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Important GIT OPD Cases for MD Medicine

Clinical Features | Investigations | Management with Dosage & Brand Names

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1. GASTROESOPHAGEAL REFLUX DISEASE (GERD)

Clinical Features

• Classic symptoms: Heartburn (pyrosis) - burning retrosternal pain, worse after meals, on bending, lying flat
• Regurgitation of sour/bitter material
• Waterbrash (excessive salivation)
• Dysphagia (if stricture develops - alarm symptom)
• Nocturnal cough, hoarseness, laryngitis (extra-esophageal manifestations)
• Dental enamel erosion (palatal surfaces of maxillary teeth)
• Worsened by: obesity (BMI >30 has OR 1.94), large meals, spicy/fatty food, alcohol, caffeine, pregnancy
• Complications: erosive esophagitis, Barrett's esophagus, esophageal adenocarcinoma

Investigations

1. Clinical diagnosis in typical cases - no testing initially required
2. Upper GI endoscopy (OGD): First-line for alarm features (dysphagia, weight loss, anemia, hematemesis); to diagnose esophagitis, Barrett's, stricture
3. 24-hour pH monitoring: Gold standard for diagnosis - confirms acid exposure time
4. Esophageal manometry: If surgical treatment planned, to assess LES pressure and motility
5. Barium swallow: Only if endoscopy unavailable; shows reflux, hiatus hernia
6. H. pylori testing (urea breath test or stool antigen): Rule out co-existing infection

Management

• Weight loss (most important - OR reduction proven)
• Head-of-bed elevation (15-20 cm)
• Avoid eating 2-3 hours before bed
• Avoid triggers: spicy food, fatty food, alcohol, coffee, mint, chocolate
• Small frequent meals
• Smoking cessation

• Acute healing: 4-8 weeks
• Maintenance (chronic GERD): long-term PPI; step-down to H2RA if possible
• Surgical: Laparoscopic Nissen fundoplication for failed medical therapy or large hiatus hernia

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2. PEPTIC ULCER DISEASE (PUD)

Clinical Features

• Duodenal ulcer (DU - most common):
  • Epigastric pain - burning/gnawing, relieved by food and antacids
  • Hunger pain, nocturnal pain (wakes patient at 2-3 AM)
  • H. pylori present in ~90% DU
• Gastric ulcer (GU):
  • Epigastric pain - worsened by food
  • Nausea, early satiety, weight loss
  • H. pylori in ~70% GU; NSAIDs in most others
• Alarm features: hematemesis, melena, dysphagia, weight loss, vomiting, family history of gastric cancer
• Complications: bleeding (most common), perforation, gastric outlet obstruction, malignant transformation (GU only)

Investigations

1. OGD (upper endoscopy): DEFINITIVE test - visualizes ulcer, site, size; biopsy from gastric ulcer (to exclude malignancy - 6-8 biopsies from margins and base)
2. H. pylori testing:
   • Urea Breath Test (UBT): Non-invasive, most accurate; sensitivity/specificity >95%
   • Stool antigen test: Accurate, non-invasive, useful for post-treatment testing
   • Rapid urease test (CLO test): Done on endoscopic biopsy
   • Serology (IgG): Low specificity; cannot distinguish active from past infection - NOT for post-treatment confirmation
3. Barium meal: If endoscopy unavailable; shows ulcer crater
4. CBC: Anemia if chronic blood loss
5. Serum gastrin: If Zollinger-Ellison syndrome suspected (multiple/refractory ulcers)
6. CXR/CT abdomen: If perforation suspected (pneumoperitoneum)

Management

• Stop NSAID if possible
• PPI: Pantoprazole 40 mg OD for 4-8 weeks (duodenal), 8-12 weeks (gastric)
• If NSAID must be continued: add Misoprostol 200 mcg QID (Cytotec) or PPI

• Magaldrate (Aldrox) or Aluminium hydroxide + Mg hydroxide (Gelusil, Digene) - 1-2 tsp after meals and at bedtime

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3. IRRITABLE BOWEL SYNDROME (IBS)

