MARCH 2006Gastroenterology                                       IN    PRI MARY CARECHAIRMAN’S MESSAGE                    ...
GORD.TAMED                                                                                                                ...
EDITORIALUEGW REPORTOesophageal reflux disease                                                           Bridge overin infa...
Endoscopy wit                                                                            H OW I D O IT - A P E R S O NAL V...
thout sedation                                                                                                      tolera...
w.   Colorectal cancer                                                    GASTROENTEROLOGICAL                             ...
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ESPCG                                      E U R O P E A N     S O C I E T Y      F O R                                   ...
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Gastroenterology

  1. 1. MARCH 2006Gastroenterology IN PRI MARY CARECHAIRMAN’S MESSAGE JOURNAL OF THE PRIMARY CARE SOCIETY FOR W elcome to the relaunched journal of the Primary Care Society for Gastroenterology. ‘Gastroenterology in Primary Care’ will be endoscopists meeting in November. Much is changing in the field of endoscopy provision and I am pleased GASTROENTEROLOGY produced quarterly and report on news, to report that the society is being seen developments and meetings in the field. as the definitive voice on the issues The journal will also serve as the surrounding the provision of endoscopy This issue... mouthpiece of the PCSG and, as well as services outside hospital. other content, carry reports of all our The NHS is currently in a greater Bridge over meetings. This year we will be holding state of change than at any time in its troubled water? our session at the British Society of history. Throughout this flux we have Millennium Issues of Gastroenterology meeting on the the opportunity to define both the Gastroenterology in Perspective afternoon of 21st March. Details of the scope and standards of our area of programme appear on the back page of special interest. I hope this journal will this issue. In addition we shall have our be a major tool in achieving this. Polish Annual Scientific Meeting in October Richard Stevens experience and will be holding the definitive GP Chairman, PSCG screening in Poland has now spread to 58 centresGASTROENTEROLOGY IN PRIMARY CARE: ESPCG continuesan exciting future to grow Ten national group members and individual members It is very good to see the launch of service provision. In particular we have, based commissioning will give all of us from a further nineGastroenterology in Primary Care, over many years, attempted to improve the opportunity to review our patients’ countries.the journal of the Primary Care the terms and conditions under which needs and, working together, improveSociety for Gastroenterology. GP endoscopists worked, in either service provision, perhaps byCongratulations to Editor Richard contracting for services with non-Spence, the Society’s Chairman traditional providers. Finally, theRichard Stevens and the PCSG continued expansion of the GPs withCommittee for their energy in Special Interests programme provideshitting the streets with this an enabling framework for much of thispublication at a time of great work, although PCTs and hospitals havechange and opportunity in the NHS. so far been slow to grasp the potential The publication of the January White value of general practitioners withPaper on Care Outside Hospital re- expertise in particular clinical areas in Endoscopyemphasises the primacy of primary care helping them to set and develop without sedationin the provision of healthcare services prescribing and management strategy How I do it - aand, although we might have concerns across whole PCTs and across the personal view fromabout where the money is coming from, interface between general practice and John Gallowaysets out new directions of travel for the community or hospital settings, and the the hospital.provision of services, many of which work of GP endoscopists and So, 2006 looks like being an exciting British Society ofhave profound implications for the endoscopy nurses in providing more time for primary care gastroenterology Gastroenterologyprovision of GI services by general endoscopy capacity outside hospital is and we hope that our new publication Annual Meetingpractitioners and their teams. likely to become even more important will reflect this excitement and provide Birmingham The PCSG has always tried to support in the years ahead. Issues of useful guidance and contacts for 21 March 2006evidence-based management of accreditation of endoscopists working everyone interested in this importantgastrointestinal problems and also to in the community will undoubtedly clinical area.support general practitioners actively arise, and the Society is set to play an Professor Roger Jonesengaged in research, education and active role in this area too. Practice President, PCSG
