Upper GI Disease

Where we are

Dr Gary MackenzieConsultant 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)

OGD

• Addition of antacid for breakthrough (Gaviscon Advanced)

• Addition of ranitidine for nocturnal symptoms

• pH/manometry. Consider Surgery

Self medication

General Practice

Gastroenterologist

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 Ablationfor 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 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

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 LOSRelaxation

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

• Increasing strong department

• Bringing more services locally

• Provide better GI services

Summary