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Contents
Preface ix
Acknowledgements xi
List of abbreviations xiii
List of figures xvii
An explanation of the text xix

Part I GASTROENTEROLOGY 1

1. Common upper GI presentations 5

1.1 Dyspepsia 5
1.2 Dysphagia 8
1.3 Upper GI bleeding 10
1.4 Vomiting 14
2. Common small bowel presentations 21
2.1 Malabsorption 21
2.2 Weight loss 26
2.3 Malnutrition 29
3. Common colonic presentations 39
3.1 Diarrhoea 39
3.2 Constipation 43
3.3 Rectal bleeding (lower GI bleeding) 46
3.4 Iron deficiency anaemia 48
3.5 Abdominal pain 51
4. Common liver presentations 55
4.1 Jaundice 55
4.2 Liver failure 60
4.3 Alcohol withdrawal 63
4.4 Liver mass 66
4.5 Abnormal liver function tests 68
5. Oesophagus 73
5.1 Anatomy 73
5.2 Gastro-oesophageal reflux disease 74
5.3 Barrett’s oesophagus 76
5.4 Hiatus hernia 78
5.5 Achalasia 80
5.6 Oesophageal spasm 82
5.7 Oesophageal cancer 84
vi Contents

6. Stomach and duodenum 89

6.1 Anatomy 89
6.2 Physiology 90
6.3 Peptic ulcer disease 90
6.4 Gastritis 94
6.5 Pernicious anaemia 96
6.6 Gastroparesis 99
6.7 Gastric cancer 101
7. The small bowel 107
7.1 Anatomy 107
7.2 Physiology 108
7.3 Coeliac disease 110
7.4 Whipple’s disease 115
7.5 Small intestine bacterial overgrowth 116
7.6 Gastrointestinal infections 118
7.7 Lactose intolerance 127
7.8 Small bowel tumours 128
8. Colorectal disease 133
8.1 Anatomy 133
8.2 Irritable bowel syndrome 134
8.3 Inflammatory bowel disease 137
8.4 Crohn’s disease 139
8.5 Ulcerative colitis 141
8.6 Diverticular disease 144
8.7 Ischaemic colitis 146
8.8 Solitary rectal ulcer syndrome 148
8.9 Pseudomembranous colitis 150
8.10 Colorectal cancer 153
9. Pancreatobiliary disease 159
9.1 Anatomy 159
9.2 Physiology 160
9.3 Cholelithiasis 162
9.4 Gallbladder carcinoma 167
9.5 Cholangiocarcinoma 169
9.6 Acute pancreatitis 170
9.7 Chronic pancreatitis 173
9.8 Pancreatic cancer 175
10. Liver disease 179
10.1 Anatomy 179
10.2 Viral hepatitis 182
10.3 Autoimmune hepatitis 189
 Contents vii

10.4 Primary biliary cirrhosis 190

10.5 Primary sclerosing cholangitis 191
10.6 Drug-induced liver injury 193
10.7 Alcohol-related liver disease 195
10.8 Non-alcoholic fatty liver disease 200
10.9 Hereditary haemochromatosis 203
10.10 Wilson’s disease 205
10.11 Hepatocellular carcinoma 207
10.12 Metastatic liver disease 209
10.13 Budd–Chiari syndrome 210
10.14 Veno-occlusive disease 212
10.15 Portal vein thrombosis 213

Part II SELF-ASSESSMENT 217

11. Gastroenterology 219

Questions 219
Common upper GI presentations: EMQ 219
Common upper GI presentations: SBA 220
Common small bowel presentations: EMQ 220
Common small bowel presentations: SBA 221
Common colonic presentations: EMQ 221
Common colonic presentations: SBA 222
Common liver presentations: EMQ 222
Common liver presentations: SBA 223
Oesophagus: EMQ 223
Oesophagus: SBA 224
Stomach and duodenum: EMQ 225
Stomach and duodenum: SBA 226
The small bowel: EMQs 227
The small bowel: SBA 228
Colorectal disease: EMQs 229
Colorectal disease: SBAs 231
Pancreatobiliary disease: EMQ 232
Pancreatobiliary disease: SBA 232
Liver disease: EMQs 233
Liver disease: SBA 235
Answers 236
Common upper GI presentations: EMQ 236
Common upper GI presentations: SBA 236
Common small bowel presentations: EMQ 237
Common small bowel presentations: SBA 237
Common colonic presentations: EMQ 238
viii Contents

