be educated about the potential for rebound symptoms and the transient nature of these symptoms.
2. Patient Involvement: Engage patients in shared decision-making. Provide information about the intended treatment duration and the benefits and risks of long-term PPI use. Resources such as educational brochures and decision aids can support this process (RACGP, 2024), (Contemporary Clinic, 2024).

Special Considerations

1. Patients Who Should Not Deprescribe: Deprescribing is not recommended for patients with Barrett’s esophagus, severe erosive esophagitis, peptic strictures, a history of bleeding ulcers, or those requiring gastroprotection while on NSAIDs or aspirin.
2. Alternative Therapies: For some patients, switching to alternative therapies such as H2 receptor antagonists may be considered, but this should be done cautiously, keeping in mind the potential for symptom return and individual patient preferences (RACGP, 2024).

Making a diagnosis, decision making and reasoning

What are your differential diagnoses for Michael? What if he had a negative bowel cancer screening test four months ago? What would the differential diagnoses be if this was a 33-year-old female? What would the differential diagnoses be if this was a child (with rectal bleeding)? Would you organise any investigations?  

Differential Diagnoses:

• Michael’s Case:
  • Colorectal cancer
  • Hemorrhoids
  • Anal fissures
  • Diverticulosis
  • Inflammatory bowel disease (IBD)
• Negative Bowel Cancer Screening Test Four Months Ago:
  • Hemorrhoids
  • Anal fissures
  • Diverticulosis
  • IBD
• 33-Year-Old Female:
  • Hemorrhoids
  • Anal fissures
  • Endometriosis involving the bowel
  • IBD
• Child with Rectal Bleeding:
  • Anal fissures
  • Juvenile polyps
  • Meckel’s diverticulum
  • Intussusception
  • Investigations: Consider a physical exam and possibly a referral to a pediatric gastroenterologist.

Clinical management and therapeutic reasoning

How would you manage the repeat prescription request? How would your management change if Michael had a diagnosis of haemorrhoids or colon cancer? How would your advice differ if Michael was a child?

Repeat Prescription Request:

• Review his current symptoms and response to pantoprazole.
• Ensure there is an ongoing indication for the medication.
• Discuss potential side effects and long-term use implications.

Management with Haemorrhoids or Colon Cancer:

• Haemorrhoids:
  • Conservative treatment: high-fiber diet, adequate hydration, topical treatments.
  • Referral to a specialist if severe.
• Colon Cancer:
  • Immediate referral to a gastroenterologist or colorectal surgeon.
  • Arrange for colonoscopy and further imaging as needed.
  • Discuss treatment options and support.

Advice for a Child:

• Emphasize reassurance to the parents.
• Consider less invasive initial management.
• Referral to a pediatric specialist if needed.

Preventive and population health 

What concerns may Michael have about having a colonoscopy or gastroscopy? How might your management be affected if you were working in a rural or remote setting? What resources or guidelines would you use to determine the recommended prevention strategies for this presentation?

Preventive and Population Health

Concerns About Colonoscopy or Gastroscopy:

• Fear of discomfort or pain.
• Anxiety about the findings.
• Concern about the preparation process.
• Reassure about the procedure’s safety and importance.

Management in Rural or Remote Setting:

• Consider telehealth consultations.
• Utilize local health services and traveling specialists.
• Provide clear instructions for at-home preparation.

Resources and Guidelines:

• Use guidelines from the National Health and Medical Research Council (NHMRC) or relevant local health authorities.
• Refer to evidence-based guidelines for colorectal cancer screening and management.

Professionalism

How would you respond if Michael refused to have his rectal bleeding investigated?

• Respect his autonomy while educating him on the risks.
• Discuss alternative management options.
• Document his refusal and continue to provide supportive care.

General practice systems and regulatory requirement

How do you ensure you have an effective recall system? If Michael had no symptoms but a positive faecal occult blood test (FOBT) result, how do you complete a notification of a positive result to the National Bowel Cancer Screening Program?

Ensuring Effective Recall System:

• Use electronic medical records to set reminders.
• Follow-up calls or messages for upcoming appointments.
• Maintain a robust tracking system for test results and follow-ups.

Notification of Positive FOBT Result:

• Complete the required notification forms.
• Inform Michael and discuss the next steps, such as a colonoscopy referral.

