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Gastrointestinal health

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Instructions

This section provides a summary of the area of practice for this unit and highlights the importance of this topic to general practice and the role of the GP.

Gastrointestinal presentations rank within the top 15 presentations to general practice in Australia.1 With a vast array of clinical presentations that impact all age groups and genders, from acute and sub-acute to chronic presentations, general practice is often the first point of contact. The most common gastrointestinal conditions that are managed by general practitioners (GPs) include gastroesophageal reflux disease (GORD), constipation in children, irritable bowel syndrome (IBS), gastroenteritis (including traveller’s diarrhoea), inflammatory bowel disease (Crohn’s disease and ulcerative colitis), coeliac disease, non-alcoholic fatty liver disease (NAFLD)/non-alcoholic steatohepatitis (NASH), hepatitis C and Helicobacter pylori infection.1

The GP’s role encompasses preventive health screening, diagnosis and management of acute and chronic conditions. Given the breadth of knowledge that is required for this area, one useful approach is to divide topics into organ-related systems and then further subdivide into acute and chronic presentations. GPs need to remain up to date with clinical guidelines, especially in chronic and terminal gastrointestinal conditions, to ensure management plans are supported by evidence-based practice.2 Allied health professionals (eg dieticians, psychologists, pharmacists) may also form part of a multidisciplinary team that assists in managing patients with gastrointestinal presentations. All members of this team should be included in patient clinical conferencing and participate in shared decision-making and advocacy for patient care.3

Gastrointestinal conditions impacting children can present as early as the first few weeks of life. GPs should be aware of age-specific disorders as well as the red flag signs and symptoms indicating the need for urgent referral or transfer to a tertiary centre. Another vital GP skill is the ability to differentiate between passing tummy trouble and a digestive disorder, given the impact these conditions can have on a child’s growth and development, in addition to the effect on parents and families.4

GPs also play a vital role in assisting with patient participation in the National Bowel Cancer Screening Program, and in understanding the difference between screening versus diagnostic tests.5 This is particularly important in under-screened populations such as Aboriginal and Torres Strait Islander peoples, people from culturally and linguistically diverse communities, individuals experiencing social disadvantage and very remote populations.6-8 GPs should be familiar with the risk factors for colorectal cancer and use resources to aid their decision-making.9 Socioeconomic status and health behaviours can contribute to gastrointestinal presentations and impact treatment. These are multifactorial and include poor nutrition, smoking, drug use, alcohol intake and obesity.10 The GP's role in identifying, counselling and supporting change in these areas is important in holistic care of the patient and in achieving positive treatment outcomes.

Screening for hepatitis B and C infection should also be offered to groups with increased prevalence, including Aboriginal and Torres Strait Islander peoples, patients within the justice system and migrants, refugees and asylum seekers from high-risk countries.11 GPs are now able to treat conditions such as hepatitis C in the community and need to be aware of opportunities to upskill as new regimens for disease management become available. Access to treatment can also be impacted by geographic region and will require ongoing advocacy and support from GPs.12

In rural and remote settings, GPs may encounter barriers to care such as access to further investigations including imaging and access to non-GP specialists for opinion and procedures such as gastroscopy and colonoscopy.13 Awareness of the services available within their network, including telehealth consultations with non-GP specialists, and connections with neighbouring medical services is vital for GPs and patients to ensure they are adequately supported.

References
  1. Cooke G. Common general practice presentations publication frequency. Aust Fam Phys 2013;42(1):65–68.
  2. Government of Western Australia Department of Health. Diagnostic Imaging Pathways – Abdominal Pain (Chronic). East Perth, WA: DoH, 2014
  3. Basnayake C. Treatment of irritable bowel syndrome. Aust Prescr 2018;41(5):145–49.
  4. McGrath KH, Alex G. The challenge of outpatient clinical triage in paediatric gastroenterology: Who is referred and what is needed? Aust J Gen Pract 2019;48(4):230–33.
  5. Cancer Council Australia. Clinical practice guidelines for the prevention, early detection, and management of colorectal cancer. Sydney, NSW: Cancer Council Australia, 2017 [Accessed 4 November 2021].
  6. Australian Institute of Health and Welfare. Cancer in Aboriginal and Torres Strait Islander peoples of Australia: an overview. Canberra, ACT: AIHW, 2013 [Accessed 17 September 2021].
  7. Lotfi-Jam K, O’Reilly C, Feng C, Wakefield M, Durkin S, Broun K. Increasing bowel cancer screening participation: Integrating population-wide, primary care and more targeted approaches. Public Health Res Pract 2019;29(2):2921916.
  8. Australian Institute of Health and Welfare. National Bowel Cancer Screening Program monitoring report 2021, Summary 2021. Canberra, ACT: AIHW, 2021 [Accessed 16 October 2021]
  9. The Royal Australian College of General Practitioners. Guidelines for preventive activities in general practice. 9th edn. East Melbourne, Vic: RACGP, 2016.
  10. Gastroenterological Society of Australia. Gastro-oesophageal reflux disease in adults. Mulgrave, Vic: GESA, 2011 [Accessed 4 November 2021].
  11. Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine. B Positive, Hepatitis B for Primary Care. Sydney, NSW: ASHM, 2018 [Accessed 17 September 2021].
  12. Nirwan, J.S., Hasan, S.S., Babar, ZUD. et al. Global Prevalence and Risk Factors of Gastro-oesophageal Reflux Disease (GORD): Systematic Review with Meta-analysis. Sci Rep 10, 5814 (2020)
  13. Parkin G, Bell SW, Mirbagheri N. Colorectal cancer screening in Australia: An update. Aust J Gen Pract 2018;47(12):1.

