Endoscopy When to use it and How to get the most out of it. Dr Deepak Suri Consultant Gastroenterologist/Hepatologist. Highgate Private Hospital

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1 Endoscopy When to use it and How to get the most out of it Dr Deepak Suri Consultant Gastroenterologist/Hepatologist Highgate Private Hospital E:

2 Case 1 49 year old man Asymptomatic Type 2 diabetes on metformin annual DM surveillance bloods Hb 104 MCV 74 Ferritin 12 egfr >90 Urinalysis negative

3 Which tests are appropriate? True/false vote Iron and TIBC Faecal occult blood Coeliac serology Gastroscopy Colonoscopy

4 Which tests are appropriate? Iron and TIBC Faecal occult blood Coeliac serology Gastroscopy Colonoscopy FALSE FALSE TRUE TRUE TRUE

5 Case 2 37 year old woman No GI symptoms Regular menstrual cycle No FH of GI cancer Tired all the time Hb 96 MCV 72 Ferritin 10 egfr >90 Urinalysis negative

6 Which tests are appropriate? True/false vote Iron and TIBC Faecal occult blood Coeliac serology Gastroscopy Colonoscopy

7 Which tests are appropriate? Iron and TIBC Faecal occult blood Coeliac serology Gastroscopy Colonoscopy FALSE FALSE TRUE FALSE FALSE

Intestinal iron absorption Dietary Fe 3+ reduced to Fe 2+ Gastric acid Duodenal cytochrome B Fe 2+ taken up into mucosal cells by DMT1 Upregulated in iron deficiency

8 Intestinal iron absorption Dietary Fe 3+ reduced to Fe 2+ Gastric acid Duodenal cytochrome B Fe 2+ taken up into mucosal cells by DMT1 Upregulated in iron deficiency Cytosolic Fe 2+ binds to ferritin or is released by ferroportin Fe 2+ oxidised to Fe 3+ and binds to transferrin Stein J. et al. Nat. Rev. gastroenterol. 7, (2010)

9 Lab tests in Iron Deficiency Anaemia Laboratory measure Hb MCV/MCHC Ferritin Transferrin saturation IDA

10 Ferritin Serum ferritin reflects iron stores Low ferritin reliably indicates iron deficiency <15 µg/l diagnostic of absolute iron deficiency Affected by acute-phase reaction Intracellular molecule released by tissue necrosis Interpret with caution in inflammatory disease but a low ferritin is always abnormal

12 IDA: key points Lower limit of Hb normal range defines anaemia Any level of anaemia should be investigated in the presence of iron deficiency Ferritin most powerful test for demonstrating iron deficiency All patients: coeliac serology and urine dip for blood Upper and lower GI investigation considered in all postmenopausal women and all men unless overt non- GI blood loss Faecal occult blood testing?

13 Lower GI investigation Several modalities available Flexible sigmoidoscopy Colonoscopy CT colonography CT mini-prep (Ba enema obsolete)

Suggested Investigative algorithm Patient with symptoms suggestive of bowel cancer anaemia, weight loss, change of bowel habit, rectal bleeding To detect bowel cancer To detect bowel

g palpable mass) and staging Colonoscopy CT Pneumocolon CT Colonography Minimal Preparation CT Routine CT Full bowel prep Sedation i.

14 Suggested Investigative algorithm Patient with symptoms suggestive of bowel cancer anaemia, weight loss, change of bowel habit, rectal bleeding To detect bowel cancer To detect bowel cancer in those with contraindications to or previous failed colonoscopy/be. To detect larger lesions in frail/elderly patients To detect advanced lesions (e.g palpable mass) and staging Colonoscopy CT Pneumocolon CT Colonography Minimal Preparation CT Routine CT Full bowel prep Sedation i.v buscopan No radiation Biopsy possible (May not visualise entire colon) Full bowel prep i.v contrast and buscopan Rectal air insufflation Supine and prone positions (Polyps not reliably detected) Oral prep only for 48 hours (no bowel prep) i.v contrast No bowel prep i.v contrast

15 Prep Key indications PR bleeding (fresh blood) Polyp detection <10mm Cancer detection Diarrhoea Flexible sigmoidoscopy PO4 enema/ unprepped PR bleeding in young patients Assessment of IBD/acute diarrhoea Colonoscopy Oral bowel cleansing CRC/polyp detection Investigation of diarrhoea PR bleeding in >45 CT colonogram Oral bowel cleansing +/- contrast CRC/polyp detection +/ /- CT mini prep Oral contrast Suspected CRC - +/- + -

