Morning Rounds: Gastroenterology Series

The upper GIT from oesophageal reflux to gastric malignancy. Covers GERD and its primary mechanism (transient LES relaxation), Barrett's oesophagus with its adenocarcinoma risk and the role of goblet cells on biopsy, achalasia cardia with the bird-beak sign and myenteric plexus pathology, peptic ulcer disease with H. pylori eradication and the urea breath test, and gastric carcinoma with Virchow's node, Lauren classification, and the linitis plastica pattern of the diffuse type.

From functional disorders to inflammatory and infective bowel disease. Covers IBS with Rome IV criteria and the red flag exclusions, Crohn's disease versus ulcerative colitis (transmural vs mucosal, skip lesions vs continuous, granulomas vs crypt abscesses, the smoking paradox), intestinal tuberculosis with Stierlin's sign and the critical reason to exclude TB before starting anti-TNF therapy, coeliac disease with HLA-DQ2/DQ8 and the Marsh classification, and acute infective diarrhoea distinguishing secretory from invasive disease with the HUS trap of E. coli O157.

The full spectrum of viral liver disease with India-specific weighting. Covers HEV as the dominant cause of epidemic waterborne jaundice and its 20–25% mortality in the third trimester of pregnancy, HBV serology in complete detail (window period, vaccination vs recovery, HBeAg and infectivity), the precore mutant trap where anti-HBe positivity does not mean low infectivity, HCV diagnosis with the two-step anti-HCV then HCV RNA approach and genotype 3 as India's predominant strain cured by sofosbuvir-based DAAs, and fulminant hepatic failure with HDV superinfection vs co-infection and King's College Criteria.

Structural, metabolic, and toxic liver disease from daily clinical practice. Covers alcoholic liver disease with the AST:ALT >2:1 pattern, Maddrey's Discriminant Function, and GGT as the most sensitive alcohol marker; NAFLD and NASH with the metabolic syndrome link, lean NAFLD in Indians, and the liver biopsy as the only way to distinguish steatosis from steatohepatitis; cirrhosis and portal hypertension with SAAG, SBP diagnosis and treatment, and the variceal bleed protocol; Wilson's disease with ATP7B, Kayser-Fleischer rings, and the 24-hour urinary copper test; and hepatic encephalopathy with precipitants, lactulose, rifaximin, and the protein restriction myth.

Acute and chronic pancreatic disease including the India-specific tropical variant. Covers acute pancreatitis with GET SMASHED causes, Ranson's criteria, Atlanta severity grading, and aggressive IV fluid resuscitation as the cornerstone; complications of acute pancreatitis distinguishing pseudocyst from walled-off necrosis, Cullen's and Grey Turner's signs, and hypocalcaemia from saponification; tropical (fibrocalculous) pancreatitis — FCPD — with its large calculi, ketosis-resistant diabetes, and PERT treatment; carcinoma of the pancreas with Courvoisier's law, the double duct sign, and the head vs body/tail clinical contrast; and the endocrine tumours — insulinoma with Whipple's triad and C-peptide, Zollinger-Ellison syndrome with the secretin test and MEN-1.

Gallstone disease and its biliary complications in full clinical depth. Covers cholelithiasis with the three stone types — cholesterol (5 Fs), black pigment (haemolysis), brown pigment (infection) — and the gallbladder carcinoma link in the Gangetic belt; acute cholecystitis with Murphy's sign, early laparoscopic cholecystectomy, acalculous cholecystitis, Mirizzi syndrome, and gallstone ileus with Rigler's triad; choledocholithiasis with Charcot's triad, MRCP as the gold standard non-invasive investigation, and ERCP as the treatment; acute cholangitis with Reynold's pentad, Tokyo Guidelines severity grading, and emergency biliary decompression; and primary sclerosing cholangitis with its beads-on-a-string MRCP appearance, UC association, cholangiocarcinoma risk, and the IgG4-SC differential.

Ten cases covering the oncological, vascular, and surgical GIT topics that do not fit neatly into a single organ system. Hepatocellular carcinoma: surveillance protocol, BCLC staging, the non-invasive arterial enhancement / washout diagnostic criterion, fibrolamellar variant, and sorafenib's mechanism. Anorectal surgery: haemorrhoid grading and treatment ladder, anal fissure with the IAS hypertonia mechanism and GTN first-line therapy, fistula-in-ano with Goodsall's rule and Parks classification, and anorectal abscess spaces with Fournier's gangrene as the life-threatening complication in diabetic patients. Carcinoid tumour: why liver metastases are needed, urinary 5-HIAA, right-sided cardiac disease, and octreotide. Acute mesenteric ischaemia: pain out of proportion, SMA embolism from AF, thumbprinting, and CT angiography as the time-critical investigation. Upper GI bleed: Rockall score, Forrest classification, dual endoscopic therapy. Lower GI bleed: age-based cause distribution, diverticular and angiodysplastic bleeding, the Meckel's rule of 2s.