Instructions

This section lists the knowledge, skills and attitudes that are expected of a GP for this contextual unit. These are expressed as measurable learning outcomes, listed in the left column. These learning outcomes align to the core competency outcomes of the seven core units, which are listed in the column on the right.

Communication and the patient–doctor relationship
Learning outcomes Related core competency outcomes
The GP is able to:   
  • effectively communicate diagnosis and management of gastrointestinal conditions, considering the patient’s level of health literacy
 1.1.1, 1.1.2, 1.1.3, 1.1.6, AH1.3.1, 1.2.1, 1.3.1
  • use shared decision-making to develop patient-centred management plans for the management of chronic gastrointestinal disease
 1.2.2, 1.4.3, 1.4.4, 1.4.2, RH1.4.1
  • communicate the evidence relating to screening tests for colorectal cancer, including the pros and cons, appropriate use and follow-up of abnormal screening tests
 1.2.1, 1.2.3
Applied knowledge and skills
Learning outcomes Related core competency outcomes
The GP is able to:   
  • take a history and examine paediatric and adult patients for common gastrointestinal presentations
 2.1.1, 2.1.2
  • diagnose and manage acute, sub-acute and chronic gastrointestinal conditions in children and adults
 2.1.3, 2.1.4, 2.1.6, 2.1.7, 2.1.8, 2.3.1, AH2.3.1, RH2.3.1, RH2.1.1
  • recognise the need for careful detailed history-taking for presentations of vague or non-specific gastrointestinal symptoms
 2.1.1, 2.1.4, 2.1.10
  • identify and manage red flags in gastrointestinal presentations, including acute abdomen and potential cancers through investigation and referral to specialists
 2.1.3, 2.1.4, 2.1.6, 2.1.8, 2.1.10, AH2.1.2, 2.3.1, 2.3.3
Population health and the context of general practice
Learning outcomes Related core competency outcomes
The GP is able to:   
  • use planned and opportunistic approaches to discuss screening, preventive care and gastrointestinal health promotion
 3.1.1, 3.1.4
  • reflect on and take steps to minimise barriers to gastrointestinal healthcare, including limited resources, stigma and cultural norms
 3.2.1, 3.2.2, 3.2.4, AH3.2.2, RH 3.2.1
  • understand the gastrointestinal health problems of specific community groups (eg Aboriginal and Torres Strait Islander peoples, people from culturally and linguistically diverse backgrounds and people with developmental disabilities)
 AH 3.2.1, AH 3.2.2
Professional and ethical role
Learning outcomes Related core competency outcomes
The GP is able to:   
  • seek opportunities to share and learn new skills from other health professionals involved in the care of patients with chronic gastrointestinal diseases
 4.2.1, 4.2.2, 4.3.1, 4.1.1
Organisational and legal dimensions
Learning outcomes Related core competency outcomes
The GP is able to:   
  • develop, maintain, coordinate and evaluate disease management programs, including recall and prompted care systems, both within general practice and with multidisciplinary teams
 5.1.3, 5.2.1, 5.2.2
 
  • apply ethical considerations in team approaches in caring for patients with gastrointestinal conditions across different healthcare sectors (eg sharing of health records)
 5.2.1, 5.2.3
  • fulfil mandatory reporting responsibilities for notifiable gastrointestinal diseases
 5.2.3

Instructions

This section includes tips related to this unit from experienced GPs. This list is in no way exhaustive but gives you tips to consider applying to your practice.

Extension exercise: Speak to your study group or colleagues to see if they have further tips to add to the list.

