23 Dec 2025
The 12 Days of Gut-mas
Based on a popular well known Christmas carol this episode reminds us about prescribing thoughtfully, recognising key red flags, and keeping often-missed diagnoses like bile acid diarrhoea, coeliac disease and liver disease on the radar. The episode also reinforces the importance of early-life microbiome influences and structured differential diagnosis for abdominal symptoms in primary care.
Prescribing and de-prescribing
• Taper PPIs rather than stopping abruptly to avoid rebound acid hypersecretion, driven by upregulated gastrin during PPI therapy.
• Always link NSAID use and H. pylori status to ulcer risk, and remember: gastric ulcers typically cause pain with meals, duodenal ulcers 2–3 hours after eating.
Diagnosis, tests and red flags
• Use three coeliac test “groups”: serology (tTG/EMA, with total IgA checked), genetics (HLA‑DQ2/DQ8) and duodenal biopsies; ensure patients eat gluten for at least six weeks pre‑testing and to endoscopy.
• Actively screen for GI red flags: dysphagia and weight loss (upper GI), PR bleeding and unexplained iron‑deficiency anaemia (lower GI), and escalate for urgent investigation.
Practical tools and endoscopy indications
• Use the Bristol Stool Chart (types 1–7) routinely in consultations to standardise conversations about stool form and avoid ambiguous “food analogies.”
• Remember the three main indications for endoscopy: diagnostic (e.g. dyspepsia, chronic diarrhoea), surveillance (Barrett’s, polyp follow‑up) and therapeutic (RFA/EMR in Barrett’s, polyp removal).
Conditions to consider and not miss
• Keep bile acid diarrhoea prominent in the differential for IBS‑D: up to ~40% of IBS‑D patients may have it, particularly with ileal disease/resection, Crohn’s, or post‑cholecystectomy.
• Maintain a broad GI bleeding differential beyond cancer (e.g. gastritis, peptic ulcer, Mallory–Weiss tear, haemorrhoids/fissures, liver disease/coagulopathy, IBD, angiodysplasia, diverticular disease).
Liver disease, microbiome and early life
• Remember major causes of liver failure in primary care: excess alcohol, paracetamol overdose, DILI, autoimmune hepatitis, Wilson’s disease, haemochromatosis, viral hepatitis B/C and progressive MASLD.
• Support breastfeeding where possible to promote a healthy infant microbiome (HMOs favouring bifidobacteria) and recognise how birth mode and early microbes shape immune development and later allergy/immune risk.
Structuring abdominal symptom assessment
• For undifferentiated abdominal symptoms, consciously work through a core list: IBS, lactose intolerance, coeliac disease, gastroenteritis, SIBO, IBD, diverticular disease, colorectal cancer, peptic ulcer disease, gallstones/biliary colic, pancreatic insufficiency and medication‑related causes (e.g. metformin, NSAIDs, antibiotics).
• Use these categories to guide targeted history, examination, basic tests and thresholds for referral back to gastroenterology or specialist services.