  2. 2. GORD.TAMED Fast symptom control that lastsProtium® 40 mg, Protium® 20 mg, Protium® i.v. (pantoprazole) Syndrome and other pathological hypersecretory conditions: Start treatment with by non-selective non-steroidal anti-inflammatory drugs (NSAIDs) should bePrescribing Information two 40 mg tablets daily. Thereafter titrate dosage up or down as needed using restricted to patients who require continued NSAID treatment and have an(refer to Summaries of Product Characteristics for full information). measurements of gastric acid secretion to guide. With doses above 80 mg daily, increased risk to develop gastrointestinal complications. The increased riskPresentation: Protium® 40 mg, Protium® 20 mg: gastro-resistant tablets contain divide dose and give twice daily. Dosage may be increased temporarily above should be assessed according to individual risk factors, e.g. high age40 mg or 20 mg pantoprazole as pantoprazole sodium sesquihydrate. Protium® 160 mg but should not be applied longer than required for adequate acid (>65 years ), history of gastric or duodenal ulcer or upper gastrointestinali.v: Vials containing 40 mg pantoprazole as pantoprazole sodium in the form of control. Treatment duration is not limited and should be adapted according to bleeding. Side effects: Common: Headache, diarrhoea, constipation,a white dry substance. Uses: Protium® 40 mg: Healing and symptomatic relief clinical needs. i.v. therapy: For intravenous administration, when oral therapy flatulence, upper abdominal pain. Please refer to Summary of Productof duodenal ulcer (DU), gastric ulcer (GU), and reflux oesophagitis (moderate is not appropriate. Reconstitute with 10 ml physiological Sodium Chloride Characteristics for information on other side effects. Drug interactions:and severe). Zollinger-Ellison Syndrome (ZES) and other pathological Solution before use for intravenous infusion. The solution may be further Protium® is metabolised in the liver via the cytochrome P450 enzyme system,hypersecretory conditions. Eradication of Helicobacter pylori, in combination diluted, if required, with 100 ml Sodium Chloride Solution or Glucose 5%. The however no clinically significant interactions have been observed in specific testswith two antibiotics, in patients with DU or gastritis. Protium® 20 mg: Long-term reconstituted solution must be used within 12 hours of preparation. Treatment with antipyrine, caffeine, carbamazepine, diazepam, diclofenac, digoxin,management and prevention of relapse in reflux oesophagitis. Treatment of with Protium® i.v. should not be continued for longer than 7 days and as soon ethanol, glibenclamide, metoprolol, naproxen, nifedipine, phenprocoumon,mild reflux disease and associated symptoms. Prevention of gastroduodenal as oral therapy is possible. Adults: One vial (40 mg) per day by slow intravenous phenytoin, piroxicam, theophylline, warfarin and an oral contraceptive. As withulcers induced by non-selective non-steroidal antiinflammatory drugs (NSAIDs) injection or infusion over 2-15 minutes (DU, GU or moderate to severe reflux other acid suppressants, the absorption of pH-dependent drugs such asin patients at risk with a need for continuous NSAID treatment. Protium® i.v DU, oesophagitis). Zollinger-Ellison Syndrome and other pathological hypersecretory ketoconazole may be altered. Foods or antacids do not affect bioavailability ofGU, moderate and severe reflux oesophagitis, ZES and other pathological conditions: Start treatment with 80 mg daily. Thereafter titrate dosage up or Protium®. Basic NHS Price: 28 x 40 mg tablets £21.69, 28 x 20 mg tabletshypersecretory conditions. Dosage and administration: Oral therapy: The down as needed using measurements of gastric acid secretion to guide. With £12.31, 5 x 40 mg vials £26.57. Legal Category: POM. Marketingtablets should be swallowed whole with water. Adults: Healing – one 40 mg doses above 80 mg daily, divide dose and give twice daily. Dosage may be Authorisation numbers: Protium® 40 mg – PL 20141/0002, Protium® i.v. – PLtablet daily for 2-4 weeks (DU) or 4-8 weeks (GU and moderate or severe reflux increased temporarily above 160 mg but should not be given longer than 20141/0003, Protium® 20 mg – PL 20141/0001. Protium® is a registeredoesophagitis). Longer-term treatment may be prescribed in individual cases. required for adequate acid control. Rapid acid control: A starting dose of 2 x 80 trademark of ALTANA Pharma AG, Germany. Further information is available fromMaintenance – in reflux oesophagitis, one 20 mg tablet daily increasing to one mg is usually sufficient to reduce acid output into the target range (<10 mEq/h) ALTANA Pharma Ltd, Three Globeside Business Park, Fieldhouse Lane, Marlow,40 mg tablet daily for healing, if relapse occurs. Revert to 20 mg on healing. within one hour. Revert from i.v. administration to oral therapy as soon as Bucks SL7 1HZ. Telephone 01628 646400. Last updated: December 2005.Treatment exceeding one year should only be prescribed after careful clinically justified. Elderly & renally impaired: Do not exceed 40 mg per day. PAN214/040106/Pconsideration of the benefit/risk ratio. Mild reflux – one 20 mg tablet daily for Children: Not recommended. Severe hepatic impairment: Reduce daily dose2-weeks. In patients wit h healed reflux, reoccurring symptoms can be to 20 mg (see Contraindications, warnings, etc). Contraindications,controlled with 20 mg once daily when required. H. pylori eradication regimens warnings, etc: Protium® should not be used in cases of known hypersensitivity Information about adverse event reporting can be– 40 mg twice daily in combination with twice daily doses of clarithromycin 250 to any of its constituents. Exclude malignancy before starting therapy. Avoid use found at www.yellowcard.gov.ukmg and metronidazole 400 mg, or clarithromycin 500 mg and amoxicillin 1 g, during pregnancy and lactation. Pantoprazole may reduce the absorption of Adverse events should also be reported to ALTANA Pharmataken for 7 days. Prevention of NSAID induced ulcers: one 20mg tablet per day. vitamin B12 (cyanocobalamin) with long-term treatment. Monitor liver Pharmacovigilance, please call Freephone 0808 141 0047Elderly: Do not exceed 40 mg per day except in H. pylori eradication. Renally enzymes in patients with severe hepatic impairment, particularly during long-impaired: Do not exceed 40 mg per day. Children: Not recommended. Severe term therapy. In the case of a rise in liver enzymes, Protium® should behepatic impairment: Reduce dose to one 40 mg tablet on alternate days or one discontinued. Investigate patients who do not respond after 4 weeks (20 mg20 mg tablet daily (see Contraindications, warnings, etc). Zollinger-Ellison dose). Use of Protium® 20 mg as a preventive of gastroduodenal ulcers induced
  3. 3. EDITORIALUEGW REPORTOesophageal reflux disease Bridge overin infancy and childhood troubled water?Dr Richard Spence troublesome reflux and showed data The UEGW provided a veryinteresting session on this subject. Dr demonstrating a steady increase in reflux through to teenage. The risk T he theme of a primary care/secondary care bridge chosen by the PCSG for the Millennium Issues of Gastroenterology in Perspective remains as appositeChristian Poeta from Tubingen in for developing reflux appears to be as ever and a strong bridge is now needed moreGermany spoke on problems of higher when it is present in infancy urgently than ever before.reflux in neonates. As a neo- and she suggested that adult GERD The exacerbation of the purchaser-provider split embedded innatologist, his interest in the subject may start in childhood and may be a Payment by Results (PBR) and Practice Based Commissing (PBC) willwas sparked by the fact that 19% of lifelong disease. have far reaching consequences. Added to this is theinfants admitted to US Paediatric Even more alarming top slicing by Strategic Health Authorities (SHAs) ofHospitals are put on prokinetics was the presentation 15% of total NHS local budgets to place with the(cisapride or metoclopramide). Why? from Dr Frederic independent sector, where private providers of health Making the diagnosis at this Gottrand, Lille, France care are invited to bid for services hitherto largelytender age is difficult since reflux is on the presence of contained within the NHS. SHAs already have lists ofso easily facilitated. Aggravating Barrett’s oesophagus in preferred providers drawn up and the bidding processfactors are the frequent, high volume children, 5 years being the has started. Some GPs are looking at the feasibility offeeds and the lower oesophageal youngest reported age for Limited Liability Partnerships (LLPs) to try to retainsphincter (LES) is “under water” most the condition. Diagnosis this budget with an “NHS” body, despite the privateof the time. Measurements show a depends on the finding of partnership status. This major undertaking requiresnormal reflux rate of 3-5 episodes an intestinal metaplasia in investment of time and money. In other areas privatehour but the acid content is low. The biopsies. Even adenocarcinoma providers are looking to take over management of PCTs.main abnormality in infants with occurs; he described 14 patients Through all this major change it is likely that there will be areflux disease (GERD) is a higher acid under the age of 25 years of whom degree of destabilisation of some existing services. PBR and PBC arecontent in the refluxate, although the 10 died. Biopsy recommendation by their nature opposing forces. Through PBR hospitals will try tonumber of reflux episodes is not during endoscopy is the same as with increase health resource group (HRG) activity for individual patients.increased and gastric emptying is adults, ie 4 quad-rantic biopsies Forward looking Trusts my well try to draw elements of primary carenot delayed. Measuring intra- every 1 cm of Barrett’s mucosa, and into this activity through “outreach” clinics. GP groups or consortia,oesophageal pH is also no good then regular endoscopic surveillance. on the other hand, will use PBC to try to achieve savings bybecause pH is >4 in 92% of preterm (Clearly more “joined-up thinking” is regulating their referral patterns, and will unquestionably use theinfants. needed regarding the indications for services of GPSIs to provide a cheaper alternative service to An important differential diagnosis endoscopy in young adults presenting secondary care referral. Added to this, private providers may try tois cow’s milk allergy (can occur in with troublesome reflux symptoms). pick off “cherries” from primary care, e.g. chronic diseasepre-term babies). Diagnosis is made Finally, Dr Marc Benninga, management, currently earning well under the Quality andfrom blood eosinophilia, and Amsterdam, Holland discussed the Outcomes Framework (QoF) points payments. They may also employeosinophilic infiltrates can be safety of acid-suppressing drugs in “cheaper” professionals from elsewhere to deliver services -demonstrated in antral mucosa. The children, showing that PPIs heal American Physician Assistants are already working in the NHS.conclusion was that GERD is a severe GORD and resolve symptoms British GPs and Consultants may have become over-priced in theserious problem for only few; reflux and have a high margin of safety. eyes of some policy makers.is usually physiological; in the Concerns have been expressed that in These changes threaten the integrity of both primary andpresenter’s view there should be no neonates there might be a risk secondary NHS care and it is more vital than ever that an effectiveneed for prolonged hospitalisation and rarely of neutropenia precipitating dialogue exists between the two. All the more surprising, therefore,the use of prokinetics is unjustified. bacteraemia. In Holland cisapride is that the BSG “GI Service Review” completely fails to mention the A later speaker (Dr Sylvia still allowed for the under 3s and is contribution made by GPs to the gastroenterology workforceSalvatore, Varese, Italy) estimates often co-prescribed with a PPI. I heard (section 4.2).that 5-9% of infants have about Sandifer’s syndrome for the We are now seeing the fragmentation of the NHS that many had first time (where the child develops assumed would always exist in its present breadth. Its preservation abnormal head and neck postures in as a comprehensive healthcare system, previously the envy of the response to gross acid reflux). world, will only take place by cooperation between primary and Dr Anders Paerregaard, secondary care doctors at a level that has not been achieved up to Copenhagen, chaired the session now. This cooperation needs to take place right across the new and expressed the concern that many models of working that emerge in the immediate future. What is still feel regarding the actual certain is that healthcare provision in Britain is going to look very longterm consequences of acid different in 2-3 years time. suppression. Editor, Dr Richard Spence, GP and Endoscopist, Bristol
  4. 4. Endoscopy wit H OW I D O IT - A P E R S O NAL V modern day videoscopes. Intubation was more Handling of the endoscope. traumatic, often done blind and the whole The endoscopist should guide the endoscope procedure would take longer to get adequate with the right hand and not leave this to the views. Duodenal intubation was also traumatic assistant. The left hand alone should manipulate as the pylorus had to be entered by force in both wheels and the valves. The right hand r Galloway is a GP endoscopist, many cases. The introduction of fibreoptic andD treasurer of the PCSG andRCGP representative on JAG later videoscopes of a diameter slightly less than 10mm radically facilitated the procedure. In should rarely leave the insertion tube, except for taking biopsies. Keeping control of the insertion tube and its economy of gentle movement are particular, intubation with a narrow endoscope, probably the most important tips for a 15- 20 years ago nearly all upper GI performed under direct vision was easier and successful unsedated procedure.endoscopy was performed with sedation improved image quality, giving panoramic viewsand local throat anaesthesia. Sedation of the upper GI tract leading to fasterusually included a cocktail of intravenous procedures. Most diagnostic upper GIdiazepam and pethidine with an average endoscopy with a single biopsy for a CLO testdose of 1 0mg and 50 mg respectively. should not take more than 3-4 minutes and thisThis would heavily sedate most patients is one reason why sedation is less necessary.and few would have much memory of theprocedure. Patients would sleep for Informed consentseveral hours afterwards and not be Informed consent is a very important part ofpermitted to operate machinery or drive gastroscopy. I send out an explanation leafletuntil the next day because of the long with the consent form to the patient once I havehalf life of diazepam. received a referral. Patients can read through This tendency to heavy sedation allowed the the leaflet before booking their appointmentendoscopist to spend a long time carrying out the and discuss the procedure with a qualifiedprocedure on an uncomplaining patient. health professional