Australia’s National Bowel Cancer Screening Program

Overview: Australia’s National Bowel Cancer Screening Program (NBCSP) aims to reduce the morbidity and mortality associated with bowel cancer by detecting the disease early when it is most treatable.

Eligibility and Frequency

• Age Group: As of 1 July 2024, the program includes Australians aged 45 to 74. Previously, the program targeted those aged 50 to 74.
• Frequency: Eligible individuals receive a free screening test kit every two years (National Cancer Screening Register, 2024), (Cancer Council, 2024).

Screening Test and Procedure

• Test Kit: Participants receive a Faecal Occult Blood Test (FOBT) kit by mail, which they can use at home to collect a stool sample. The sample is then sent to a lab for analysis.
• Positive Result Management: If the test result is positive, indicating the presence of blood in the stool, the individual is advised to consult their doctor for further diagnostic procedures, typically a colonoscopy.

Risk Factors and Positive Result Follow-up

• Colonoscopy: Following a positive FOBT result, a colonoscopy is usually recommended to examine the colon more thoroughly and identify the source of bleeding or any other abnormalities (National Cancer Screening Register, 2024).
• Follow-up Colonoscopy Frequency
  • Abnormal Results: If the colonoscopy identifies abnormalities such as polyps, the follow-up schedule depends on the findings. Typically, another colonoscopy may be scheduled within 1 to 5 years, depending on the number, size, and type of polyps removed.
    • Low-Risk Polyps (1-2 small adenomas <10 mm)
      • Recommendation: Follow-up colonoscopy in 5-10 years.
      • Rationale: These polyps have a lower risk of progressing to cancer (Gupta et al., 2020).
    • High-Risk Polyps (3-10 adenomas, any adenoma ≥10 mm, or adenomas with high-grade dysplasia or villous features)
      • Recommendation: Follow-up colonoscopy in 3 years.
      • Rationale: These polyps have a higher risk of progressing to cancer, warranting closer surveillance (Gupta et al., 2020).
    • More than 10 Adenomas
      • Recommendation: Follow-up colonoscopy in less than 3 years.
      • Rationale: The high number of polyps indicates a significant risk, and closer monitoring is necessary (Gupta et al., 2020).
    • Serrated Polyps (Sessile serrated adenomas/polyps)
      • <10 mm without dysplasia: Follow-up in 5 years.
      • ≥10 mm or with dysplasia: Follow-up in 3 years.
      • Traditional serrated adenomas: Follow-up in 3 years.
      • Rationale: Serrated polyps can also progress to colorectal cancer, especially larger ones or those with dysplasia (Gupta et al., 2020).
  • Normal Results: If the colonoscopy does not find any significant issues, the individual usually returns to routine screening with the FOBT every two years (Cancer Council, 2024).

Additional Investigations

1. CT Abdomen
   • Indications: A CT abdomen is not typically part of routine follow-up after colonoscopy unless there are specific indications such as symptoms suggesting complications or other abdominal pathologies.
   • Rationale: Colonoscopy is the preferred method for evaluating the colon directly. CT scans may be used if there is suspicion of extra-colonic disease or complications that need further imaging (Hur et al., 2007).
2. Other Investigations
   • Stool DNA Tests: These may be used as adjuncts to monitor patients at high risk who cannot undergo regular colonoscopy.
   • Fecal Immunochemical Test (FIT): Useful for routine surveillance in average-risk individuals but not typically after polypectomy.
   • Serum Tumor Markers (e.g., CEA): May be monitored in patients with known colorectal cancer but are not used for routine polyp follow-up.

Procedural skills

How do you explain to Michael how to take a rectal swab to exclude rectal infections/STIs?

Managing uncertainty

What advice would you give Michael if he had only had one episode of bright rectal blood on the toilet paper? How do you manage a patient with undifferentiated abdominal pain?

