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Endoscopy Should Everyone Be Tested

What will be covered. Specific issuesHealth economics of endoscopy. Specific issues. Iron deficiencyPositive coeliac serologyB12 deficiencyAge threshold for endoscopyBarrett's oesophagusGastric ulcer. Iron deficiency selecting patients for endoscopy. All malesAll non-menstruating femalesSe

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Endoscopy Should Everyone Be Tested

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    1. Endoscopy – Should Everyone Be Tested? Primary Care Management of Dyspepsia Symposium Roland Valori Consultant Gastroenterologist Gloucestershire Royal Hospital December 2003

    2. What will be covered Specific issues Health economics of endoscopy

    3. Specific issues Iron deficiency Positive coeliac serology B12 deficiency Age threshold for endoscopy Barrett’s oesophagus Gastric ulcer

    4. Iron deficiency selecting patients for endoscopy All males All non-menstruating females Selected menstruating females: positive coeliac serology GI symptoms Family history ? older patient

    5. Positive coeliac serology Need for duodenal biopsy depends on type of serology available degree of suspicion of coeliac

    6. Duodenal biopsy and coeliac serology when to endoscope

    7. B12 deficiency Always do intrinsic factor antibodies coeliac serology Follow rules for coeliac serology Barium follow through if there are GI symptoms

    8. “The challenge for GPs is to maximise detection of serious and treatable disease while minimising cost and adverse effects of investigation”

    9. Number of significant symptoms at time of diagnosis

    10. The threshold should be 55 the evidence Christie et al, Gut 1997;41:513-7 Gillen et al, Am J Gastroenterol 1999;94:75-9 Effective Health Care bulletin 2000: Volume 6 Two-week wait rule for upper GI cancer http://www.doh.gov.uk/cancer Draft NICE guidelines 2003

    11. Barrett’s oesophagus Two issues surveillance endoscopy of Barrett's to identify early cancer screening patients with GORD to identify Barrett's suitable for surveillance

    12. BSG Barrett’s oesophagus guidelines “it is recommended that endoscopic surveillance every 2-3 years should be considered in patients with endoscopically visible CLO, particularly those fit enough to undergo oesophagectomy should HGD or carcinoma be detected”

    13. BSG Barrett’s oesophagus guidelines Surveillance recommendation is based on case series evidence Cost-effectiveness is highly sensitive to annual incidence of carcinoma in Barrett's >1% not too expensive 0.5-1.0% Ł62,000/QALY <0.5% prohibitively expensive

    14. Endoscopy and bowel cancer Using endoscopy as part of a screening strategy, mortality from bowel cancer can be reduced by 15%

    15. Effect of FOBT screening on incidence of colorectal cancer

    16. Bowel cancer screening In November 2002 Alan Milburn announced that there would be a bowel cancer screening programme Ł1300 – 2500/QALY Ł23 – 42 million/year

    17. Bowel cancer screening Endoscopic workload expressed as procedures or sessions per year per million population:

    18. Waiting list: second wave pilot site X (population of 330,000)

    19. Implementing screening Not until the symptomatic service is ‘sorted’: modernisation of endoscopy services more and better trained endoscopists quality assurance process

    20. Modernisation Is all about getting it right for the patient using capacity efficiently controlling demand using cost/benefit evidence resourcing the demand capacity gap properly

    21. Modernisation Is all about getting it right for the patient using capacity efficiently controlling demand using cost/benefit evidence resourcing the demand capacity gap properly

    22. Annual open access endoscopy referral rate for West Gloucestershire GP practices (1996-7)

    23. Endoscopic findings in a random adult population Sweden Random sample invited for OGD* 1001/1363 accepted Age range 20-81 Mean age 53.5 51.3% women

    24. Endoscopic diagnosis Stroud (344) Sweden (1001) Forest of Dean (391)

    25. Problems with nihilistic approach Dealing with people Dealing with GPs who are dealing with people Endoscoping influences behaviour, it may lead to: reduced worry fewer symptoms reduced consultation reduced medication use

    26. Alternative strategies to manage dyspepsia Early endoscopy Empirical treatment Test and treat Test and ‘scope

    27. Alternative strategies to manage dyspepsia Early endoscopy Empirical treatment Test and treat Test and ‘scope

    31. Conclusions Do not ignore iron deficiency

    32. Conclusions Beware of Barrett's propaganda surveillance can do harm as well as good we do not know the balance of good and harm cost-effectiveness depends on the incidence of cancer in the population surveyed Whatever, it is hugely expensive compared with other interventions

    33. Conclusions Early endoscopy for patients with dyspepsia aged >55 it appears to be ‘cost-effective’ cancer is much more likely to be found

    34. Conclusions For younger patients: if typical reflux symptoms treat empirically if non-specific dyspepsia test for Hp and treat endoscope if patient or doctor has concerns about cancer patient needs to take regular NSAIDs

    35. Conclusions If you want to save the life of a patient with dyspepsia arrange a flexible sigmoidoscopy

    36. Hp and reflux disease The net effect is to reduce the number of subjects with milder GORD symptoms, but to increase the (smaller) number with more severe symptoms

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