involved with the service.Occasionally patients would be over sedated and This is a valuable way of allaying fears before- Both wheels and valves manipulated with therequire ventilation and administration of reversing hand and filters out any patient who feels they left handagents. The hypoxia that occurred was not fully would be unsuitable for an unsedated procedure.appreciated until pulse oximetry was routinely Preparing the patientused and this lead to progressively lighter sedation The unsedated patient I usually spray the patient’s throat in a separatewith short acting midazolam alone and the term There is a slight difference in technique for the room from where the procedure is performed. Ilight conscious sedation was born. This means that unsedated patient. The group of patients willing ask the patient to lie down on an examinationthe patient should be conscious, responsive and to have the procedure done without sedation couch and explain that the throat spray has acalm. This lighter level of sedation demands greater are to a certain extent self selecting but most banana flavour which helps to disguise the bitterspeed and dexterity from the endoscopist. The can be persuaded if their fears and anxieties are taste of xylocaine. I explain that the throat spraymortality associated with gastroscopy of 1 in 2000 overcome beforehand with a full explanation of will make the throat numb for about 10 to 15reported by Amanda Quine in 1995 was in part the procedure. Anxieties are usually about minutes and that the procedure will last aboutrelated to the sedation techniques used in the past. whether they will be able to breathe normally, 3-5 minutes. I ask the patient to allow the spray choking and gagging and whether the to build up in a pool in the back of their mouthEndoscopy outside the hospital procedure will be painful. Some patients are and not to swallow until I have finished spraying. When I started endoscopy outside hospital in more worried about what will be found and this I usually use about 10 puffs of spray and warn1994 I had to weigh up the risks of even light has to be addressed too. I reassure the patient the patient that they will feel a warm sensation asconscious sedation and opted only to offer that there will be no pain, they will be able to the local anaesthetic starts to work. Havingendoscopy without intravenous sedation, using breathe normally and gagging will be sprayed their throat and having taken away anyonly local anaesthetic throat spray. I felt in minimised by the throat spray and limited dentures I escort the patient into the endoscopypractice there was little difference in the patient usually to the first few seconds of intubation. room and introduce them to the two nurses whoexperience between light sedation and no Because great care is taken not to rush, most will look after them throughout the procedure.sedation. Those patients who are intolerant of patients are pleasantly surprised. I emphasisethe procedure may become disinhibited with that concentrating on slow regular breathing is The endoscopysmall doses of midazolam making the procedure very helpful as it reduces the gag reflex and Talking to the patient throughout the proceduremore difficult for the endoscopist. helps the patient to focus. (It opens the pharynx with encouraging words is essential as is giving Original fibreoptic gastroscopes were large in and usually keeps the epiglottis out of the way them a running commentary of progress anddiameter and the image was poor compared to -swallowing and choking close the passage). how much longer it will take. The patient is
  5. 5. thout sedation tolerated in the throat but lack of rigidity can lead to curling up in the pharynx if there is any muscular spasm. I have overcome this by applying the locks on the up/down control untilV I E W F R O M J O H N G A L LO WAY the endoscope is in the upper oesophagus. . The diameter of the endoscope allows it to asked to lie on their left side and one nurse is manipulation and then pull back into the pass through strictures with ease and intubation positioned at their head and one at their side to antrum to take a CLO test if necessary. It is easy of the pylorus is remarkably comfortable for the hold their right hand and assist me in taking to retrovert the endoscope at this stage as patient. The endoscope cannot remove large biopsies. Before intubation, I shield the patient’s sufficient air will have been insufflated to get a amounts of liquid quickly and biopsies are smaller, eyes from the endoscope and then place it in good view of the cardia. I tend to take any lesion although using disposable forceps with long their mouth and wait for a few seconds to get a biopsies on the way out minimising the need to alligator jaws and a locating prong give good good view of the back of the tongue and soft move the endoscope any more than necessary. results. The flimsiness of the endoscope means palate. The dialogue starts with me explaining Before leaving the stomach it is easy to get that a highly contractile stomach takes