Clinical Features (Rome IV Criteria)

• Recurrent abdominal pain, at least 1 day/week for 3 months, associated with 2 or more:
  • Related to defecation
  • Change in stool frequency
  • Change in stool form/appearance
• IBS-D (diarrhea-predominant): Loose/watery stools, urgency, >3 bowel movements/day
• IBS-C (constipation-predominant): Hard/lumpy stools, straining, <3 bowel movements/week
• IBS-M (mixed): Alternating diarrhea and constipation
• Bloating, abdominal distension, mucus in stool
• Worsened by stress, food; relieved by defecation
• NO alarm features (no blood, no nocturnal symptoms, no weight loss, no fever)
• Female predominance; onset typically <45 years

Investigations

1. CBC: Rule out anemia, eosinophilia
2. ESR/CRP: If elevated, suggests IBD - not IBS
3. Stool exam + culture: Rule out infection, parasites (Giardia, amoeba)
4. Stool calprotectin: If elevated >50 mcg/g, suggests IBD; <50 = IBS more likely
5. TSH: Rule out thyroid disease
6. Celiac serology (anti-tTG IgA): Rule out celiac disease
7. Colonoscopy: If >45 years, alarm features present, or abnormal lab findings

Management

• Reassurance and explanation of functional nature
• Low FODMAP diet (reduces fermentable carbohydrates)
• Fiber supplementation for IBS-C: Ispaghula (Isabgol) - 1 tsp in water BD
• Regular exercise, stress management, cognitive behavioral therapy (CBT)
• Avoid caffeine, alcohol, fizzy drinks

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4. INFLAMMATORY BOWEL DISEASE (IBD)

4A. ULCERATIVE COLITIS (UC)

• Bloody diarrhea with mucus (cardinal symptom)
• Tenesmus (feeling of incomplete evacuation), urgency
• Lower abdominal crampy pain, relieved by defecation
• Systemic: fever, weight loss, anemia (in severe disease)
• Extra-intestinal: uveitis, episcleritis, aphthous ulcers, erythema nodosum, pyoderma gangrenosum, primary sclerosing cholangitis, ankylosing spondylitis
• Truelove and Witts criteria - mild/moderate/severe classification
• Toxic megacolon - emergency complication

1. Stool exam and culture: Rule out infection (C. difficile, Salmonella, Shigella, Campylobacter)
2. CBC: Anemia (iron deficiency), leukocytosis in severe disease
3. CRP/ESR: Elevated in active disease
4. Serum albumin: Low in severe disease
5. Colonoscopy with biopsies (GOLD STANDARD): Continuous inflammation from rectum upwards; mucosal biopsies; NEVER do full colonoscopy in acute severe UC (risk of perforation) - use flexible sigmoidoscopy instead
6. Stool calprotectin: Useful for monitoring disease activity
7. Plain AXR: If toxic megacolon suspected (colon >6 cm = dilation)
8. MRI enterography: For assessing extent and complications

4B. CROHN'S DISEASE (CD)

• Abdominal pain (RIF - ileocecal most common), diarrhea (non-bloody unless colonic)
• Weight loss, malnutrition, fatigue
• Perianal disease: fistulae, fissures, skin tags, abscesses
• Skip lesions (discontinuous involvement)
• Cobblestone mucosa, transmural inflammation
• Strictures, fistulae, abscesses as complications
• Extra-intestinal: same as UC
• String sign of Kantor on barium follow-through

• MRI enterography (best for small bowel disease and fistulae)
• CT scan abdomen: abscesses, obstruction
• Capsule endoscopy (if small bowel involvement suspected)
• ASCA positive (anti-Saccharomyces cerevisiae antibody) in ~60% CD
• pANCA positive in UC

• Mild CD: Budesonide 9 mg OD (ileocecal disease), mesalamine (limited efficacy)
• Moderate-severe: Prednisolone 40-60 mg/day + immunomodulators (azathioprine/methotrexate)
• Methotrexate (CD only, not UC): 25 mg IM weekly for induction; 15 mg weekly maintenance (Folitrax, Methofar) - give folic acid 5 mg/day
• Biologics: Same as UC; Ustekinumab (IL-12/23 inhibitor) also approved - 520 mg IV single dose, then 90 mg SC every 8 weeks (Stelara)