Common colonic presentations: SBA 239

Common liver presentations: EMQ 239
Common liver presentations: SBA 240
Oesophagus: EMQ 240
Oesophagus: SBA 241
Stomach and duodenum: EMQ 241
Stomach and duodenum: SBA 242
The small bowel: EMQs 243
The small bowel: SBA 244
Colorectal disease: EMQs 245
Colorectal disease: SBAs 247
Pancreatobiliary disease: EMQ 247
Pancreatobiliary disease: SBA 248
Liver disease: EMQs 248
Liver disease: SBA 250
Preface
Have you ever found gastroenterology overwhelmingly complicated? Have you
struggled to recall the basics in a clinical situation? Or are you simply short of
time and have exams looming? If so, this concise, practical guide will help you.
Written by doctors for doctors, this book presents information in a wide
range of formats including flow charts, boxes, summary tables and colourful
diagrams. No matter what your learning style is, we hope that you will find the
book appealing and easy to read. We think that the innovative style will help
you, the reader, to connect with this often feared topic, to learn, understand
and even enjoy it, and to apply what you have learned in your clinical practice
and in the pressured run-up to final examinations.
In writing the book, we have drawn on our recent personal experience
as medical students and junior doctors, and hope this book will offer the
less-experienced a portable and practical guide to gastroenterology that will
complement larger reference texts. We hope you find it helpful!
AUTHORS
Arash Assadsangabi MD MRCP – Specialist Registrar in Gastroenterology
and General Internal Medicine, Royal Hallamshire Hospital, Sheffield, UK
Lucy Carroll MBChB LLM – Foundation 1 Doctor, Huddersfield Royal
Infirmary, West Yorkshire, UK
Andrew Irvine – Medical Student, University of Sheffield, Sheffield, UK
EDITORIAL ADVISOR
Keith Dear – Consultant Gastroenterologist, Chesterfield Royal Hospital,
Chesterfield, UK
EDITOR-IN-CHIEF
Rory Mackinnon BSc(Hons) MBChB MRCGP – GP Partner, Dr Cloak &
Partners, Southwick Health Centre, Sunderland, UK
SERIES EDITORS
Andrew MN Walker BMedSci MBChB MRCP (London) – British Heart
Foundation Clinical Research Fellow and Honorary Specialist Registrar in
Cardiology, University of Leeds, UK
Harriet Walker – CT1 in Plastic Surgery, Derriford Hospital, Devon, UK
Acknowledgements
We thank the editors for their invaluable help during the writing of this book,
particularly Harriet Walker and Andy Walker for their c­ ontributions. Thanks
also to Servier Medical Art for the use of their images for this book. We also
thank Dr Andrew Hopper and Dr Rathinavel Balamurugan, who provided us
several of the radiological images.
List of abbreviations
• γGT: gamma-glutamyl transferase
• ACE: antegrade colonic enema
• AFP: α-fetoprotein
• ALD: alcoholic liver disease
• ALP: alkaline phosphatase
• ALT: alanine aminotransferase
• ANA: antinuclear antibody
• APC: argon plasma coagulation
• ARDS: acute respiratory distress syndrome
• AST: aspartate aminotransferase
• AUDIT: Alcohol Use Disorders Identification Test
• AXR: abdominal X-ray
• BCLC: Barcelona Clinic Liver Cancer classification
• BMI: body mass index
• BP: blood pressure
• BSG: British Society of Gastroenterology
• CCK: cholecystokinin
• CD: Crohn’s disease
• CDT: Clostridium difficile toxin
• CEA: carcinoembryonic antigen
• CF: cystic fibrosis
• CMV: cytomegalovirus
• CNS: central nervous system
• COPD: chronic obstructive pulmonary disease
• CRC: colorectal cancer
• CRP: C-reactive protein
• CSF: cerebrospinal fluid
• CT: computed tomography
• CXR: chest X-ray
• DEXA: dual-energy X-ray absorptiometry
• DF: discriminate function
• DRE: digital rectal examination
• EBV: Epstein–Barr virus
• ED: emergency department
• EGG: electrogastrography
• EMA: endomysial antibody
• EMR: endoscopic mucosal resection
• ERCP: endoscopic retrograde cholangiopancreatography
• ESD: endoscopic submucosal dissection
xiv List of abbreviations