Differential Diagnoses for Rectal Bleeding

Rectal bleeding can be caused by a range of conditions, including:

1. Hemorrhoids
2. Anal fissures
3. Diverticulosis
4. Colorectal polyps
5. Colorectal cancer
6. Inflammatory bowel disease (IBD)
7. Gastrointestinal (GI) infections
8. Angiodysplasia
9. Peptic ulcers
10. Upper GI bleeding with brisk transit (unlikely, but possible)

Red Flags in History for Rectal Bleeding

When taking Michael’s history, it’s essential to look out for red flags that may indicate a more serious underlying condition:

• Significant weight loss
• Change in bowel habits (e.g., diarrhea or constipation)
• Persistent abdominal pain
• History of colorectal cancer or polyps in the family
• Anemia (symptoms like fatigue, pallor)
• Melena (black, tarry stools)
• Large volume of blood or recurrent bleeding episodes
• Age over 50 (increased risk of colorectal cancer)
• Recent onset of symptoms in an individual with no prior history of rectal bleeding

Risk Factors for Colon Cancer in Australia

Colon cancer, also known as colorectal cancer, is influenced by various risk factors. In Australia, these risk factors include lifestyle, environmental, genetic, and medical factors.

Lifestyle and Environmental Risk Factors

1. Diet and Nutrition:
   • High Red and Processed Meat Consumption: Frequent consumption of red and processed meats increases the risk of colon cancer (Giovannucci, 2002).
   • Low Fiber Intake: A diet low in fiber is associated with an increased risk of colorectal cancer (Vajdic et al., 2017).
2. Obesity and Physical Inactivity: Excess body weight and lack of physical activity significantly contribute to the risk of colon cancer. Obesity, particularly central obesity, is a strong risk factor (Giovannucci, 2002).
3. Smoking and Alcohol Consumption:
   • Smoking: Both current and former smoking are linked to an increased risk of colorectal cancer (Vajdic et al., 2017).
   • Alcohol: High alcohol consumption is another modifiable risk factor, with higher risks noted for those consuming more than two alcoholic drinks per day (Giovannucci, 2002).

Genetic and Medical Risk Factors

1. Family History: A family history of colorectal cancer significantly increases an individual’s risk. The risk is particularly high if a first-degree relative has been diagnosed with the disease
2. Genetic Syndromes: Certain hereditary conditions, such as Lynch syndrome and familial adenomatous polyposis (FAP), greatly increase the risk of developing colorectal cancer (Giovannucci, 2002).
3. Inflammatory Bowel Disease (IBD): Chronic inflammatory conditions of the colon, such as Crohn’s disease and ulcerative colitis, are associated with a higher risk of colorectal cancer (Giovannucci, 2002).

Modifiable Risk Factors and Prevention

1. Dietary Adjustments: Increasing the intake of fruits, vegetables, and high-fiber foods can help reduce the risk.
2. Regular Physical Activity: Engaging in regular physical exercise is beneficial in lowering the risk of colon cancer (Morrison et al., 2013).
3. Limiting Alcohol and Avoiding Tobacco: Reducing alcohol consumption and avoiding tobacco use can significantly decrease the risk.

Advice for a Single Episode of Bright Rectal Blood

If Michael had only experienced one episode of bright rectal blood on the toilet paper, the advice would be as follows:

• Reassurance: Single episodes of bright red blood are often caused by benign conditions such as hemorrhoids or anal fissures, especially if the bleeding is minimal.
• Observation: Advise Michael to monitor his symptoms and return if the bleeding recurs, increases, or if he develops any red flag symptoms.
• Lifestyle Modifications: Suggest increasing fiber intake, staying hydrated, and avoiding straining during bowel movements to prevent hemorrhoids or fissures.
• Follow-up: Recommend a follow-up visit to re-evaluate and ensure no further episodes have occurred or other symptoms have developed.

Managing a Patient with Undifferentiated Abdominal Pain

When managing a patient with undifferentiated abdominal pain, a thorough and systematic approach is necessary:

1. History and Physical Examination
   • History: Detailed history of pain (onset, location, duration, intensity, character, aggravating/relieving factors), associated symptoms (nausea, vomiting, bowel habits, urinary symptoms, fever).
   • Physical Examination: Full abdominal examination including inspection, auscultation, palpation, and percussion. Look for signs of peritonitis, masses, or hernias.
2. Laboratory and Imaging Investigations
   • Basic Tests: Complete blood count (CBC), electrolytes, liver function tests (LFTs), amylase/lipase, urinalysis.
   • Imaging: Ultrasound or CT scan of the abdomen may be indicated based on the clinical scenario.
3. Assessment and Differentials
   • Based on the clinical findings and investigations, form a differential diagnosis list. Common differentials include gastroenteritis, appendicitis, cholecystitis, pancreatitis, bowel obstruction, diverticulitis, and renal colic.
4. Management Plan
   • Symptomatic Treatment: Pain relief, antiemetics, hydration.
   • Specific Treatment: Based on the diagnosis (e.g., antibiotics for diverticulitis, surgical consultation for appendicitis).
   • Monitoring and Follow-up: Regular monitoring of symptoms and review of investigation results. Ensure appropriate follow-up to reassess and modify the treatment plan as necessary.
5. Referral and Specialist Input
   • Refer to a specialist (e.g., gastroenterologist, surgeon) if needed, based on the clinical scenario and initial findings.

