1. Suspected Upper GI cancer 2WW pathway: direct access pilot
Dr Nina Lewis
Consultant Gastroenterologist and Honorary Assistant Professor

2. 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

3. 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

4. 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

5. 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

6. 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)

7. Oesophageal cancer
Most common presenting symptom is dysphagia

8. Oesophageal cancer
Dysphagia is caused by the malignant stricturing

9. Lung cancer can present with dysphagia

10. 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%

11. Chronic peptic ulcer disease
Helicobacter accounts for:
85% duodenal ulcers
60% gastric ulcers
NSAIDs account for:
14% duodenal ulcers
30% gastric ulcers

12. 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

13. Functional dyspepsia

14. 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

15. 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

16. Iron def anaemia and bowel cancer
~50% people
with incident
bowel cancer
have evidence
of IDA

17. 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

18. Gastric cancer Often asymptomatic
Presence of weight loss, post-prandial vomiting, iron def anaemia all reflect advanced disease

19. Lower GI pathway and diarrhoea

20. Diarrhoea can be caused by many things

21. Diarrhoea can be caused by many things

22. Weight loss is worrying

23. 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)

24. 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)