16 Bowel preparation Pt info leaflet, Gastroscopy Procedures & Digestive Examination at Highgate Hospital Safety in bowel preparation Consent Diabetes Anti-platelet and anti-coagulents

Bowel prep Requires considered approach NPSA alert 2009 Clinical assessment for contraindications and risks Explanation on safe use must be provided to patient Complications:

17 Bowel prep Requires considered approach NPSA alert 2009 Clinical assessment for contraindications and risks Explanation on safe use must be provided to patient Complications: individual patient risk factors and wrong choice/inappropriate bowel preparation Never attempt bowel prep in bed bound patient unless discussed first with Consultant gastroenterologist

18 Bowel prep: diet Unless diet followed carefully prep is usually unsuccessful Low residue diet 3 days before procedure Avoid fibre ie fruit/vegetables/whole grains White pasta/eggs/ice lollies/clear soup OK Clear fluids/black coffee/black tea after lunch the day prior to procedure

19 Moviprep Polyethylene glycol and ascorbic acid Non-absorbable/iso-osmotic Passes through bowel without net absorption or secretion: limits electrolyte shifts Safer in renal and cardiac disease Must be diluted in large volumes of water >2L to achieve cathartic effect

20 Picolax Sodium picophosphate/magnesium citrate Hyper-osmotic: promotes colonic evacuation by drawing large volumes of water into the colon (approx 1.8 litres of water per 45 ml of preparation) Diluted in small volumes of water (ie 250 ml)

21 Regular medication and colonoscopy ACE inhibitors and angiotensin II receptor blockers Ameliorate physiological response to hypovolaemia May cause deterioration in renal function during bowel preparation Discontinue on day of administration of bowel prep Reinstated 72 h post procedure Diuretics Predispose to intravascular volume depletion egfr required prior to contemplating bowel prep Use moviprep not picolax Unless there is significant risk of pulmonary oedema, diuretics should be discontinued on the day of bowel prep If diuretics cannot be discontinued safely the patient is unfit for bowel prep NSAIDS Reduce renal perfusion and limit capacity to compensate for reduced renal perfusion Discontinue on the day of administration of bowel prep and hold for 72 hours

22 Management of anticoagulation for endoscopy

23 Lower GI investigations: summary Carefully consider indication before deciding which test to request Consider axial imaging first in frail elderly Colonoscopy and bowel prep require reasonable fitness and mobility If in doubt discuss with gastroenterology before requesting an investigation

24 DIRECT ACCESS ENDOSCOPY PATHWAY Does your patient have the appropriate symptoms in the UPPER GI and LOWER GI Inclusion criteria? Yes No UPPER GI; inclusion Referral Criteria New onset or changing dyspepsia associated with anyone of the following: - Known Barrets oesophagus - Gastric dysplasia/atrophy or intestinal metaplasia - Previous gastric surgery - Pernicious anaemia Dyspepsia associated with vomiting or weight loss Patients >55 years with undiagnosed / unexplained new dyspeptic symptoms Patients with recent onset of reflux symptoms that fails to respond to PPI and/or or gastro prokinetic therapy For duodenal biopsy (positive Coeliac serology) LOWER GI: Referral Criteria Rectal bleeding UPPER GI: Exclusion Referral Criteria Those who should be referred to Upper GI 2ww Outpatients Progressive unintential weight loss (may need OGD but if there are no GI symptoms consider Chest x-ray, TFTs & blood sugar pre referral) Persistent vomiting Epigastric mass Those who should be referred to Routine Outpatients Those with endoscopically proven reflux or peptic ulcer disease not responding to treatment Those who are not fit for day case procedure LOWER GI: Exclusion Referral Criteria Those who should be referred to Colorectal 2ww Outpatients Altered bowel habit Diarrhoea Those who would not tolerate bowel preparation at home Significant co-morbidities (severe heart failure, several renal failure or airways disease) Patients who are on anticoagulant medication Patients who should be referred to Routine Outpatients Not fit for a day case procedure Under the age of 16 years Patient meets referral criteria (Please see page 2 for referral process) UPPER GI Gastroscopy NOTES 1.If your patient is taking ANTICOAGULANTS please ensure INR checked 1 week before Endsocopy appointment. 2.If your patient is taking Remember to stop the proton pump inhibitor and H2 -receptor antagonist TWO WEEKS before the endoscopy where symptoms allow. (Allows less false ve CLO test and less likely to mask suspicious findings) LOWER GI Flexible Sigmoidoscopy (PLEASE CONSIDER BELOW) Your patient may be offered Haemorrhoid banding at their Endoscopy appointment should this be deemed necessary as a treatment NOT APPROPRIATE FOR THR DIRECT ACCESS PATHWAY Please consider other Referral Pathways: 2 Week Cancer Pathway Routine Outpatient appointment Page 1