control that I am advancing the scope over the tongue panoramic views to make sure no lesions are and pushes it about more, prolonging the and that they may feel a slight gag reaction but missed. I will also deflate the stomach before procedure. Also incarcerated hiatus hernias and not to worry as it will be short lived. I advance a leaving which makes the patient more cup and spill deformities are difficult to reduce little further asking the patient to concentrate comfortable. Oesophageal biopsies can be taken and navigate for the same reasons. on their breathing as I go beyond the soft palate on the way out, again minimising movement of Ultra slim endoscopes are not so robust. into the pharynx and visualise the larynx. I then the endoscope. Withdrawal is done gently Already I have had a guide wire break and the advance the scope towards the back of the making sure the endoscope is straight so as not narrow channels have retained a cleaning brush larynx and intubate the upper oesophagus, to cause any trauma on extubation. which required a rebuild of the endoscope - sometimes asking the patient to take a swallow The patient should be reassured all the time. I luckily under guarantee. Pentax assure me that if the scope is not advancing freely. give a running commentary and tell them what the ultra slim endoscopes do not return to the to expect at every point. Progress should be repair department any more frequently than reported - signalling when you are half done, standard diameter endoscopes but common three quarters done, nearly finished and that sense dictates that such fine instruments needs they may feel a slight tug as you take a biopsy careful handling by the operator and support staff. but no pain. If the patent belches, coughs or gags I would hate to be without the ultra slim reassure them that it is okay and not to worry. endoscope now, but if I had a choice I would After taking biopsies, especially in the stick with the 9 mm model as it is more robust oesophagus, warn the patient that they may and endoscopy is usually faster with a more taste a little blood. controllable instrument. But, I have re-scoped a Aim the endoscope toward the area marked After the procedure I ask the patient to rest few patients who were intolerant of the XXXX to intubate the oesophagus on their back for a minute or two and let them procedure before and they have been much wipe away any saliva with a tissue. Then I escort happier with the ultra slim endoscope. This is the end of the most difficult part of the them back to a consulting room and give them procedure for the patient and it is worth telling a full explanation about the findings and further them this for reassurance. I also pause now for management. I tell them that the numbness in the patient to compose themselves and regulate the throat will wear off in a few minutes following their breathing while I wash away any sputum which they will be able to have a cold drink. or lubricating jelly from the lens. Because they have had no sedation there is no I proceed down the oesophagus into the restriction in their activities for the rest of the day. stomach insufflating very little air to minimise gas bloat and belching as this can be Ultraslim gastroscope uncomfortable and upsetting for the patient. I A recent acquisition to my department has been Ultra slim gastroscopes are about 25% of the will always try to aspirate any fluid from the a Pentax ultra slim gastroscope. This is only 6 cross sectional area compared to a 9 mm scope stomach at this stage to reduce the risk of reflux mm in diameter and has a tiny cross sectional during the procedure. I only insufflate enough area. This endoscope has some important Conclusions air to visualise the pylorus so that I can intubate advantages but there are disadvantages as well. I feel that most upper GI endoscopy can be the duodenum and then reassure the patient The image is comparable to a standard 9 mm performed without intravenous sedation. The that there will be no more pushing of the gastroscope but because of its size water procedure has to be highly interactive to endoscope. Intubation of the duodenum can be droplets from the washer are slower to clear achieve the high success rate that I enjoy of unpleasant as sometimes the endoscope has to from the lens. Insufflation is slower because of 98% completion. Patients are self selecting so be pushed through a closed pylorus and if the the smaller air channel. The endoscope is narrow this success rate would not be the same for all stomach is too full of air it can result in enough to pass through the nostril but I find comers. It is less consuming of resources and uncontrollable belching followed by a spell of that this is more uncomfortable than through does away with the need for recovery beds and gagging. I take any duodenal biopsies at this the mouth and still favour the latter as a route attached staff. It is safe as most complications stage without too much further scope of intubation. The small size is very well of upper GI endoscopy are sedation related.