Identifying and managing the significantly ill patient

What are the acute gastrointestinal conditions that must not be missed in this presentation? When would you send Michael directly to hospital?

Acute GI Conditions That Must Not Be Missed

1. Acute Appendicitis
   • Sudden onset of abdominal pain, often starting around the umbilicus and then localizing to the right lower quadrant (RLQ).
   • Associated with nausea, vomiting, and anorexia.
   • Rebound tenderness and positive Rovsing’s, psoas, or obturator signs.
2. Acute Cholecystitis
   • Right upper quadrant (RUQ) pain, often radiating to the back or right shoulder.
   • Fever, nausea, vomiting.
   • Murphy’s sign positive.
3. Perforated Peptic Ulcer
   • Sudden, severe abdominal pain, often with signs of peritonitis.
   • History of peptic ulcer disease.
   • Free air under the diaphragm on upright chest X-ray.
4. Acute Pancreatitis
   • Severe epigastric pain radiating to the back.
   • Nausea, vomiting, and abdominal distention.
   • Elevated serum amylase or lipase levels.
5. Bowel Obstruction
   • Cramping abdominal pain, vomiting, distention, and inability to pass gas or stool.
   • High-pitched bowel sounds early, followed by silence.
6. Diverticulitis with Complications (e.g., perforation, abscess)
   • LLQ pain, fever, and altered bowel habits.
   • Signs of localized peritonitis or systemic sepsis.
7. Mesenteric Ischemia
   • Severe abdominal pain out of proportion to physical findings.
   • Risk factors include atrial fibrillation, atherosclerosis.
   • Metabolic acidosis, elevated lactate.
8. Acute GI Bleeding
   • Hematemesis, melena, or significant hematochezia.
   • Hypotension, tachycardia, and signs of hypovolemic shock.
   • History of peptic ulcer disease, liver disease, or use of NSAIDs/anticoagulants.

Criteria for Sending Michael Directly to Hospital

Michael should be sent directly to the hospital if any of the following criteria are met:

1. Hemodynamic Instability
   • Hypotension (systolic BP < 90 mmHg).
   • Tachycardia (HR > 100 bpm).
   • Signs of shock (e.g., pallor, diaphoresis, altered mental status).
2. Severe or Acute Onset Abdominal Pain
   • Severe pain that is sudden in onset and not relieved by simple measures.
   • Pain associated with signs of peritonitis (e.g., rebound tenderness, rigidity).
3. Significant Rectal Bleeding
   • Large volume of blood in the stool or ongoing significant bleeding.
   • Hematochezia with signs of hypovolemia.
4. Signs of Acute Abdomen
   • Peritonitis (rebound tenderness, guarding).
   • Abdominal distention with absent bowel sounds (suggestive of bowel obstruction).
5. Suspected Gastrointestinal Perforation
   • Severe abdominal pain with signs of sepsis or peritonitis.
   • History of peptic ulcer disease with acute exacerbation.
6. Severe Systemic Symptoms
   • Fever with chills and rigors suggestive of sepsis.
   • Uncontrolled vomiting or inability to tolerate oral intake.
7. History of Recent Surgery or Known GI Pathology
   • Recent abdominal surgery with new onset of severe symptoms.
   • Known history of GI conditions with acute exacerbation (e.g., IBD flare with severe symptoms).

Immediate Actions

• Initial Stabilization: If in a clinical setting, initiate IV access, fluid resuscitation, and monitoring of vital signs.
• Urgent Referral: Arrange for immediate transfer to the hospital, preferably with ambulance services if the patient is unstable.
• Communication: Provide detailed handover to the receiving emergency department, including history, clinical findings, and interventions initiated.