FNP gastroenterology: GERD, IBD, liver disease, and GI management in primary care

Alarm symptoms requiring urgent evaluation (endoscopy): Dysphagia, odynophagia, unintentional weight loss, vomiting blood (haematemesis), melena, iron-deficiency anaemia, age >45 with new symptoms, palpable epigastric mass.

Stepwise treatment:

• Step 1: Lifestyle modifications (HOB elevation, weight loss, avoid triggers — fatty food, alcohol, caffeine, late meals, mint, chocolate, smoking cessation)
• Step 2: H2 receptor antagonists (famotidine) for mild/intermittent symptoms
• Step 3: PPIs (omeprazole, pantoprazole) for frequent or moderate GERD — most effective for erosive esophagitis. Take 30–60 minutes before first meal of day.
• Step 4: Refer gastroenterology for refractory GERD, Barrett's surveillance, or surgical evaluation (Nissen fundoplication)

Barrett's esophagus surveillance: After GERD for ≥5 years, especially in White males ≥50 with BMI ≥30, smoking history, central obesity. Endoscopy screening if multiple risk factors. Dysplasia-free Barrett's: endoscopy every 3–5 years.

Rome IV criteria for IBS: Recurrent abdominal pain ≥1 day/week for 3 months (onset ≥6 months ago) related to ≥2 of: (1) defecation, (2) change in stool frequency, or (3) change in stool form/appearance. Subtypes: IBS-C (constipation), IBS-D (diarrhoea), IBS-M (mixed), IBS-U (unclassified).

Management: IBS-C: increased fibre, osmotic laxatives (polyethylene glycol), lubiprostone, linaclotide. IBS-D: loperamide for immediate relief, rifaximin (antibiotic for non-constipation IBS), eluxadoline, tricyclics (amitriptyline low-dose), alosetron (5-HT3 for women with severe IBS-D). All types: low-FODMAP diet, stress management, cognitive-behavioural therapy. Rule out celiac disease (anti-tTG IgA + total IgA) and IBD before diagnosing IBS.

Key distinction for FNP exams:

• Ulcerative colitis: limited to colon, continuous mucosal inflammation starting at rectum, bloody diarrhoea, rectal urgency, elevated risk of CRC after 8–10 years, colectomy is curative
• Crohn disease: any segment GI tract (mouth to anus), transmural inflammation, skip lesions, fistulae/strictures/abscesses, granulomas on biopsy, not curable surgically

Medical management hierarchy: 5-aminosalicylates (mesalamine) for mild-moderate UC. Corticosteroids for acute flares. Immunomodulators (azathioprine, 6-MP). Biologics for moderate-severe: anti-TNF (infliximab, adalimumab), anti-integrin (vedolizumab), anti-IL-12/23 (ustekinumab), JAK inhibitors (upadacitinib). Monitor for infection, TB reactivation, lymphoma risk with immunosuppressants.

CRC surveillance in UC: Begin colonoscopy at 8 years of pancolitis or 12–15 years of left-sided colitis; every 1–3 years thereafter based on dysplasia risk.

USPSTF 2021 recommendations: Begin CRC screening at age 45 (lowered from 50 — B recommendation for 45–49; A recommendation for 50–75). Continue through age 75. For age 76–85: individualised decision (C recommendation). Stop screening after 85 (D recommendation).

Acceptable screening tests (FNP prescribing): Annual high-sensitivity stool-based tests (FIT or gFOBT), stool DNA test (Cologuard) every 1–3 years, colonoscopy every 10 years, CT colonography every 5 years, flexible sigmoidoscopy every 5 years. Any positive non-colonoscopy test requires diagnostic colonoscopy follow-up (not repeat stool test).