  6. 6. w. Colorectal cancer GASTROENTEROLOGICAL RESOURCES ON THE WEB screening COMPARING POLAND AND THE UKDr Richard Spence POLANDThe Polish experience was presented by Prof Jaroslaw Regula(a good name for the job?). CRC screening commenced in Poland inthe year 2000 in a few centres, and has now spread to 58 centres, Minehead w w Dr Huw Thomas, GP, Gastrohep www.gastrohep.com This subscription service (£75 per year) is an excellent resource for all matters gastroenterological. It has excellent summaries of recent published articles.with 50,148 people having been screened by the end of 2004. Theage group screened is 50-66 years, or 40-66 with positive familyhistory. Caecal intubation rate has increased from 85-91% and therehave been 51 complications including 5 perforations, but no deaths. Pathology was found in 1:20 with 4-8% advanced adenomasand 5% advanced neoplasia. Odds ratio for males to females is 1.8 The DAVE project - Digital Atlas ofso that men have nearly double the incidence of pathology Video Education (gastroenterology).compared to women at the same age. So men may need CRC www.thedaveproject.orgscreening earlier in life. “Colonoscopy is cheap in Poland” and is This is a collection of teaching toolsthe preferred screening method. which include video endoscopy clips supported by radiological and surgical Remember all the PCSG publications UK PLANS images which is free to use for non and other information is available atDr Alastair Watson from Liverpool presented the UK plans for commercial purposes. Users can the website: www.pcsg.org.uka national CRC screening programme, due to roll out in 2006 and submit their own clips.based in 8 selected national centres. There is a belief that there is The Feldman GastroAtlas Onlinea long development cycle from adenoma to cancer (5-25 years) is also a good (free) resource forwhich was based on a few early papers. slides for presentations etc. Access Screening has 2 meanings: www.gastroatlas.com - you have to 1. opportunistic screening where the cost is low. register but there is no charge. 2. population based screening where the cost is high.Dr Watson says “I don’t believe any country in the world can afford PCSG Email Listcolonoscopy to screen the population”. There is an active email list which is open to all who are interested in There are 6 available screening tools: gasterenterological issues. It is free to 1. Faecal occult blood (guiac) join - please encourage any GP’s or 2. Faecal occult blood (immune) BMJ learning nurses you meet to join the list. Go to 3. Flexible sigmoidoscopy www.bmjlearning.com the website and click on the email list 4. Colonoscopy This site has some interesting online button to join, or send an email to 5. CT colography courses in all areas including pcsg-request@jiscmail.ac.uk The list 6. Faecal DNA test @ gastroenterology. It is free to BMA is moderated - so signing up will not The gold standard is to demonstrate a reduction in mortality members and has interesting new result in “spam” mail - and it is a greatfrom CRC. To do this 10-15 years of follow-up are needed. Three modules on C.Difficile and IBS - medium to discuss a variety of issues.large studies have reported such reduction. updates in management. Recent topics have included tariff The percentage reductions in mortality were: Users can build up a portfolio of prices for endoscopic procedures, Nottingham, UK 15% completed courses and print commissioning endoscopy services, Funen, Denmark 18% certificates ready for the annual and GPSI in Endoscopy. Archives of Minnesota, USA 21% appraisal visits! past postings are also available at the Of the endoscopic procedures, flexible sigmoidoscopy detects PCSG website.only 50% of proximal adenomas, but colonoscopy “has thepotential to kill someone”. The planned UK programme is evidence-based and will be basedon faecal occult blood in the 60-69 age group, repeated every 2years. If positive, colonoscopy will be offered “in 2 weeks”.Recruitment will be from the national population database and“bypasses primary care physicians - who are very busy people”. Cost is estimated at £58 million in Year 1; colonoscopy workloadis estimated at 61,274 examinations, requiring 39 full time“consultant colonoscopists”!
