Suspected Upper GI cancer 2WW pathway: direct access pilot Dr Nina Lewis Consultant Gastroenterologist and Honorary Assistant Professor
What I think Dysphagia needs oesophageal cancer and lung cancer excluding. In appropriate patients, dysphagia lends itself to be investigated in a direct-to-test way
What I think Dysphagia needs oesophageal cancer and lung cancer excluding. In appropriate patients, dysphagia lends itself to be investigated in a direct-to-test way. Patients presenting with any weight loss, iron def anaemia or diarrhoea need to be assessed in an outpatient clinic so that tests appropriate for the individual patient are organised
What I think Dysphagia needs oesophageal cancer and lung cancer excluding. In appropriate patients, dysphagia lends itself to be investigated in a direct-to-test way Patients presenting with any weight loss, iron def anaemia or diarrhoea need to be assessed in an outpatient clinic so that tests appropriate for the individual patient are organised Many patients do not fit into typical symptomology for a specific cancer but please continue to follow your instinct and refer
Processing of Upper GI 2WW referrals Cancer Office deliver paper copies of upper GI 2WW referrals in a marked folder to Front Desk, City Hospital Endoscopy Nina Lewis or Lorraine Clark vet referrals daily by 13:00 Straight to test OGD Gastroenterology clinic
Processing of Upper GI 2WW referrals Cancer Office deliver paper copies of upper GI 2WW referrals in a marked folder to Front Desk, City Hospital Endoscopy Nina Lewis or Lorraine Clark vet referrals daily by 13:00 Straight to test OGD Gastroenterology clinic Dysphagia Dyspepsia (that seems straightforward)
Oesophageal cancer Most common presenting symptom is dysphagia
Oesophageal cancer Dysphagia is caused by the malignant stricturing
Lung cancer can present with dysphagia
Proportion of dyspepsia cases Causes of dyspepsia Cause Proportion of dyspepsia cases Chronic peptic ulcer disease 10-15% Gastro-oesophageal reflux (with or without oesophagitis) 5-15% Malignancy <2% Functional (non-ulcer) dyspepsia 60-65%
Chronic peptic ulcer disease Helicobacter accounts for: 85% duodenal ulcers 60% gastric ulcers NSAIDs account for: 14% duodenal ulcers 30% gastric ulcers
Gastro-oesophageal reflux Absence of oesophagitis at endoscopy does not exclude reflux (may require pH studies) Common exposures: - young men - abdominal truncal obesity - hiatus hernia - delayed gastric emptying
Functional dyspepsia
Processing of Upper GI 2WW referrals Cancer Office deliver paper copies of upper GI 2WW referrals in a marked folder to Front Desk, City Hospital Endoscopy Nina Lewis or Lorraine Clark vet referrals daily by 13:00 Straight to test OGD Gastroenterology clinic Iron def anaemia Weight loss Diarrhoea Palpable mass Anyone you are worried about
Upper GI 2WW outpatient assessment for iron def anaemia Test to confirm or refute she has bowel cancer Test to confirm or refute she has UGI cancer Look for other site of malignancy particularly if weight loss is present Imaging +/- cystoscopy to confirm or refute she has urological cancer if haematuria present Small bowel biopsy to exclude coeliac disease Gastric biopsy to exclude helicobacter-associated gastritis whilst on aspirin
Iron def anaemia and bowel cancer ~50% people with incident bowel cancer have evidence of IDA
Upper GI 2WW outpatient assessment for iron def anaemia Test to confirm or refute she has bowel cancer Test to confirm or refute she has UGI cancer Look for other site of malignancy particularly if weight loss is present Imaging +/- cystoscopy to confirm or refute she has urological cancer if haematuria present Small bowel biopsy to exclude coeliac disease Gastric biopsy to exclude helicobacter-associated gastritis whilst on aspirin
Gastric cancer Often asymptomatic Presence of weight loss, post-prandial vomiting, iron def anaemia all reflect advanced disease
Lower GI pathway and diarrhoea
Diarrhoea can be caused by many things
Diarrhoea can be caused by many things
Weight loss is worrying
Processing of Upper GI 2WW referrals Cancer Office deliver paper copies of upper GI 2WW referrals in a marked folder to Front Desk, City Hospital Endoscopy Nina Lewis or Lorraine Clark vet referrals daily by 13:00 Straight to test OGD Gastroenterology clinic Iron def anaemia Weight loss Diarrhoea Palpable mass Anyone you are worried about Dysphagia Dyspepsia (that seems straightforward)
Pilot: GP direct access to Upper GI 2WW OGD or 2WW clinic GP direct access following 2WW UGI referral Straight to test OGD Gastroenterology clinic Iron def anaemia Weight loss Diarrhoea Palpable mass Anyone you are worried about Dysphagia Dyspepsia (that seems straightforward)