• ESR: erythrocyte sedimentation rate

• EUS: endoscopic ultrasound
• FAP: familial adenomatous polyposis
• FAST: Fast Alcohol Screening Test
• FBC: full blood count
• FOB: faecal occult blood
• FODMAP: fermentable oligo-di-monosaccharides and polyols
• FSH: follicle-stimulating hormone
• FVL: factor V Leiden
• GI: gastrointestinal
• GIST: gastrointestinal stromal tumours
• GOJ: gastro-oesophageal junction
• GORD: gastro-oesophageal reflux disease
• GP: general practitioner
• Hb: haemoglobin
• HCC: hepatocellular carcinoma
• HLA: human leukocyte antigen
• HNPCC: hereditary non-polyposis colorectal carcinoma
• HR: heart rate
• HUS: haemolytic uraemic syndrome
• IBD: inflammatory bowel disease
• IBS: irritable bowel syndrome
• IEL: intra-epithelial lymphocyte
• IgA: immunoglobulin A
• IV: intravenous
• IVC: inferior vena cava
• LDH: lactate dehydrogenase
• LFT: liver function test
• LH: luteinizing hormone
• LOS: lower oesophageal sphincter
• MALT: mucosa-associated lymphoid tissue
• MCV: mean corpuscular volume
• MC&S: microscopy, culture and sensitivity
• MELD: Model for End-Stage Liver Disease
• MMSE: Mini-Mental State Examination
• MND: motor neurone disease
• MRA: magnetic resonance angiography
• MRCP: magnetic resonance cholangiopancreatography
• MS: multiple sclerosis
• MUST: Malnutrition Universal Screening Tool
• NAAT: nucleic acid amplification test
• NAFLD: non-alcoholic fatty liver disease
 List of abbreviations xv

• NASH: non-alcoholic steatohepatitis

• NBM: nil by mouth
• NG: nasogastric
• NJ: nasojejunal
• NSAID: non-steroidal anti-inflammatory drug
• OGD: oesophago-gastro-duodenoscopy
• PAS: periodic acid–Schiff
• PBC: primary biliary cirrhosis
• PCOS: polycystic ovary syndrome
• PCR: polymerase chain reaction
• PEG: percutaneous endoscopic gastrostomy
• PEJ: percutaneous endoscopic jejunostomy
• PICC: peripherally inserted central catheter
• Plt: platelet
• PPI: proton pump inhibitor
• PR: pulse rate
• PSC: primary sclerosing cholangitis
• PT: prothrombin time
• PTC: percutaneous transhepatic cholangiography
• PTH: parathyroid hormone
• QDS: four times per day
• RR: respiration rate
• SBP: spontaneous bacterial peritonitis
• SIBO: small intestinal bacterial overgrowth
• SLE: systemic lupus erythematosus
• SMA: smooth muscle antibody
• SRUS: solitary rectal ulcer syndrome
• SSRI: selective serotonin reuptake inhibitor
• TACE: transcatheter arterial chemo-embolization
• TB: tuberculosis
• TCA: tricyclic antidepressant
• TFT: thyroid function test
• TI: terminal ileum
• TIBC: total iron-binding capacity
• TIPS: transjugular intrahepatic portosystemic shunt
• TNM: tumour, nodes, metastases
• TPN: total parenteral nutrition
• TSH: thyroid-stimulating hormone
• tTG: tissue transglutaminase
• U&E: urea and electrolytes
• UC: ulcerative colitis
• UKELD: United Kingdom model for End-Stage Liver Disease
xvi List of abbreviations

• UOS: upper oesophageal sphincter

• USS: ultrasound scan
• UTI: urinary tract infection
• VLDL: very-low-density lipoprotein
• WCC: white cell count