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

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1 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 Committee of the BSG was asked to provide approved guidance on the indications for diagnostic endoscopy. There was none although it was common practice to validate requests for endoscopy; indeed this is a requirement of the GRS. Following this request it was agreed that a small working group of individuals from CSSC (Adam Harris), Independent Practice Committee (Simon Greenfield), Endoscopy Section (Steve Hughes and Mark Wilkinson) and Surgical Section (Roger Leicester) would produce a draft list of indications for diagnostic upper GI endoscopy, flexible sigmoidoscopy and colonoscopy. The evidence-base for this was unsurprisingly small but wherever possible, the Guidance is supported by published documents from the BSG and NICE. The first draft was circulated to the members of BSG Endoscopy Section and CSSC. An amended document was sent to William Allum (President, AUGIS) and Rupert Pullen (ACPGBI), Karen Nugent (ACPGBI) and Graham Williams (President, ACPGBI) who took the Guidance to their respective Councils; their helpful comments were addressed to produce the final document. On 22 March 2013 BSG Council approved the tripartite Guidance. Last, we appreciate fully that this Guidance cannot be fully inclusive and ultimately clinical judgement is required to determine when an endoscopy is required but taking into account these reservations, we hope that you will find this Position Statement useful. Yours faithfully Adam Harris Chair, BSG CSSC

2 Indications for diagnostic OGD Symptoms suggestive of upper gastrointestinal cancer 1-2 : 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 recent-onset dyspepsia (after stopping treatment with PPIs) abnormal or suspicious findings on barium studies, CT or US scanning Other indications: patients with haematemesis and/or melaena 3 to confirm healing of oesophageal or gastric ulcer persistent long term reflux, odynophagia or dyspepsia unresponsive to 6 weeks treatment in primary care 4 coeliac disease diagnosis (& follow up of non-responders) 5 surveillance of Barrett s oesophagus 6 to take small bowel biopsies to investigate malabsorption or enteropathy 7 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 2 surveillance or screening in patients with FAP because of the risk of duodenal polyps 8 surveillance for oesophago-gastric varices in patients with suspicion of portal hypertension (eg, decompensated liver disease, cirrhosis on liver biopsy or equivalent non-invasive testing, presence of varices on abdominal imaging) 9

3 Indications for diagnostic flexible sigmoidoscopy Investigation of diarrhoea with or without bleeding in acutely ill patients 1 Investigation of rectal bleeding in absence of altered bowel habit ( 40 years; fresh bleeding not mixed with stool) 1 Investigation of equivocal radiological abnormalities in the rectum or sigmoid colon Surveillance of rectal stump in FAP 8 < 40 years with persistent and/or recurrent bleeding with or without change in bowel habit Surveillance by pouchoscopy for patients with IPAA (for IBD or FAP) 8 Indications for diagnostic colonoscopy Symptoms suggestive of colorectal cancer 1 : 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 10 Non-menstruating women with unexplained iron deficiency anaemia 10 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) 7 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

4 Assessment of neo-terminal ileal recurrence of Crohns following right hemi-colectomy to determine need for medical therapy 11 Assessment of extent and activity of known IBD 11 To confirm mucosal response to treatment with biological agents in patients with Crohn s disease 11 Screening in patients with significant family history of, or other risk factors for, colorectal cancer 8 In patients with positive faecal occult blood tests as part of NHS national bowel cancer screening programme Surveillance of patients with IBD 8,11 Surveillance after resection of colorectal cancer 8 Surveillance after removal of adenomas and in patients with FAP 8 After identification of adenomas at flexible or rigid sigmoidoscopy and for clearing the colon of synchronous neoplasia in patients with colorectal cancer 8,11 References 1. Referral guidelines for suspected cancer. NICE Clinical guidelines, CG 27 (2005) 2. Guidelines for the Management of Oesophageal and Gastric Cancer. Allum WH, Blazeby JM, Griffin SM et al. Gut 2011; 60: Acute Upper GI Bleeding. NICE Clinical Guideline CG 141 (2012) 4. Dyspepsia. Managing Dyspepsia in Primary Care. NICE Clinical Guideline CG17 (2004) 5. Coeliac disease. NICE Clinical Guideline CG 86 (2009) 6. BSG Guidelines for the diagnosis and management of Barrett s columnar-lined oesophagus. August Guidelines for the investigation of chronic diarrhoea, 2nd edition. P D Thomas, A Forbes, J Green et al. Gut 2003; 52 (Suppl V):v1 v15 8. Guidelines for colorectal cancer screening and surveillance in moderate and high risk groups (update from 2002). Gut 2010; 59: Jalan R and Hayes PC. UK Guidelines for management of variceal haemorrhage in cirrhotic patients. June

5 10. Guidelines for the Management of Iron Deficiency Anaemia. Goddard AF, James MW, McIntyre AS, Scott BB. Gut 2011; 60: Guidelines for the management of inflammatory bowel disease in adults. Mowat C, Cole A, Windsor A, et al. Gut 2011; 60(5): Colonoscopic surveillance for prevention of colorectal cancer in people with ulcerative colitis, Crohn's disease or adenomas. NICE Clinical Guideline CG 118 (2011)