Dyspepsia denotes a symptom and not a disease, it covers upper abdominal pain, fullness, early satiety, bloating and nausea. It can occur with gastric and duodenal ulceration and gastric cancer but most commonly it is of uncertain origin.
Urgent endoscopic investigation is required if dyspensi is accompanied by 'alarm features' (e.g. bleeding, dysphagia, recurrent vomiting or weight loss). Urgent investigation should also be considered for patients over 55 years with unexplained, recent-onset dyspepsia that has not responded to treatment.
Patients with dyspepsia should be advised about lifestyle changes (avoidance of excess alcohol and of aggravating foods such as fats); other measures include weight reduction, smoking cessation and raising the head of the bed. Some medicaitons may cause dyspepsia - these should be stopped if possible.

Gastro-oesophageal reflux disease (GORD) is associated with heartburn, acid regurgitation and sometimes, difficulty swallowing (dysphagia); oesophageal inflammation (oesophagitits) and ulceration. The management of GORD includes drug treatment, lifestyle changes and is some cases surgery.
Initial treatment is guided by the severity of symptoms and treatment is then adjusted according to response.
For mild symptoms of GORD initial management may include the use of antacids and alginates, histamine H₂-receptor antagonists may relieve the symptoms and permit reduction in antacid consumption, however, proton pump inhibitors provide more effective relief of symptoms. When symptoms abate, treatment is titrated down to a level which maintains remission.
For severe symptoms of GORD or for patients with a proven or severe pathology (e.g. oesophagitis, oesophageal ulceration, oesophagopharyngeal reflux, Barrett's oesophagus), initial management involves the use of a proton pump inhibitor; patients need to be reassessed if symptoms persist despite treatment for 4-6 weeks with a proton pump inhibitor. When symtoms abate, treatment is titarated down to a level which maintains remission.

Antimuscarinics reduce intestinal motility. They can be used for the management of irritable bowel syndrome.

These antispasmodics are believed to be direct relaxants of intestinal smooth muscle and may releive pain in irritable bowel syndrome

Eradication of Helicobacter pylor reduces recurrence of gastric and duodenal ulcers and the risk of rebleeding, the presence of H.pylori should be confirmed before starting eradication treatment. Acid inhibition combined with antibacterial treatment is highly effective in the eradication of H.pylori; reinfection is rare.
For initial treatment, a one-week triple-therapy regimen that comprises a proton pump inhibitor, clarithromycin and either amoxicillin or metronidazole can be used. These regimens eradicate H.pylori in about 85% of cases, there is usually no need to continue antisecretory treatment (with a proton pump inhibitor or H₂-receptor antagonist), however, if the ulcer is large, or complicated by haemorrhage or performation, then antisecretory treatment is continued for a further 3 weeks.

GI-bleeding and ulceration can occur with NSAID use. The risk of serious upper GI side-effects varies between individual NSAIDs. Whenever possible, the NSAID should be withdrawn if an ulcer occurs.
Patients at high risk of developing GI complications with a NSAID include those over 65 years, those with a history of peptic ulcer disease or serious GI complication, those taking other medicines athat increase the risk GI side-effects, or those with serious co-morbidity (e.g. cardiovascular disease, diabetes, renal or hepatic impairment).
In a patient who has developed an ulcer, if the NSAID can be discontinued, a proton pump inhibitor usually produces the most rapid healing. On healing, patients should be tested for H.pylori and given eradication therapy if indicated.

Histamine H₂-receptor antagosits heal gastric and duodenal ulcers by reducing gastric acid output as a result of histamine H₂-receptor blockade; they are also used to relieve symptoms of GORD. Maintenance treatment with low doses for the prevention of peptic ulcer disease has largely been replaced in H.pylori positive patients by eradication regimens. In adults, H₂-receptor antagonists are used for the treatment of functional dyspepsia and may be used for the treatment of uninvestigated dyspepsia without alarm features. H₂-receptor antagonist therapy can promote healing of NSAID-associated ulcers (particularly duodenal) and also reduce the risk of acid aspiration in obstetric patients at delivery.

PPIs are effective short term treatments for gastric and duodenal ulcers; they are also used in combination with antibacterials for the eradication of H.Pylori and can be used for the treatment of dyspepsia and GORD. PPIs are also used for the prevention and treatment of NSAID associated ulcers. In patients who need to continue NSAID treatment after an ulcer has healed. the dose of PPI should normally not be reduced because asymptomatic ulcer deterioration may occur.

Particular care is required in those presenting with 'alarm featurs', in such cases gastric malignancy should be ruled out before treatment.

Measurement of serum magnesium concentrations should be considered before and durring prolonged treatment with a PPI, especially when used with other drugs than can cause hypomagnesaemia or with digoxin.

Antimotility drugs relieve symptoms of acute diarrhoea by binding to opiod receptors in the GI tract and thereby prolonging the duration of intestinal transit. They are used in teh management of uncomplicated acute diarrhoea in adults, however, are not recommended for acute diarrhoea in young children; fluid and electrolyte replacement are of primary importance in severe cases of acute diarrhoea and may also be necessary in cases of dehydration. Loperamide is used due to its action on opiod recepetors in the GI tract and because it does not readily cross the blood brain barrier.

