When to Refer for OGD and the Work Up of Upper GI Malignancies Dr Hong Qiantai Registrar, Department of Surgery GP Forum 27 May 2017 38 year old female, non-smoker, BMI 29 Works as investment banker Presents with on and off epigastric pain and discomfort for 2 weeks Usually worse after heavy meals, and alcohol intake No fever, or jaundice No constitutional symptoms Treatment: Trial of conservative management with PPIs and lifestyle modification 1
38 year old female, non-smoker, BMI 29 Works as investment banker Presents with on and off epigastric pain and discomfort for 2 weeks Usually worse after heavy meals, and alcohol intake No fever, or jaundice No constitutional symptoms Treatment: Trial of conservative management with PPIs and lifestyle modification 38 year old female, non-smoker, BMI 29 Comes back after the trial of conservative management 2 weeks later Still having epigastric pain and discomfort, now totalling 4 weeks with increasing frequency of symptoms Treatment: Consider further investigations, including US HBS and referral for OGD 2
38 year old female, non-smoker, BMI 29 Comes back after the trial of conservative management 2 weeks later Still having epigastric pain and discomfort, now totalling 4 weeks with increasing frequency of symptoms Treatment: Consider further investigations, including US HBS and referral for OGD 56 year old male, smoker, BMI 28 Works as a property agent Presents with new onset abdominal bloating for 2 weeks Usually worse after heavy meals, and alcohol intake No fever, or jaundice Treatment: Further investigation with US HBS and referral for OGD and Colonoscopy 3
56 year old male, smoker, BMI 28 Works as a property agent Presents with new onset abdominal bloating for 2 weeks Usually worse after heavy meals, and alcohol intake No fever, or jaundice Treatment: Further investigation with US HBS and referral for OGD and Colonoscopy When to refer for OGD Symptoms of Upper GI disease Patients > 55yo with unexplained / persistent recent-onset dyspepsia Dysphagia, recurrent vomiting Non-cardiac chest pain Upper abdominal pain Surveillance of high risk patients Known Barrett s oesophagus Polyposis syndromes Therapeutic intervention Melena / evidence of GI bleeding 4
Things patients ask us - OGD in KTPH Use of flexible endoscopy introduced through the mouth Day procedure Can be done under Sedation or even Local anaesthesia Endoscope inserted to D2/3 and examined carefully with pictures taken Biopsies may be taken HP fast test also done Things patients may ask - Risks of OGDs Risks of sedation Risks of OGD Bleeding Aspiration Perforation ( 1 in 10,000 ~ 0.01%) 5
Things patients ask Any alternatives? Imaging US Abdomen CT Abdomen and Pelvis PET scan However they do not offer the ability to visualise and biopsy lesions Role of Urea Breath test UGI Malignancy in Singapore (Males) 6
UGI Malignancy in Singapore (Females) When to suspect UGI CA? Presenting complaints Oesophageal CA Dysphagia Persistent vomiting Constitutional symptoms Iron deficiency anaemia Gastric CA Upper abdominal pain Upper abdominal mass Worsening dyspepsia Constitutional symptoms Iron deficiency anaemia 7
How to work up UGI CA? Invasive investigations Oesophageal CA OGD Gastric CA OGD EUS CT, TAP PET CT Scan EUS CT, TAP Diagnostic Laparoscopy Lung Function Tests Assessment of nutrition Assessment of nutrition How to work up for UGI CA? Role of tumor markers No clear guidelines recommending the use of tumor markers as screening for Gastric or Oesophageal CA CEA, CA19-9 and CA 72-4 are the most commonly used tumor markers More useful at predicting advanced disease rather than for diagnosis Most effective for surveillance if noted to be elevated pre-operatively Clinical significance of serum tumor markers for gastric cancer: a systematic review of literature by the Task Force of the Japanese Gastric Cancer Association. Gastric Cancer. 2014 Jan;17(1):26-33 Gastric cancer: tumor markers as predictive factors for preoperative staging. J Gastrointest Cancer. 2011 Sep;42(3):127-30. 8
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