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5. ACUTE VIRAL HEPATITIS

Clinical Features

• Prodromal phase (1-2 weeks): Fever, malaise, anorexia, nausea, vomiting, myalgia, right hypochondrial discomfort, aversion to smoking
• Icteric phase: Jaundice (yellow skin + sclera), dark urine (tea-colored), pale stools (clay-colored), pruritus, hepatomegaly (tender)
• Recovery phase: Gradual resolution over weeks
• Hepatitis A and E: Feco-oral transmission, self-limiting
• Hepatitis B, C, D: Parenteral/sexual transmission; risk of chronicity
• Hepatitis E in pregnancy - severe, mortality up to 20%

Investigations

1. LFTs: Elevated ALT/AST (>10x normal), raised bilirubin (direct + indirect), ALP mildly raised
2. Viral serology:
   • Hep A: Anti-HAV IgM (acute), IgG (immunity)
   • Hep B: HBsAg (current infection), Anti-HBc IgM (acute), HBeAg, HBV DNA
   • Hep C: Anti-HCV antibody (screening), HCV RNA (confirmatory)
   • Hep E: Anti-HEV IgM
3. PT/INR: Marker of synthetic function; prolonged PT = severe hepatitis
4. CBC: Lymphocytosis (viral); leukocytosis suggests bacterial
5. Serum albumin: Low in severe disease
6. Blood glucose: Hypoglycemia in fulminant hepatitis
7. Ultrasound abdomen: Rule out biliary obstruction; assess liver echogenicity, splenomegaly

Management

• Bed rest during symptomatic phase
• Adequate hydration and nutrition (high carbohydrate diet)
• Avoid hepatotoxic drugs (paracetamol, alcohol, statins)
• Hepatitis A/E: No antivirals; supportive care only
• Hepatitis B (acute): Usually self-limiting; antivirals only if severe (PT >50% normal, bilirubin >10 mg/dL):
  • Tenofovir (TDF) 300 mg OD (Tenvir, Viread) OR Entecavir 0.5 mg OD (Baraclude, Entehep)
• Hepatitis C (acute): Treat to prevent chronicity:
  • Sofosbuvir 400 mg + Ledipasvir 90 mg (Sofosvel, Hepcinat) OD x 12 weeks
  • Or Sofosbuvir + Velpatasvir (Velasof, Sovaldi) OD x 12 weeks
• Symptomatic:
  • Antiemetic: Ondansetron 4-8 mg TDS (Emeset, Zofran)
  • Pruritus: Cholestyramine 4 g sachet BD (Questran) or Hydroxyzine 25 mg HS (Atarax)
  • Vitamin K (if coagulopathy): 10 mg IV daily x 3 days

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6. CHRONIC LIVER DISEASE (CLD) / CIRRHOSIS

Clinical Features

• Jaundice, ascites (abdominal distension, shifting dullness, fluid thrill)
• Pedal edema
• Hematemesis/melena (from esophageal varices)
• Encephalopathy (confusion, asterixis/flapping tremor, drowsiness)
• Splenomegaly (portal hypertension)
• Signs of liver cell failure: spider naevi (>5), palmar erythema, leukonychia, Dupuytren's contracture, gynecomastia, testicular atrophy, caput medusae, fetor hepaticus

Investigations

1. LFTs: Elevated bilirubin, low albumin, raised PT (Child-Pugh score)
2. CBC: Thrombocytopenia (hypersplenism), anemia
3. Serum electrolytes: Hyponatremia (dilutional)
4. Renal function: Creatinine (rule out hepatorenal syndrome)
5. Coagulation: PT/INR (marker of prognosis)
6. USG abdomen + Doppler: Liver echogenicity, size, ascites, splenomegaly, portal vein diameter (>13 mm = portal hypertension), hepatic vein flow
7. Endoscopy (OGD): Esophageal/gastric varices grading
8. Liver stiffness (FibroScan/Fibroscan): Non-invasive fibrosis assessment
9. Liver biopsy: Definitive (if etiology unclear or NASH staging needed)
10. AFP: Screen for hepatocellular carcinoma (every 6 months)
11. Ascitic fluid analysis: Diagnostic tap - cell count, SAAG (>1.1 = portal hypertension), culture, protein, cytology