Chronic inflammatory bowel diseases include Chron's disease and Ulcerative colitis.

Chron's disease is a chronic, inflammatory bowel disease that mainly affects the GI tract. It is characterised by thickened areas of the GI wall with inflammation extending through all layers, deep ulceration and fissuring of the mucosa and the presence of granulomas; affected areas may occur in any part of the GI tract, interspersed with areas of relatively normal tissue. Chron's disease may present as recurrent attacks, with acute exacerbations combined with perods of remission or less active disease. Symptoms depend on the site of disease but may include abdominal pain, diarrhoea, fever, weight loss and rectal bleeding.
The aims of drug treatment are to reduce symptoms and maintain or improve quality of life, whilst minimising toxicity related to drugs over both the short and long term.

Ulcerative colitis is a chronic inflammatory condition, characterised by diffuse mucosal inflammation - it has a relapsing-remitting pattern. It is a life long disease that is associated with significant morbidity. It most commonly presents between the ages of 15 and 25 years, altough diagnosis can be made at any age. The pattern of inflammation is continuous, extending from the rectum upwards to a varying degree. Inflammation of the rectum is referred to as proctitis, and inflammation of the rectum and sigmoid colon as proctosigmoiditis. Left sided colitis refers to disease involving the colon distal to the splenic flexure. Extensive colitis affects the colon proximal to the splenic flexure, and included pan-colitis wher ethe whole colon is involved. Common symptoms of active disease or relapse include bloody diarrhoea, and urgent need to defaecate and abdominal pain.
Treatment is focussed on treating active disease to manage symptoms and to induce and maintain remission, the extent of disease should be considered when choosing the route of administration for both aminosalicylates and corticosteroids; whether oral treatment, topical treatment or both are to be used. If the inflammation is distal, a rectal preparation is adequate but if the inflammation is extended, systemic medication is required. 

Patients receiving aminosalicylates and their carers, should be advised to report any unexplained bleeding, bruising, pupura, sore throat, fever or malaise that occurs during treatment.

• If it is necessary to switch a patient to a different brand of mesalazine, the patient should be advised to report any changes in symptoms.

Constipation is defaecation that is unsatisfactory because of infrequent stools, difficult stool passage, or seemingly incomplete defaecation. It can occur at any age and is commonly seen in women, the eldery and during pregnancy.
New onset constipation, especially in patients over 50 years of age, or accompanying symptoms such as anaemia, abdominal pain, weight loss, or overt or occult blood in the stool should provoke urgent investigation because of the risk of malignancy or other serious bowel disorder.

In all patients with constipation, an increase in dietary fibre, adequate fluid intake and exercise is advised. Misconceptions about bowel habits have led to excessive laxative use. Laxative abuse may lead to hypokalaemia. Before prescribing laxatives it is important to be sure that the patient is constipated and that constipation is not secondary to an underlying undiagnosed complaint.

Bulk-forming laxatives are of particular value in adults with small hard stools if fibre cannot be increased in the diet, onset of of action is up to 72 hours. Symptos of flatulence, bloating and cramping may be exacerbated. Adequate fluid intake must be maintained to avoid intestinal obstruction.

Stimulant laxatives increase intestinal motility and often cause abdominal cramp; manufacturer advises they should be avoided in intestinal obstruction.

Faecal softeners are claimed to act by decreasing surface tension and increasing penetration of intestinal fluid into the faecal mass.

Osmotic laxatives increase the amount of water in the large bowel, either by drawing fluid from the body into the bowel or by retaining the fluid they were administered with.

Haemorrhoids or piles are abnormal swellings of the vascular mucosal and anal cushions around the anus. Internal haemorrhoids arise above the dentate line and are usually painless unless they become strangulated. External haemorrhoids originate below the denate line and can be itchy or painful. Women are predisposed to developing haemorrhoids during pregnancy. The aims of treatment are to reduce the symptoms (pain, bleeding and swelling), promote healing and prevent recurrence.

An anal fissure is a tear or ulcer in the lining of the anal canal, immediately within the anal margin. Clinical features of anal fissure include bleeding and persistent pain on defecation, and a linear split in the anal mucosa. The aim of treatment is to relieve pain and promote healing of the fissure.

Bile acid sequestrants act by binding bile acids, preventing their reabsorption; this promotes hepatic conversion of cholesterol into bile acids.

Pancreatic enzyme replacement therapy with pancreatin is the mainstay of treatment for exocrine pancreatic insufficiency. Pancreatin contains the three main groups of digestive enzymes: lipase, amylase and protease. These enzymes respectively digest fats, carbohydrates and proteins into their basic components so that they can be adsorbed and utilised by the body.

• Pancreatin should be administered with meals and snacks.
• The dose should be adjusted, as necessary, to the lowest effective dose according to the symptoms of maldigestions and malabsorption.