Gastro Pathways – Rationalising care in 2015 Dr Miles Parkes Consultant Gastroenterologist

Themes GI presentations to 1ry care – v common NB – most referrals are excellent!  - but some do not require secondary care Reality of limited resources Need for reasonable uniformity of care Within 1ry care At 1ry / 2ry interface Within 2ry care Myriad NICE guidelines (dyspepsia, IBS, IBD etc.) Frequently shifting; CCG consistency eg re dyspepsia. Relentless political ‘trumping’ re cancer diagnostics

Within CUH GI Medicine + Surgery (upper GI + colorectal) now within single Digestive Disease directorate Aim: single point of triage GP’s refer patients to Digestive Disease Pass through CCG referral management? Triage by consultant to most appropriate clinic(s) => Patient chooses which one they can make / want Falls within C&B rules

New GI proformas / guidelines Aim to cover most common presentations to avoid unnecessary hospital referrals hence incl some guidance eg re calprotectin On Referral Proformas Some information that is required (sorry) Some boxes to tick PLEASE do incl (invaluable) para of text re context / need for referral – esp for eg IBS, dyspepsia etc.

Frontsheet Demogs …….. For the desired action please tick the appropriate box below O.P. Appointment □ Advice only □ Endoscopy only □ Please complete the appropriate proforma for the following conditions: For all other conditions, including suspected IBD, please supply this frontsheet with a letter + lab results. We will triage all referrals to the appropriate clinic: please supply enough information to enable appropriate allocation. Rectal Bleeding   Iron Deficiency Anaemia   Suspected Coeliac Disease   Dyspepsia   Mainly primary care management Irritable Bowel Syndrome   Mainly primary care management Hernia   Bowel management service   Rectal Bleeding   Iron Deficiency Anaemia   Suspected Coeliac Disease   Dyspepsia   Mainly primary care management Irritable Bowel Syndrome   Mainly primary care management Hernia   Bowel management service  

IBS and Bowel Symptoms in Young Patients If it’s IBS a positive diagnosis always helps management: most should be managed in primary care Main Symptoms IBS Abdo pain + Bloating + Change in bowel habit IBS diagnosis Abdo pain + abnormal bowel pattern – diarrhoea, constipation or (typically) rapidly alternating Abdo pain eased by defecation Plus 2 or more of Bloating Symptoms made worse by eating +/- specific foods Passage of mucus Tiredness Plus normal baseline tests (FBC, CRP, coeliac serology) Red Flags for IBD or neoplasia Refer for assessment If severe IBD please phone on-call gastro SpR Unexplained weight loss Rectal bleeding without haemorrhoidal features FH bowel or ovarian cancer Age >60 + change in bowel pattern >6 weeks Unexplained anaemia Abdominal mass or Rectal mass Raised ESR / CRP - mild  ESR/CRP can be 2ry to e.g. obesity - check fecal calprotectin (see below) Investigations Baseline tests (results required for any hospital referral) Hb, MCV, CRP or ESR, Coeliac screen (TTG) If normal but IBD still suspected check fecal calprotectin (see box below) The following are NOT necessary in patients with typical IBS symptoms + normal baseline tests Abdo ultrasound or CT Sigmoidoscopy/Colonoscopy Fecal Calprotectin (Fecalp) A test for bowel inflammation >200 means gut inflammation = refer; or if > 100 + other features of IBD = refer <50 = normal; 50-200 = equivocal – repeat after 3 months NB this is a sensitive test prone to false positives – e.g. caused by NSAIDs, liver cirrhosis, gastroenteritis or infectious colitis (Salmonella, C diff etc.) Addenbrooke’s/CATCH IBS guidelines October 2014

Management of IBS/Bowel Symptoms in young patients If it’s IBS a positive diagnosis always helps subsequent management: mostly managed in primary care Patients that may warrant referral (NB this is the exception!) Severe symptoms as assessed by- Multiple days off work/study On strong opiates Recurrent A+E attendances Lifestyle/self help/exercise Diet, lifestyle, stress management, regular exercise (yoga, pilates+ graded exercise) all help; also self help via IBS network; and assess psychological symptoms. Fibre Review fibre intake and adjust (usually reduce dietary fibre) Discourage intake insoluble fibre (eg bran); if fibre needed, increase to soluble eg oats or use cracked linseed daily (1 teaspoon increasing to 1 tablespoon bd). BDA leaflet Follow up Agree follow up based on symptom responses to interventions. Assess each time for red flag symptoms Consider Dietician referral If diet considered to be major factor in symptoms and dietary/lifestyle advice being followed then refer community dietician for consideration exclusion diet/group work First line pharmacological treatment Single or combination All can be safely used long-term if necessary Adjust according to response Pain – trial antispasmodics eg mebeverine, buscopan Diarrhoea – trial anti-motility = Regular loperamide – titrate to response. Can use liquid (fine dose adjustments) or ‘imodium instants’ for rapid effect Constipation –Non fermentable fibre – cracked linseed (1 tsp bd to 1 tbsp bd), or celevac (3 bd) or normacol (1 sachet bd) or Stool softener laxatives eg Magnesium hydroxide 20ml od/bd or movicol NB care with lactulose  gas; senna pain; consider trial of prucalopride for 4 weeks. Aim is soft well-formed stool passed easily and with control Alternating diarrhoea / constipation: use non-fermentable fibre supplements as above. Take daily (do not stop on ‘diarrhoea’ days) to regulate the bowel. Second line pharmacological treatment Tricyclics the most effective pain management in IBS. Take 3-4 months to work (be patient!). Start at low dose 10mg nocte amitriptyline - increase to 25mg after 2 weeks. Daytime sleepiness wears off – persevere! F/U at 3-4 months. Continue medium-long term if effective. If truly intolerant try SSRIs (generally less effective). Psychological intervention Consider CBT, hypnotherapy, and/or psychological therapy if do not respond to above pharmacological treatments (refractory IBS) Consider secondary care advice/guidance Addenbrooke’s/CATCH IBS guidelines October 2014 Links to NICE, BSG guidelines, BDA etc

Example referrals to ? reconsider

Dyspepsia – non-fast-track

Dyspepsia Flow Chart

Issues Rarity of PUD if HP-ve and no NSAIDs Extreme rarity of UGI cancer <55yrs And doesn’t present with simple dyspepsia Mx of IBS / constipn in pts with epigastric pain Scoping to manage pt (and doctor) anxiety What about Barrett’s?

Summary New referral process for GI We’re happy to advise incl some words as well as boxes ticked! We’re happy to advise Feedback welcome