Transcript Training Day 2008 - Spire Healthcare

Upper GI Disease
Where we are
Dr Gary Mackenzie
Consultant Gastroenterologist
Introduction
• Reflux
– Complications
• Barrett’s Surveillance and new NICE Guidance
• Schatzki Rings and Eosinophilic Oesophagitis
• Local service development
• Capsule Endoscopy: The first two years
Reflux
Treatment of reflux
• PRN Antiacids
• PRN PPI/ H2 Blockers
• Regular PPI, (?BD ?Nexium)
Self medication
General Practice
OGD
• Addition of antacid for breakthrough
(Gaviscon Advanced)
Gastroenterologist
• Addition of ranitidine for nocturnal
symptoms
• pH/manometry. Consider Surgery
Surgeons
Complications of reflux
disease
Peptic Strictures
• Relatively long history
• Symptoms not intermittent
• Often history of reflux
• May require multiple
dilatations
• Risk is 2% of Perforation
Peptic Strictures
Barrett’s Surveillance
Barrett’s
Barrett’s
• Confers an increased risk of oesophageal
cancer of 30-120x
• There is a rapidly rising incidence
• Dissappointing results from surveillance
programs (RCT currently)
Barrett’s Surveillance
• Discussion of risks and benefits
• Quadrantic biopsies every 2cm
• On PPI. Histology:
– No dysplasia: 2yearly
– Indeterminant: Re-evaluate 3months then if no
dysplasia 2years
– LGD: 6 monthly intervals
– HGD: Repeat immediately and discuss MDT
Current Treatment
• Treatment dose of a PPI
• Consider NSAIDs/ Aspirin
• Surveillance
• Radiofrequency ablation for HGD
• Oesophagectomy for Cancer
Radiofrequency Ablation
for High Risk Patients
Recent NICE Guidance
£6000 vs £21000
Radiofrequency Ablation
• The device:
– Essentially a novel form of bipolar electrocoagulation
– It circumvents previous problems of treating extended
areas and controlling the depth of the burn
Radiofrequency Ablation
• HALO 360 Device:
After treatments
Schatzki Rings and
Eosinophilic Oesophagitis
Schatzki Ring
• Fibrous band in the distal oesophagus
• Causes intermittent dysphagia
• Predisposed to by:
– Reflux
– Eosinophilic oesophagitis
• 80% disrupted by quadrantic biopsies
• Some require dilatation
Schatzki Ring
Eosinophilic Oesophagitis
• Infiltrate of eosinophils into the oesophageal
wall
• Not to be confused with reflux
• Greater than 10 per HPF
• Responds to dry swallowed steroid inhaler
Local Service Development
Local Service development
Manometry and pH testing
• Support other services:
– Upper GI surgery
– Gastroenterology
– Respiratory medicine
• Long current waits:
– Guildford approx. 6 months
– Brighton now only take pre-op referrals
HRM system
24 hour pH catheter
Normal Study
Significant acid reflux
HRM catheter
HRM:
Low LOS Pressure
HRM:
Nutcracker Oesophagus
HRM: Post fundoplication
dysphagia
NSSD
Poor LOS
Relaxation
Capsule Endoscopy:
The first 2 years
Recap
• Novel way of imaging the small bowel
– 11mm x 25mm long.
– Connects using ECG leads
– Endoscopic quality pictures of the small bowel
Indications
• GI Bleeding
– Overt with normal OGD and Colonoscopy
– Occult often presenting as recurrent Iron
Deficiency Anaemia
• Abdominal Pain
– Diagnosis of Crohn’s Disease
– Unresponsive Coeliac disease
Small bowel GI Bleeding
Crohn’s Disease
Cancers
Results so far…
• 112 studies in 2 years
– 7 active bleeding subsequently treated.
– 2 Small bowel cancers and 2 small
bowel polyps.
– 16 patients with Crohn’s Disease.
– 36 other bleeding abnormalities: NSAID
injury, angiodysplasia
– 4 unresponsive Coeliac Disease
– 1 small bowel benign stricture
– Rest minor abnormalities or normal.
68/112 changed management
Summary
• Increasing strong department
• Bringing more services locally
• Provide better GI services