1. Upper GI Disease Where we are Dr Gary Mackenzie Consultant Gastroenterologist

3. Introduction Reflux –Complications Barrett’s Surveillance and new NICE Guidance Schatzki Rings and Eosinophilic Oesophagitis Local service development Capsule Endoscopy: The first two years

4. Reflux

5. 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

6. Complications of reflux disease

7. Peptic Strictures Relatively long history Symptoms not intermittent Often history of reflux May require multiple dilatations Risk is 2% of Perforation

8. Peptic Strictures

9. Barrett’s Surveillance

10. Barrett’s

11. Confers an increased risk of oesophageal cancer of 30-120x There is a rapidly rising incidence Dissappointing results from surveillance programs (RCT currently)

12. 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

13. Current Treatment Treatment dose of a PPI Consider NSAIDs/ Aspirin Surveillance Radiofrequency ablation for HGD Oesophagectomy for Cancer

14. Radiofrequency Ablation for High Risk Patients Recent NICE Guidance £6000 vs £21000

15. 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

16. Radiofrequency Ablation HALO 360 Device:

17. After treatments

18. Schatzki Rings and Eosinophilic Oesophagitis

19. 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

20. Schatzki Ring

21. 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

22. Local Service Development

23. 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

24. HRM system

25. 24 hour pH catheter

26. Normal Study

27. Significant acid reflux

28. HRM catheter

29. HRM: Low LOS Pressure

30. HRM: Nutcracker Oesophagus

31. HRM: Post fundoplication dysphagia NSSD Poor LOS Relaxation

32. Capsule Endoscopy: The first 2 years

33. Recap Novel way of imaging the small bowel –11mm x 25mm long. –Connects using ECG leads –Endoscopic quality pictures of the small bowel

34. 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

35. Small bowel GI Bleeding

36. Crohn’s Disease

37. Cancers

38. 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

39. Increasing strong department Bringing more services locally Provide better GI services Summary