Management

• Salt restriction (<2 g/day sodium)
• Spironolactone 100-400 mg/day (Aldactone, Spiromide) - first-line diuretic for ascites
• Furosemide 40-160 mg/day (Lasix) - add-on; ratio 100:40 with spironolactone
• Therapeutic paracentesis for tense ascites + albumin infusion (8 g per liter drained; Albuject 20%)
• Terlipressin (hepatorenal syndrome): 1-2 mg IV bolus every 4-6 hours (Glypressin)

• Diagnose: Ascitic PMN >250 cells/mm³
• Treatment: Cefotaxime 2 g IV TDS x 5 days (Claforan) OR Piperacillin-tazobactam
• Prophylaxis: Norfloxacin 400 mg OD (Norflox) long-term for secondary prevention
• Albumin: 1.5 g/kg IV on day 1, then 1 g/kg on day 3 (prevents HRS)

• Terlipressin 2 mg IV stat (Glypressin) - vasoconstrictor
• Emergency OGD: Band ligation (EVL) first-line; sclerotherapy alternative
• Somatostatin/Octreotide: 50 mcg IV bolus then 50 mcg/hr infusion (Sandostatin)
• Propranolol (primary/secondary prophylaxis of varices): 20-40 mg BD, titrate to reduce HR by 25% (Inderal, Ciplar)
• Carvedilol: 6.25-12.5 mg OD (Cardivas) - alternative

• Identify and treat precipitant (infection, GI bleed, constipation, drugs)
• Lactulose 30-60 mL TDS/QID (Duphalac, Looz) - to achieve 2-3 loose stools/day
• Rifaximin 550 mg BD (Xifaxan) - adjunct, reduces recurrence
• Low protein diet (transient; avoid prolonged protein restriction)

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7. ACUTE PANCREATITIS

Clinical Features

• Sudden onset severe epigastric pain radiating to back (boring/girdle pain)
• Nausea, vomiting (does NOT relieve pain)
• Abdominal tenderness, guarding
• Fever in infected necrosis
• Causes: Gallstones (most common), alcohol, drugs, hypertriglyceridemia, trauma (MIGET mnemonic)
• Cullen's sign: Periumbilical bruising (retroperitoneal bleed)
• Grey-Turner's sign: Flank bruising (hemorrhagic pancreatitis)

Investigations

1. Serum amylase: Elevated >3x normal (rises in 2-12 hrs, normalizes in 3-5 days)
2. Serum lipase: More specific and sensitive; stays elevated longer (preferred over amylase)
3. CBC: Leukocytosis, hemoconcentration (high Hct = severe)
4. LFTs + bilirubin: If gallstone pancreatitis
5. Serum calcium: Hypocalcemia (sign of severity)
6. Serum triglycerides: If no obvious cause
7. Blood glucose: Hyperglycemia
8. BUN/Creatinine: Renal failure
9. USG abdomen: Gallstones, bile duct dilation, pancreatic edema
10. CECT abdomen (CT severity index - Balthazar score): After 48-72 hours; gold standard for severity, necrosis, abscess, pseudocyst
11. MRCP: If choledocholithiasis suspected without biliary dilation on USG

Management

• Nil by mouth initially, then early oral feeding as tolerated (within 24-48 hrs if tolerated)
• IV fluids: Aggressive fluid resuscitation - Ringer's Lactate 250-500 mL/hr in initial phase (preferred over normal saline)
• Analgesia (critical):
  • Tramadol 50-100 mg IV/IM TDS (Tramazac, Tramadol)
  • Diclofenac 75 mg IM BD (Voveran)
  • Patient-controlled analgesia in severe cases
  • Avoid morphine (theoretical spasm of Sphincter of Oddi - though largely refuted)
• Antiemetics: Ondansetron 4-8 mg IV TDS (Emeset)

