Endo Express Newsletter – December 2014
JAG Accreditation Achieved
We are delighted to announce that Braintree, Witney, Peterborough and Ipswich units have all achieved full JAG accreditation recently. This award is achieved after a robust online questionnaire followed by a full day visit which includes an inspection of all policies, documentation and processes as well as interviewing staff.
JAG accreditation is the formal recognition that an endoscopy service has demonstrated that it has the competence to deliver against documented standards. It is intended to increase patient confidence in the service, improve the management and efficiency of the service and stimulate continuous improvement in processes and patient outcomes.
To read more about what this involves please click here.
New Barrett’s Guidelines
You may have started to notice that patients who undergo regular surveillance for their Barrett’s are having varying follow up periods.
The new British Society Guidelines for the Diagnosis and Management of Barrett’s Oesophagus was released late last year and changed the way Barrett’s is diagnosed and followed up.
As always, Barrett’s is an endoscopic and histological diagnosis. The new guidelines highlight the importance of the presence of intestinal metaplasia in the biopsies as a risk for cancer development. Previously, columnar lined oesophagus was the key.
There has also been a division between short (less than 3cm) and long segment Barrett’s, with different follow up periods for the groups. Presence of dysplasia is managed in the same way as before.
So, a patient with less than 3cm of Barrett’s and with no intestinal metaplasia on the biopsies will have a repeat in 3 years – if this shows the same as before, they can be discharged. They will need to remain on long term PPIs.
If intestinal metaplasia is present, the surveillance will be three yearly.
For longer Barrett’s segments, the surveillance will remain at every two years.
The new guidelines also discuss screening for Barrett’s and suggest the following –
‘Endoscopic screening can be considered in patients with chronic GORD symptoms and multiple risk factors (at least three of age 50 years or older, white race, male sex, obesity). However, the threshold of multiple risk factors should be lowered in the presence of a family history including at least one first-degree relative with Barrett’s or oesophageal adenocarcinoma. ‘
Referral Guidelines Update
All patients with unexplained iron deficiency anaemia need to undergo an OGD and colonoscopy as per BSG guidance. For these patients, please include their blood results. We need to see some proof that the anaemia is iron deficiency caused; Fe, TIBC, Ferritin are best, as well as a recent FBC result. It would also be extremely helpful if you could include Coeliac testing results (TTg or EMA) to determine the necessity of duodenal biopsies.
Oral bowel preparation and kidney disease
Some years ago, we switched to Moviprep as our standard bowel preparation pre colonoscopy. This not only has the advantages of being an extremely effective and good prep for the colon, but it is also the recommended preparation for patients with CKD3, 4 and 5.
Patients with any form of kidney disease need an up to date eGFR, urea and creatinine result (within the last three months) included in their referral.
For all patients, a summary of their record including repeat prescriptions and past medical history is most useful.
New H Pylori Test
InHealth Endoscopy has a new H Pylori test which will give a result within FIVE minutes. As with the previous test, two gastric biopsies are mixed with a reagent and a colour change indicates the presence of H Pylori. Rather than the previous 24 hour wait, the patient will know their result before they have left the procedure room!
The result will be communicated in the initial report sent to the GP, reducing admin time on both sides and the risk of a lost result.
New service additions
We are always looking to improve and add to the service that we offer to patients and GPs.
Two new services have started recently in some of our units and we are in discussions to add these to all units.
For those patient with obscure gastrointestinal bleeding (defined as GI bleeding, both overt and occult, with a normal OGD and colonoscopy) or suspected small bowel Crohn’s, a video capsule endoscopy is now the recommended investigation.
The patients may need to undergo full bowel preparation, as per colonoscopy, and then can take the capsule when it suits them. Our chosen capsule stores all its data onboard so there is no need for a sensor belt to be fitted and worn. The capsule is retrieved using the kit provided and returned to the unit (by post if preferred); a report will be issued within 48 hours.
Available in some units at present is band ligation of haemorrhoids for those patients who are found to have haemorrhoids on flexible sigmoidoscopy or colonoscopy and for whom conservative measures have not worked.
A simple and painless procedure, the bands are applied through a specially designed proctoscope just after the endoscopy has been completed. This one stop service diagnoses and treats the patient in one appointment.
Eosinophilic Oesophagitis is a relatively new disease which is characterised by symptoms of dysphagia, food impaction or spontaneous perforation and is most commonly seen in children, adolescents and younger adults. It is associated with other forms of atopies such as asthma, hayfever and eczema and is associated with characteristic endoscopic signs in 90% of cases and with histological changes of marked eosinophilia and fibrotic remodelling.
It is a chronic inflammatory, allergic reaction and it is thought that milk and wheat are the most likely culprits, although eggs, soy, peanuts, fish and shellfish are also implicated. It is possible that both inhaled and swallowed products could have an etiological effect. The appearance on endoscopy is varied and can range from rings horizontally in the oesophagus resembling stacked coins or the tracheal cartilages and also roughened appearance to the mucosa like paper mache. Also, there are often minor tears seen in the segment on simple passage of the scope showing friability. Oesophageal biopsies are taken in the affected area but also in the distal and proximal oesophagus to ensure comparison and will show an eosinophilic infiltrate with fibrotic changes and remodelling. Given its ultimate conclusion, this will lead to strictures.
Prevalence of this is roughly similar to that of Crohn’s Disease. Treatment can be with dietary restriction, medication or both. Dietary restriction can obviously involve all those mentioned above but the most common factors being milk and wheat is a simpler dietary restriction. PPIs have very little effect but can have some improvement, thought to occur because one of the chemical moieties in the PPIs is of an anti-eosinophilic nature. The standard treatment is with swallowed topical steroids, usually Budesonide or Fluticasone, diluted with a carbohydrate liquid. Unfortunately, no drug is licensed for use of this as an official classification is still to be found. It is thought that a License will be given soon. There is good evidence that both dietary and medication treatment leads to remodelling of fibrotic segments to a more normal appearance. It seems however this is a chronic disease and will need long-term management and intermittent endoscopy to ensure disease control.