  1. Be mindful of the need to screen for blood-borne viruses in patients from culturally diverse backgrounds, refugees, those that identify as Aboriginal or Torres Strait Islander, or patients with high-risk behaviours. Screen for other blood-borne conditions if one is diagnosed.
  2. Develop both pharmacological and non-pharmacological strategies to manage constipation in children. Non-pharmacological methods are extremely important, and giving parents written plans with advice is helpful as there is a lot of information to remember. Going through the handout together with the parents in the consultation room is another useful strategy.
  3. Understand how to manage diarrhoea in children, including how to manage it at home, when to refer to non-GP specialists or hospital, and ‘time out’ guidelines (for childcare and school).
  4. Ensure your practice has an adequate recall and reminder system for investigating bowel cancer. Remember, although uncommon, bowel cancer can affect young people and so a diagnosis of colorectal cancer should be considered in all patients with persistent iron deficiency or ongoing unexplained symptoms. The faecal occult blood test (FOBT) is a screening tool for asymptomatic patients, not for symptomatic patients. If a patient is symptomatic, they should be referred straight to the gold standard diagnostic investigation.
  5. Consider screening for coeliac disease in patients who present with persistent, unexplained gastrointestinal symptoms.

Instructions

  1. Read this example of a common case consultation for this unit in general practice.
  2. Thinking about the case example, reflect on and answer the questions in the table below.

You can do this either on your own or with a study partner or supervisor.

The questions in the table below are ordered according to the RACGP clinical exam assessment areas and domains, to prompt you to think about different aspects of the case example.

Note that these are examples only of questions that may be asked in your assessments.

Extension exercise: Create your own questions or develop a new case to further your learning.

Gastrointestinal health

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.

Questions for you to consider Clinical exam assessment area Domains

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?
  1. Communication and consultation skills
 1,2,5

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?
  1. Clinical information gathering and interpretation
 2   

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?  
  1. Making a diagnosis, decision making and reasoning
 2   

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?
  1. Clinical management and therapeutic reasoning
 2   

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?
  1. Preventive and population health 
 1,2,3

How would you respond if Michael refused to have his rectal bleeding investigated?
  1. Professionalism
 4   

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?
  1. General practice systems and regulatory requirement
 5   

How do you explain to Michael how to take a rectal swab to exclude rectal infections/STIs?
  1. Procedural skills
 2   

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?
  1. Managing uncertainty
 2   

What are the acute gastrointestinal conditions that must not be missed in this presentation?

When would you send Michael directly to hospital?
  1. Identifying and managing the significantly ill patient
 2

Instructions

This section has some suggestions for how you can learn this unit. These learning suggestions will help you apply your knowledge to your clinical practice and build your skills and confidence in all of the broader competencies required of a GP.

There are suggestions for activities to do:

  • on your own
  • with a supervisor or other colleague
  • in a small group
  • with a non-medical person, such as a friend or family member.

Within each learning strategy is a hint about how to self-evaluate your learning in this core unit.

On your own

Review the literature to identify the common causes of nausea.

  • Compare this with patients you have seen in practice with nausea symptoms.
  • Reflect on your assessment and investigation approach to a patient with nausea. Are there any causes you have not previously considered?

Review a case of a child with chronic diarrhoea.

  • What is your current management plan?
  • Compare your management plan to the guidelines and reflect on any differences. If there are differences, what is the reason, and is there anything that could be changed?
  • What monitoring or follow-up has been arranged? Are there any lifestyle factors to consider?
With a supervisor

Review a case of a patient with acute abdominal pain.

  • Create a differential diagnosis list that includes ‘not to be missed’ diagnoses and red flags.
  • What did you think was the most likely cause of the symptoms? What investigations were completed for this patient? What additional investigations, if any, would you consider?
  • How would you manage this patient? What suggestions does your supervisor have? Do they have any tips for managing this type of presentation?

Present a teaching session that discusses the impact of geographical location on how patients with acute pancreatitis are managed, including access to non-GP specialist services and investigations.

  • Consider rural and remote areas and the difference there may be in accessing timely investigations and healthcare.
  • Consider patients who are away from their own home or community (eg refugees or Aboriginal and Torres Strait Islander people).
  • Reflect on the session and ask your supervisor for feedback.
In a small group

Role-play how you might sensitively inform a patient about a bowel cancer diagnosis.

  • How did you go? How did the ‘patient’ feel, and how well did they understand the discussion? Get feedback from the group.
  • How can you explain medical terminology in simple terms so the patient can understand?
  • Consider role-playing other challenging scenarios, such as a diagnosis of irritable bowel syndrome or chronic abdominal pain due to anxiety.

Role-play explaining to a patient or a patient’s family (if the patient is a child) the treatment guidelines for chronic gastrointestinal conditions (eg coeliac disease, Crohn’s disease, ulcerative colitis, fatty liver).

  • How did you go? How well did the ‘patient’ understand? Get feedback from the group.
  • Does the group have other ideas for how to approach explaining this condition?
  • Role-play the same scenario again but using some of these different approaches. Change the scenario to a patient from a culturally and linguistically diverse background, or a child with special needs.
With a friend or family member

Discuss bowel cancer screening with a family member or friend.