  7. 7. @
  8. 8. ESPCG E U R O P E A N S O C I E T Y F O R P R I M ARY C AR E G AS TR O E NTE R O LO GY Professor Greg Rubin, Professor of Primary Care, University of Sunderland The ESPCG continues to grow, with 10 national group members, including the JOURNAL OF THE PCSG, and individual members from a further 9 countries. It is actively involved in PRIMARY CARE promoting educational initiatives and research projects in general practice. Its most SOCIETY FOR recent project is a study of the diagnostic process for IBS in general practice, whileGASTROENTEROLOGY members have also been involved in the recent exercise to update the Maastricht guidelines on H pylori management. Our key meetings are held at WONCA-Europe and the UEGW meetings. This year they will be held in Florence (27-30 Aug) and Berlin (21-25 Oct) respectively. The Society’s AGM will be held during the Florence meeting. All members of the PCSG are automatically members of the ESPCG. Our website atEvent Diary www.espcg.org contains more information about our past and current activities.20-23 March 2006BSG ASM International NEWS SNIPPETS - Dr Huw ThomasConvention Centre, Endoscope decontamination When a scope is used in such Classification of Oesophagitis (IWGCO)Birmingham. and patients at risk of vCJD. patients, and the procedure is expected is recommending Barrett’s is describedPCSG session 2.30pm The Decontamination Working potentially to contaminate instruments both by the distance that theTuesday 21st March Group of the BSG has met with with lymphoid tissue (biopsies, circumferential metaplasia and the representatives from the CJD Incidents diathermy and some balloon dilatation longest tongue extends above the top25 April 2006 Panel in order to agree the consensus techniques where the balloon is drawn of the gastric folds; ie. a patient who“Endoscopy in Primary guidelines and practical advice to all back into the biopsy channel); the scope has 4 cm of circumferential metaplasiaCare” conference, endoscopists in the avoidance of risk. should be quarantined, and removed and a 2 cm tongue above this, Barrett’sDe Vere Belfry, The updated BSG decontamination from use except for further use in the is recorded as Prague; C4 & M6.Warwickshire guidelines are on the BSG website same patient. Endoscopy units could See Armstrong, D. Review article: towards consistency in the endoscopic diagnosis of Barretts oesophagus and columnar metaplasia. Alimentary Pharmacology & Therapeutics 2004 20(s5):40-47 (www.bsg.org.uk) and advise what to consider retaining fully functional Lundell et al; Endoscopic assessment of oesophagitis: clinical and functional correlates and further validation of the Los Angeles do when endoscoping patients who endoscopes that are close to classification. Gut. 1999 Aug; 45(2):172-80.1 October 2006 3 have received quantities of plasma decommissioning for potential use onPCSG (Primary Care product concentrates prior to when individuals at risk of vCJD Higher doses of mesalazineSociety for Gastro- donors were tested for vCJD (primarily http://www.advisorybodies.doh.gov.u in UC?enterology) Annual but not exclusively haemophiliacs and k/acdp/tseguidance/Index.htm The recent ASCEND trial has recentlyScientific Meeting and patients with immunodeficiency reported that mesalazine 4.8g/day wasAGM, London, Contact: syndromes). There are estimated to be Towards better endoscopic significantly more effective thansecretariat@pcsg.org.uk about 6500 of these patients in the UK, description of reflux 2.4g/day, the currently used induction and the vast majority have now been oesophagitis and Barrett’s. dose in the UK.25-26 November told of their risk (and asked to take As well as the Los Angeles staging Hanauer SB et al. Delayed-Release Oral Mesalamine at 4.8 g/day (800mg Tablet) for the Treatment of Mderately Active Ulcerative2006 certain public health precautions to system of oesophagitis, the inter- Colitis: The ASCEND II Trial. Am J Gastroenterol 2005; 100(11):1-8GP Endoscopists reduce the risk of spread to others). national working group for theSymposium (TBC) PR I MARY CAR E S OC I ETY FOR GASTROE NTE ROLOGY At the British Society of Gastroenterology Annual Meeting, Birmingham, 21 March 2006 Chairmen: Dr Richard Stevens and Professor Pali Hungin 16.15 The PCSG Debate "Public plus private sector care 14.30 Is Helicobacter pylori yesterday’s news? is better than public sector care alone for NHS patients Dr Bob Walt. Consultant gastroenterologist, University with GI problems." Hospital, Birmingham Proposed by Dr Richard Smith, Chief Executive, United 15.00 The Hepatitis C epidemic in the UK and Europe Health Europe and former editor of BMJ. Seconded by Dr Professor William Rosenberg. Professor of Hepatology, Peter Evans, General Practitioner and director of Jubilee Southampton General Hospital Surgery Endoscopy Services Opposed by Dr Peter Fisher, 15.30 Pharmacological and non-pharmacological President of NHS Consultants Association and retired treatments for irritable bowel syndrome consultant physician and gastroenterologist. Seconded by Professor Roger Jones. Professor of Primary Care, Kings Professor Elwyn Elias, BSG president 2005-2006. College London School of Medicine 17.30 Close Gastroenterology in Primary Care Editor: Dr Richard Spence, richardspence@yahoo.com Web Editor: Dr Huw Thomas, fennington@fennington.demon.co.uk Produced by the Primary Care Society for Gastroenterology, Gable House, 40 High Street, Rickmansworth, Herts WD3 1ER Tel: 01923 712711 Fax: 01923 778131 secretariat@pcsg.org.uk www.pcsg.org.uk

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