Health screening generally involves tests that aim to look for diseases before you have symptoms. Health screening is essential for the early detection of diseases and conditions. With early detection and good management of these chronic conditions or cancers, complications can be avoided or delayed, thus improving patient outcomes and survival.
Your healthcare practitioner may decide to refer you to a gastroenterologist for one of 4 common reasons:
- Elevated cancer markers
- Abnormal liver blood tests
- Liver Nodules
1. Elevated Cancer Markers
a. Alpha-Fetoprotein (AFP)
Alpha-fetoprotein (AFP) is traditionally used to screen patients at risk of liver cancer or hepatocellular carcinoma such as those with liver cirrhosis due to any cause or hepatitis B carriers. However, AFP can be raised in other cancers, such as testicular cancer, gastric cancer, biliary tract cancer, pancreatic cancer and lung cancer. AFP can also be raised in non-malignant conditions like such as liver cirrhosis, viral hepatitis, ataxia telangiectasia and pregnancy.
b. Carcinoembryonic Antigen (CEA)
Carcinoembryonic antigen (CEA) is a glycoprotein, which is present in normal mucosal cells. However, elevated levels found in blood tests can be associated with cancers, especially colorectal cancer and levels exceeding 10 ug/L are rarely due to benign disease. Sensitivity increases with advancing colorectal cancer stage. CEA levels are useful in assessing prognosis (with other factors), detecting recurrence and monitoring treatment in patients with colorectal cancer.
Conditions which may result in an elevated blood CEA level include colorectal cancer, breast cancer, lung cancer, gastric cancer, oesophageal cancer, pancreatic cancer, mesothelioma, skeletal metastases, liver cirrhosis, chronic active hepatitis, chronic renal failure, pancreatic disease, inflammatory bowel disease, diverticulitis, irritable bowel syndrome, respiratory diseases, e.g. pleural inflammation, pneumonia, smoking and atherosclerosis
c. Carbohydrate Antigen 19-9
CA19-9 is an intracellular adhesion molecule. Elevated blood levels of CA 19.9 occur primarily in patients with pancreatic and biliary tract cancers, but may also be raised in patients with colorectal, gastric, hepatocellular, oesophageal and ovarian cancers.
Conditions such as liver cirrhosis, cholestasis, cholangitis, pancreatitis and diabetes mellitus may also result in elevation of blood levels of CA 19.9.
Anaemia is also a common health screening abnormality. Anaemia in men is typically defined as a haemoglobin level of less than 13.5g/dL and in women as haemoglobin of less than 12g/ dL. Most patients with anaemia have no symptoms initially and only develop symptoms when their haemoglobin is significantly low.
Anaemia can be categorized as microcytic (MCV less than 80FL), normocytic (MCV 80-100FL) or macrocytic (MCV more than 100FL). The most common cause of microcytic anaemia is iron deficiency anaemia, although hereditary disorders like alpha thalassaemia or beta thalassaemia needs to be excluded.
The most common causes of iron deficiency anaemia are a lack of iron in the diet of vegans and vegetarians, menorrhagia, pregnancy, peptic ulcer disease, gastrointestinal cancers (colorectal, gastric and small intestinal), inflammatory bowel disease, colonic polyps and haemorrhoids
Macrocytic anaemia may be caused by Vitamin B12 deficiency.
Vitamin B12 deficiency may be found in patients who are strict vegetarians, due to pernicious anaemia, chronic alcoholism or intestinal strictures (Crohn’s disease), blind loop syndrome and bacterial overgrowth (postsurgery)
3. Abnormal Liver Blood Tests
Abnormal liver blood tests results are commonly found during health screening and patients are often asymptomatic. These abnormal liver function tests fall in three main groups:
i. An isolated elevated bilirubin level (hyperbilirubinaemia)
ii. Predominantly elevated serum alkaline phosphatase (ALP) and gamma-GT (GGT)
iii. Predominantly elevated alanine transaminase (ALT) and Aspartate transaminase (AST)
i. Causes of isolated hyperbilirubinemia include:
• Hereditary Disorders such as Gilbert’s syndrome, Crigler- Najjar syndrome, Dubin-Johnson syndrome
• Chronic liver disease
ii. Causes of raised serum alkaline phosphatase (ALP) and gamma-GT (Cholestasis) include:
• Primary biliary cirrhosis
• Drugs (tricyclic antidepressants, erythromycin, oral contraceptive pill, anabolic steroids)
• Primary sclerosing cholangitis
• Cardiac failure
• Malignancy – Liver, bilary or pancreatic cancers
iii. Predominately raised ALT/AST (‘Hepatitic picture’) include:
• Non-alcoholic steatohepatitis (NASH)
• Alcoholic hepatitis
• Chronic hepatitis B, C
• Autoimmune hepatitis
• Acute hepatitis A, B, C, EBV and CMV infection
• Metabolic-Glycogen Storage disorders, Wilson’s disease
Patients with elevated cancer markers, anaemia or abnormal liver bloods tests or liver nodules require a detailed history and physical examination and usually will require further evaluation.
Your gastroenterologist at gutCARE will take a detailed history from you for hepatitis B or C, significant alcohol intake and family history of liver cancer in cases of an elevated AFP blood test. They may perform an abdominal examination and inspection of the testes in men to exclude testicular cancer. Further investigations may include a transabdominal ultrasound, CT or MRI scan and fibroscan liver stiffness measurement and further blood tests.
If you have an elevated CEA blood test, your gastroenterologist may ask you about a history of smoking and symptoms suggestive of colorectal (per rectum bleeding, change in bowel habits) or lung (cough, hemoptysis). Gastroscopy, colonoscopy and further non-invasive imaging may be performed where appropriate.
If you have an elevated CA19-9 blood test, your gastroenterologist may require CT or MRI imaging to exclude pancreatic and biliary malignancy and a gastroscopy and colonoscopy where appropriate. Patients may also require further evaluation using state-of-the-art endoscopic ultrasound.
In patients with anaemia, your gastroenterologist at gutCARE may suggest further evaluation including a gastroscopy, colonoscopy or capsule endoscopy as well as referral to a dietician or gynaecologist.
If you have abnormal liver blood test results or liver nodule, your gastroenterologist will take complete history of your lifestyle (including recent travel, transfusions, unprotected sexual intercourse, alcohol intake, diabetes mellitus, obesity, hyperlipidemia, family history) and a thorough clinical examination for signs of chronic liver disease.
Diagnosis of the definitive cause of your abnormal live blood tests or liver nodule may include further investigations for hepatitis B, C, autoimmune hepatitis, Wilson’s disease. Your gastroenterologist may also order an ultrasound, CT, MRI, MRCP scan. Lastly to assess whether you might have liver cirrhosis, your gastroenterologist may order a Fibroscan liver stiffness assessment or liver biopsy.
The treatment of these patients is dependent on the final diagnosis following evaluation.
- digestive illnesses