What is MASLD
Metabolic dysfunction associated steototic liver disease
-1 in 3 adults
- fatty infiltration of the liver + one cardiovascular risk factor
-perform FIB4 for assessment of fibrosis or elastography
-tx lifestyle, management of risk factors, some drug tx
Dx MASLD
Raised ALT or imaging suggestive
Bmj article suggest ALT cut off 33 men and 25 women- 2 tests 4 weeks apart
-bmi >25
- waist circumference increased
-prediabetes, t2 DM
Raised triglycerides or low HDL
Bp raised
Review alcohol consumption
Rule out other causes of liver disease
IBS
Gut brain axis
-tx of anxiety stress/ CBT
-diet low FODMAP
-low dose amitriptyline
MASLD- lifestyle
Aim >5% weight loss if overweight
-physical activity 150 mins
-healthy diet
-Alcohol aim for abstinence
-coffee- caffeine and non caffeine protective effect
-smoking increased risk HCC
- drugs..GLP-1
Bariatric surgery
Monitoring
-annual cardiovascular disease review
- 3 yearly fibrosis blood FIb4 if low risk on earlier bloods
Fib 4 levels
<1.3 - low level fibrosis repeat every1-3 yr
1.3-2.67 fibriscan
In Lothian patient >65 yrs USS
Dyspepsia red flag
Weight loss
Dysphagia
Vomiting blood
Early satiety
Dyspepsia questions
Pain
Heartburn
Red flags- weight loss, dysphagia, early satiety, haematemesus
Bloating
Previous h pylori
Response to antiacid
Triggers
Alcohol
Smoke
Stress.
Drugs NSAIDs, bisphosphonates, calcium channel blockers
Dyspepsia tx
Lifestyle- no smoke alcohol
Avoid triggers- spicy food eating late at night
Stress reduction
Weight loss (5% or more of body weight or strong clinical suspicion) in a person aged 55 years or over with any of the following:
upper abdominal pain
early satiety
reflux
dyspepsia
nausea and/or vomiting
Medication
Anti-acid gaviscon
PPI
h.pylori screen no PPI for 2 weeks
PR bleeding
When did it start
What colour fresh red/ dark
On wipe mixed in
Change in vowels
Pain of defaecation
Weight loss
FH iBD or colorectal cancer
Attend for screening
Mucus
Infective symptoms- fever
Abdo pain
Foreign travel
?IBD -skin changes joint/eye
Social smoker, alcohol,
Medication- cause constipation, cox2
Investigation
Obs exam, pr,
Bloods-FBC, Ferritin, U+e, lfts clot
Weight
FIT
Facal calprotectin
Refer usoc
- rectal mass
-iron deficiency anaemia and raised FIT
-Abdominal mass
-unexplained anal ulceration
Who to FIT test
-Repeat PR bleeding and no obvious local source
-Blood mixed in with stool
-iron deficiency anaemia anaemia ferritin <30
-Persistant Abdo pain > 4 wks with weight loss > 5%
Anaemia
IDA
B12/folate
Chronic disease
Myeloproliferative
Ask about intake- vegan
Absorption
Loss- urine- dipstix
Menstruation
PR/ GI
Symptoms
-tired
-sob
-dizzy
-headaches
Chest pain palpitations
Pallor
Weight loss
Change in bowels
Bruising- haem problem
Bone pain- myeloma
Vomiting abdo pain
Dyspepsia
Dysphagia
Medication- NSAIDs
PMH - bypass surgery
IDA investigation and tx
Ferritin <30
Transferrin >3.0
Bloods on fasting sample
Address diet/ periods
Ensure u&e
Coeliac screen
USoC referral
- NHS Lothian they will FIT test
- if age >50 years and ferritin low but not anaemic refer for investigations
Coeliac disease
Gluten allergy causing body to attack lining of gut can cause malabsorption of vitamins
1% population
Tx- gluten free diet
Symptoms:
-diarrhoea, vomiting, abdo pain, bloating, weight, tired (anaemia),
-PMH or FH autoimmune
Smoking alcohol etc
Ix- coeliac screen, need gluten pre-6 weeks
For unexplained GI symptoms, anaemia, weight loss or failure to thrive in kids, FH autoimmune, t1dm, IBS exclusion,
IgA tissue transglutaminase
And total IgA as deficiency can give false negatives
IBS symptoms
10-20% population
F 2x higher
Most common and 20-30
6 months +
ABC
Abdo pain -A- abdominal pain related to defacation
Constipation - c change in bowelz
Diarrhoea
Bloating -b
No red flags- refer all age >50
Red flags- PR bleeding, weight loss,nocturnal symptoms, FH ovarian/bowel, abdo/ rectal mass
Other investigation normal
IBS investigations
FBC, u&e, crp, tft
Coeliac screen
If <45 faecal calprotectin
If > -age Or red flags FIT
Women >40 years ca125 and USS
If nocturnal symptoms exclude bile acid malabsorption
IBS management
Advise and explanation- IBS videos
-diet
8 cups water
No fizzy drink coffee/tea
Regular meals
Exercise
Limit fresh fruit to 3/ day
-anti spasmodic - mebeverine peppermint oil
-laxative/ loperamide
2nd line
- low dose TCA amitriptyline starting 10mg titrate to 30mg
- s/e dry mouth, drowsiness
- take in evening
Linaclotide- specialist initiation
CBT
Can consider probiotic trial for 4 weeks. No strong evidence. Stop in no improvement.
If not improved after 12 months consider referral