25 Indications for diagnostic OGD Symptoms suggestive of upper gastrointestinal cancer dysphagia unexplained upper abdominal pain and weight loss upper abdominal mass with or without dyspepsia persistent vomiting & weight loss unexplained weight loss iron deficiency anaemia unexplained worsening of dyspepsia patients aged 55 years with unexplained & persistent recentonset dyspepsia (after stopping treatment with PPIs) abnormal or suspicious findings on barium studies, CT or US scanning

26 Other indications: patients with haematemesis and/or melaena to confirm healing of oesophageal or gastric ulcer persistent long term reflux, odynophagia or dyspepsia unresponsive to 6 weeks treatment in primary care coeliac disease diagnosis (& follow up of non-responders) surveillance of Barrett s oesophagus to take small bowel biopsies to investigate malabsorption or enteropathy in patients with an adenocarcinoma of unknown primary after discussion at MDT surveillance for gastric dysplasia or in patients with a strong family history of gastric carcinoma

27 Other indications 2 surveillance or screening in patients with FAP because of the risk of duodenal polyps surveillance for oesophago-gastric varices

29 Management of BO For non-dysplastic Barrett s oesophagus with intestinal metaplasia or any Barrett s oesophagus >3 cm in length treat GORD symptoms perform endoscopic surveillance every 3-5 years If dysplasia or neoplasia present treatment options include endoscopic mucosal resection or radiofrequency ablation

30 Who should be screened for Barrett s oesophagus? People with chronic or severe GORD (duration >5 years or at least twice weekly symptoms or symptoms interfering with daily activity) And at least three of: Age >50 years Male sex White race Obese Smoking Or Family history of Barrett s oesophagus or oesophageal adenocarcinoma

31 Surveillance in BO progression to oesophageal adenocarcinoma among patients with non-dysplastic Barrett s oesophagus % per annum, 10% per annum in patients with high grade dysplasia. Barrett s oesophagus with intestinal metaplasia but no dysplasia, surveillance every 3-5 years Any grade dysplasia, intervention is recommended. Surveillance is not recommended if life expectancy less than five years.

32 Indications for diagnostic flexible sigmoidoscopy Investigation of rectal bleeding in absence of altered bowel habit ( 40 years; fresh bleeding not mixed with stool) <40 years with persistent and/or recurrent bleeding with or without change in bowel habit Investigation of equivocal radiological abnormalities in the rectum or sigmoid colon Surveillance by pouchoscopy for patients with IPAA (for IBD or FAP) Surveillance of rectal stump in FAP Investigation of diarrhoea with or without bleeding in acutely ill patients

33 Indications for diagnostic colonoscopy Symptoms suggestive of colorectal cancer 40 years with rectal bleeding with a change of bowel habit towards looser stools and/or increased stool frequency persisting 6 weeks or more Patients at any age with altered blood or blood mixed in stool 60 years with rectal bleeding persisting for 6 weeks or more without a change in bowel habit and without anal symptoms 60 years with a change in bowel habit to looser stools and/or more frequent stools persisting for 6 weeks or more without rectal bleeding Men of any age with unexplained iron deficiency anaemia Non-menstruating women with unexplained iron deficiency anaemia

34 Other indications: In patients with melaena after upper gi source was excluded In patients with emergency admission with rectal bleeding Clinically significant diarrhoea of unexplained origin (including microscopic colitis) Abnormal or suspicious findings in colon on barium enema, CT or virtual (CT) colonography Unexplained abnormalities of terminal ileum on small bowel imaging Persistent abdominal symptoms with raised CRP or faecal calprotectin

35 Dr Deepak Suri Consultant Gastroenterologist/Hepatologist PA Yvonne: tel /

GUIDANCE ON THE INDICATIONS FOR DIAGNOSTIC UPPER GI ENDOSCOPY, FLEXIBLE SIGMOIDOSCOPY AND COLONOSCOPY

Position Statement produced by BSG, AUGIS and ACPGBI GUIDANCE ON THE INDICATIONS FOR DIAGNOSTIC UPPER GI ENDOSCOPY, FLEXIBLE SIGMOIDOSCOPY AND COLONOSCOPY Introduction In 2011 the Independent Practice