• ICU admission
• Nasojejunal tube feeding (enteral nutrition preferred over TPN)
• Antibiotics ONLY if infected necrosis (avoid prophylactic antibiotics): Imipenem 500 mg IV TDS (Tienam) or Meropenem 1 g IV TDS (Merrem)
• ERCP within 72 hrs: If gallstone pancreatitis with cholangitis or persisting biliary obstruction
• Surgical/Endoscopic/Radiological intervention: For infected necrosis (step-up approach: percutaneous drainage first, then minimally invasive necrosectomy)

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8. GASTROENTERITIS / ACUTE DIARRHEA

Clinical Features

• Acute onset loose/watery stools (>3/day), nausea, vomiting
• Abdominal cramps
• Fever (in invasive bacterial causes)
• Blood/mucus in stool = dysentery (Shigella, Salmonella, Campylobacter, E. coli O157:H7, Entamoeba)
• Signs of dehydration: dry mouth, sunken eyes, decreased skin turgor, reduced urine output, tachycardia

Investigations

1. Stool routine/microscopy: Pus cells, RBCs, trophozoites/cysts
2. Stool culture and sensitivity: If bloody diarrhea, prolonged illness, immunocompromised
3. CBC: Leukocytosis (bacterial), eosinophilia (parasites)
4. Serum electrolytes + RFT: Hypokalemia, hyponatremia, uremia
5. Blood culture: If sepsis suspected
6. Clostridium difficile toxin assay: If recent antibiotics

Management

• Mild: ORS (WHO formula) - 200 mL after each loose stool (Electral, Pedialyte)
• Moderate-severe: IV Ringer's Lactate or Normal Saline

• Loperamide 2 mg after loose stool (max 16 mg/day) - avoid in dysentery/bloody diarrhea (Imodium)

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9. CELIAC DISEASE

Clinical Features

• Chronic diarrhea, steatorrhea (bulky, pale, foul-smelling, floats)
• Abdominal bloating, distension, crampy pain
• Weight loss, failure to thrive (children)
• Malabsorption: iron deficiency anemia, folate deficiency, vitamin D deficiency (osteoporosis), B12 deficiency
• Dermatitis herpetiformis (intensely pruritic vesicular rash over elbows, knees, buttocks)
• Aphthous ulcers, hair loss, infertility, short stature

Investigations

1. Anti-tissue transglutaminase (anti-tTG) IgA: Most sensitive and specific (>95%) - first-line test
2. Anti-endomysial antibody (EMA IgA): Very specific
3. Total serum IgA: Must check (if IgA deficient, false-negative tTG - use IgG-based tests)
4. Small bowel biopsy (via OGD + duodenal biopsy): Gold standard - villous atrophy, crypt hyperplasia, increased intraepithelial lymphocytes (Marsh classification Grade 3)
5. HLA typing: HLA-DQ2 (90%) / HLA-DQ8 (10%) - negative result rules out celiac
6. CBC, iron studies, folate, B12, vitamin D, calcium, PTH
7. DEXA scan: For bone density (osteoporosis assessment)

Management

• Strict lifelong Gluten-Free Diet (GFD): Avoid wheat, rye, barley (BROW mnemonic: Barley, Rye, Oats [contaminated], Wheat) - oats safe if certified gluten-free
• Nutritional supplementation:
  • Iron: Ferrous sulfate 200 mg TDS (Ferro-Grad, Fefol)
  • Folic acid: 5 mg OD (Folvite)
  • Vitamin D: 60,000 IU once weekly x 8 weeks, then monthly (Arachitol, D3 Must)
  • Calcium: 1000-1500 mg/day (Shelcal, Calcimax)
  • B12: Methylcobalamin 1500 mcg OD or IM if severe (Methylcobal, Nurokind)
• Refractory celiac: Budesonide 9 mg OD or Azathioprine; refer to gastroenterologist

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QUICK REFERENCE SUMMARY TABLE

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