3.1 Hepatobiliary Disorders, Peptic Ulcers & Inflammatory Bowel Disease

Hepatobiliary Disorders, Peptic Ulcers and Inflammatory Bowel Disease

These topics appear in the SCFHS SMLE Medicine outline. Medicine overall carries 30% of the blueprint; the guide publishes no separate gastrointestinal subweight or disease-frequency ranking. The clinical guidance below is for exam learning. NICE guidance applies to its UK setting and ACG guidance to its specified populations; use current Saudi guidance, local protocols and patient circumstances in practice.

Hepatitis B Serology

CDC's diagnostic guidance uses HBsAg, anti-HBs and total anti-HBc together. Typical patterns are:

IgM anti-HBc supports acute infection but can also be positive in severe flares or reactivation of chronic HBV. Isolated total anti-HBc has several possible explanations, including resolved infection with waned surface antibody, occult infection or a false-positive result; do not assign one diagnosis from that pattern alone. These are serological patterns, not a complete antiviral-treatment decision.

Gallstone Disease

NICE CG188 recommends liver function tests and ultrasound for suspected gallstone disease. If ultrasound does not demonstrate a common-bile-duct stone but the duct is dilated and/or liver tests are abnormal, consider MRCP; EUS can help when MRCP is inconclusive. Interpret imaging with the clinical findings rather than treating one wall-thickness or duct-diameter cutoff as independently diagnostic.

For acute cholecystitis, NICE recommends early laparoscopic cholecystectomy within one week of diagnosis, subject to the person's clinical and surgical circumstances. For common-bile-duct stones, it recommends duct clearance and laparoscopic cholecystectomy; clearance may occur surgically or by ERCP before or during surgery. ERCP is therefore not automatically the procedure for every gallbladder-stone presentation.

NICE reserves percutaneous cholecystostomy for gallbladder empyema when surgery is contraindicated at presentation and conservative management is unsuccessful; surgery is reconsidered after recovery.

Acute Pancreatitis

The ACG 2024 guideline describes diagnosis using two of three: compatible abdominal pain, amylase and/or lipase greater than three times the upper limit of normal, or characteristic imaging. It discourages routine admission CT solely to assess severity; CT is reserved for diagnostic uncertainty or failure to improve after initial care.

ACG suggests moderately aggressive, reassessed isotonic crystalloid hydration, with lactated Ringer solution preferred over normal saline. Additional boluses depend on hypovolaemia. Cardiovascular or renal comorbidity requires caution, and patients need monitoring for volume overload. A fixed aggressive infusion rate is not appropriate for every patient.

For mild pancreatitis, ACG suggests early oral feeding as tolerated, usually within 24–48 hours. Enteral nutrition is preferred when more severe disease needs nutritional support; parenteral nutrition is reserved for circumstances in which enteral feeding is not possible, not tolerated or inadequate. Prophylactic antibiotics are not recommended for sterile necrosis; infected necrosis or another infection requires a separate treatment plan.

Peptic Ulcers and H. pylori

The Saudi H. pylori Working Group guideline recommends testing patients with newly diagnosed peptic ulcer disease and treating confirmed infection. The group does not recommend standard empiric clarithromycin triple therapy without antimicrobial-susceptibility testing, given resistance concerns. Its recommended bismuth quadruple approach lasts 10–14 days; regimen selection also depends on previous antibiotic exposure, allergy, availability and current specialist/local guidance.

The ACG 2024 adult guideline recommends an optimised 14-day bismuth quadruple regimen when appropriate and requires demonstrated clarithromycin susceptibility before using clarithromycin triple therapy. These durations are source-specific recommendations, not interchangeable universal Saudi rules. Bismuth quadruple therapy combines acid suppression, bismuth, tetracycline and metronidazole; check the prescribed regimen rather than substituting an antibiotic without guidance.

Confirm eradication rather than relying on symptom relief. Saudi Working Group guidance recommends testing at least four weeks after completing antibiotics and at least two weeks after stopping a PPI. Urea breath testing is preferred, with stool-antigen testing an alternative. Serology is unsuitable for confirming cure because antibodies may persist.

Gastric-Ulcer Biopsy

The BSG/AUGIS/RCPath 2025 adult endoscopy consensus recommends adequate sampling of gastric ulcers, including edge and base, when feasible, to assess for underlying malignancy. If bleeding risk prevents biopsy, it recommends early repeat endoscopy within two weeks. Biopsy results must be interpreted with the endoscopic findings and follow-up; a single negative sample does not guarantee absence of malignancy.

Inflammatory Bowel Disease

NIDDK describes Crohn's disease as potentially affecting any part of the digestive tract, commonly the small intestine and beginning of the large intestine. Ulcerative colitis affects the inner lining of the large intestine. These distributions help frame the differential diagnosis but do not replace clinical, endoscopic and pathological assessment. Avoid absolute claims that rectal involvement must always be present in UC or absent in Crohn's disease.

The ACG 2025 UC guideline recommends excluding infectious causes and using ileocolonoscopy with biopsies of affected and unaffected areas to confirm UC. Severity and extent guide treatment:

• Mildly to moderately active UC: oral and/or rectal 5-ASA therapy is selected according to disease extent and response.
• Corticosteroids: may induce remission in appropriate active disease, but are not recommended for UC maintenance.
• More severe UC: specialist selection of steroid-sparing or advanced therapies is required.

The ACG 2025 Crohn's guideline recommends against oral mesalamine for induction or maintenance of luminal Crohn's disease. Ileal-release budesonide is an induction option for mild to moderate ileocecal disease, not a maintenance treatment. Moderate to severe disease may warrant early advanced therapy; treatment should not automatically follow a fixed sequence of failed older agents.

NIDDK lists important complications: Crohn's disease may cause obstruction, fistulas or abscesses; UC may cause severe bleeding or toxic megacolon. Both may have extraintestinal effects. New severe symptoms require reassessment rather than an automatic routine flare treatment.