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Upper GI Disease
Where we are
Dr Gary MackenzieConsultant Gastroenterologist
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Introduction
• Reflux– Complications
• Barrett’s Surveillance and new NICE Guidance
• Schatzki Rings and Eosinophilic Oesophagitis
• Local service development
• Capsule Endoscopy: The first two years
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Reflux
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Treatment of reflux
• PRN Antiacids
• PRN PPI/ H2 Blockers
• Regular PPI, (?BD ?Nexium)
OGD
• Addition of antacid for breakthrough (Gaviscon Advanced)
• Addition of ranitidine for nocturnal symptoms
• pH/manometry. Consider Surgery
Self medication
General Practice
Gastroenterologist
Surgeons
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Complications of reflux disease
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Peptic Strictures
• Relatively long history• Symptoms not intermittent• Often history of reflux
• May require multiple dilatations
• Risk is 2% of Perforation
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Peptic Strictures
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Barrett’s Surveillance
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Barrett’s
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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)
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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
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Current Treatment
• Treatment dose of a PPI
• Consider NSAIDs/ Aspirin
• Surveillance
• Radiofrequency ablation for HGD
• Oesophagectomy for Cancer
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Radiofrequency Ablationfor High Risk Patients
Recent NICE Guidance
£6000 vs £21000
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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
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Radiofrequency Ablation
• HALO 360 Device:
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After treatments
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Schatzki Rings and Eosinophilic Oesophagitis
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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
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Schatzki Ring
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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
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Local Service Development
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Local Service developmentManometry 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
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HRM system
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24 hour pH catheter
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Normal Study
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Significant acid reflux
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HRM catheter
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HRM: Low LOS Pressure
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HRM: Nutcracker Oesophagus
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HRM: Post fundoplication dysphagia
NSSD
Poor LOSRelaxation
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Capsule Endoscopy:
The first 2 years
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Recap
• Novel way of imaging the small bowel– 11mm x 25mm long. – Connects using ECG leads
– Endoscopic quality pictures of the small bowel
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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
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Small bowel GI Bleeding
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Crohn’s Disease
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Cancers
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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
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• Increasing strong department
• Bringing more services locally
• Provide better GI services
Summary