  • Have they done the bowel cancer screening test? Did they find it difficult? What would they have liked to know about it? What made them complete the test?
  • If they haven’t done the test, explain to them what is involved. If they are under the age of 50, would they consider doing this test once they reach 50?

Talk with a family member or friend about their experience with a child with constipation. It may be someone they know of, rather than their own experience.

  • How did they address the constipation? What did they find helpful? Where did they find information? Did they have any unmet needs?
  • What did you learn that you can apply to your practice?

Instructions

These are examples of topic areas for this unit that can be used to help guide your study.

Note that this is not a complete or exhaustive list, but rather a starting point for your learning.

  • Diagnose, investigate appropriately, and manage emergency gastrointestinal presentations in both children and adults:
    • gastroenteritis causing dehydration in infants/children
    • acute bowel obstruction
    • appendicitis
    • ischaemic bowel
    • intussusception
    • irreducible hernia
    • swallowed foreign body
    • acute gastrointestinal bleeding
    • acute cholecystitis
    • acute hepatitis
    • acute liver failure
    • acute pancreatitis
    • peritonitis.
  • Diagnose, investigate appropriately and manage dysphagia, epigastric pain and reflux symptoms due to:
    • gastro-oesophageal reflux disease (GORD)
    • eosinophilic oesophagitis
    • oesophageal stricture
    • oesophageal achalasia
    • oesophageal spasm
    • oesophageal cancer
    • ulcers – gastric, duodenal, Helicobacter pylori.
    • gastric adenocarcinoma.
  • Understand the approach to altered bowel habits caused by:
    • irritable bowel syndrome
    • diarrhoea
    • toddler’s diarrhoea
    • viral gastroenteritis
    • bacterial gastroenteritis
    • giardiasis
    • traveller’s diarrhoea
    • worms and parasitic infection
    • constipation
    • faecal incontinence
    • malabsorption syndromes
    • coeliac disease
    • fructose and lactose intolerance
    • food intolerance
    • food allergy
    • short bowel syndrome
    • Hirschsprung’s disease
    • bariatric surgery
    • long term PPI use.
  • Understand the approach to rectal bleeding caused by:
    • bowel cancer
    • inflammatory bowel disease
    • Crohn’s disease
    • ulcerative colitis
    • haemorrhoids
    • fissures.
  • Diagnose, investigate appropriately and manage upper abdominal pain symptoms due to:
    • chronic liver disease
    • hepatitis B and C
    • fatty liver
    • alcoholic liver disease
    • liver cirrhosis
    • primary biliary cirrhosis
    • portal hypertension
    • cholelithiasis
    • pancreatic malignancy
    • pyloric stenosis.
  • Diagnose, investigate appropriately and manage lower abdominal pain symptoms due to:
    • diverticular disease
    • diverticulitis
    • bowel cancer
    • sigmoid volvulus.
  • Understand the approach to discomfort in the rectum caused by:
    • skin tags
    • thrombosed haemorrhoid
    • anal abscess
    • anal pruritus
    • rectal prolapse
    • rectal cancer
    • pilonidal sinus.
  • Understand the approach to lumps in the groin caused by:
    • direct and indirect inguinal hernia
    • femoral hernia
    • incisional hernia.

Instructions

The following list of resources is provided as a starting point to help guide your learning only and is not an exhaustive list of all resources. It is your responsibility as an independent learner to identify further resources suited to your learning needs, and to ensure that you refer to the most up-to-date guidelines on a particular topic area, noting that any assessments will utilise current guidelines.

Journal articles
‌An explanation of the risks and benefits of colonoscopy. Advice on how to investigate and interpret results for coeliac disease. ‌A summary of the approach to treating chronic hepatitis C patients in general practice.
Online resources
Great overview of GORD. With management separated into severity, and a section on managing GORD in children. An in-depth outline of non-alcoholic fatty liver disease. ‌An online tool to assist in appropriately assessing, diagnosing and treating persistent non-specific lower gastrointestinal symptoms.
  • Gastroenterological Society of Australia. IBS4GPs.
This chapter in the Red book gives a succinct explanation of guidelines for screening for colorectal cancer. ‌Comprehensive clinical practice guidelines for managing children with constipation.
Learning activities
‌eLearning activities on gastrointestinal conditions and disorders.
  • The Royal Australian College of General Practitioners. gplearning:
    • check, unit 556, December 2018: Digestive 
    • check, unit 564, September 2019: Liver 
    • Gastrointestinal conditions MCQs
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Printed from the RACGP website at https://www.racgp.org.au/education/education-providers/curriculum/curriculum-and-syllabus/units/gastrointestinal-health 13/10/2024