Endoscopy Recovery Age ≥55 with weight loss - PowerPoint Presentation

Slide1

Endoscopy Recovery

Age ≥55 with weight loss

AND 1 or more

Upper abdo pain

Reflux

Dyspepsia

Dysphagia

2WW OGD

Based on NICE NG12. Section 1.2 Upper GI tract cancer

Upper GI Suspected Cancer – Recognition & Referral

Edinburgh Dysphagia Score (EDS) - Calculation

A

AgePoints

18-36040-49

450-59560-69

670-79

780-898

90-999

B

GenderMale0

Female-1

CCurrent Acid Reflux

Yes-1No0

D

Dysphagia localises to NeckYes-2No0

E

Weight

loss >3 Kg

Yes

2

No

0

FDuration of Symptoms > 6mYes-1.5No0

EDS = A+B+C+D+E+FIf score ≥ 3.5 patient requires urgent investigation as higher risk of cancerIf score < 3.5 patient can have routine endoscopy

Rhatigan et al 2010 – 574 patients

30-35% 2WW referrals EDS < 3.5

20% cancer rate with EDS >3.5

1 missed cancer with EDS <3.5 NPV – 99.3%

Murray et al 2012 – 2000 patients

3 patients with EDS of 3 had cancer NPV – 98%

Age ≥55 with weight loss

AND 1 or more

Upper abdo pain

Reflux

Dyspepsia

Dysphagia

2WW OGD

Based on NICE NG12. Section 1.2 Upper GI tract cancer

Please state

on referral

Triage

≥ 3.5 to 2WW

<3.5 within 6 weeks

˟

EDS- Edinburgh Dysphagia Score

Upper GI Suspected Cancer – Recognition & Referral

Age ≥55 with 1 or more

Non 2WW OGD

Raised platelets AND ≥ 1 of

Weight loss

Reflux

DyspepsiaUpper abdo pain

Nausea/ vomiting

Weight LossRefluxDyspepsiaUpper abdo pain

Treatment resistant dyspepsia

Upper abdo pain AND anaemia

Haematemesis

Upper GI Suspected Cancer – Recognition & Referral

Based on NICE NG12. Section 1.2 Upper GI tract cancer

Nausea /Vomiting

AND

≥ 1 of

2WW LOWER GI REFERRAL

Any age Anal/rectal/abdo mass

Abdo pain AND

w

t loss

≤50Rectal bleeding AND one or more of

Fe def anaemia

Wt loss

CBH˟

Abdo pain

≥ 50

Rectal bleedingAnd 1 or more

CBH˟

Fe def anaemia

≥50

Abdo pain OR wt loss

≤ 60

CBH˟

OR fe def anameia

≥ 60

non fe def anaemia

FIT

≥ 10

Consider GI

referral

or advice & guidance

i

f concerns/persistent symptoms

Consider repeat FIT in 3m & if remains <10 bowel ca can be excluded

FIT testing has a very high

negative predictive value for

colorectal cancer

˂

10

Based on NICE NG12. Section 1.3 Lower GI tract cancer

Please see referral template for guidance on useful investigations to request at time of referral to enable secondary care triage

Lower GI Suspected Cancer – Recognition & Referral

˟CBH – Change in bowel habit – please specify how bowels have changed.

To constipation – Ix by CTVC/CT

abdo

To diarrhoea – Ix by colonoscopy

Patients referred as 2ww with a FIT of <10

and no

iron

def

anaemia

, rectal bleed or palpable mass

will

get a face to face review and can be stepped down from the cancer pathway if appropriate

Clinical guide for triaging patients with lower gastrointestinal symptoms

16 June 2020, Version 1

Classification: Official

Publications approval reference: 001559 Specialty guides for patient management during the coronavirus pandemic

On 29 April, Sir Simon Stevens and Amanda Pritchard’s letter set out the second phase of the NHS response to COVID-19. This included stepping up non-COVID urgent services as soon as possible. This guidance sets out how to manage patients with symptoms that might be due to colorectal cancer (CRC) and to identify those most in need of urgent investigation. It is important that patients with suspected colorectal cancer are able to access care. As such, GPs should continue to refer according to current NG12 guidelines.

Guidance on the management of patients requiring endoscopy services has been published and can be found here. Prioritisation and triage of symptomatic patients referred on a 2WW pathway To support appropriate referral from primary care, trusts should consider providing specialist telephone advice and guidance to GPs prior to formal referral and also to allow direct telephone consultations between patients and specialists.

Patient-reported symptoms together with blood test results (full blood count, ferritin, Urea and electrolytes and C-reactive protein), and the use of faecal immunochemical test (FIT) can be used to help clinicians prioritise referrals. Clinical teams will need to provide a triage process that reflects their local endoscopy and imaging capacity, including capacity from non-acute and independent sector provider sites.

Clinical guidance From the published evidence,

in the absence of iron deficiency anaemia, a palpable abdominal mass, rectal bleeding, or obstructive symptomsa FIT <10ug/gm has a negative predictive value (NPV) for CRC of >95%.

While the NPV and positive predictive value (PPV) of FIT test results 10-100ug/gm are unknown, preliminary data (supported by data from our FIT pioneers sites) show that a FIT test >100ug/gm is associated with a 1:4 chance of CRC or other significant pathology.

Patients should be therefore be considered for further investigation in accordance with the following:

1. For urgent endoscopy or CT (CTC or plain CT) • Early signs of a large bowel obstruction, eg lower abdominal pain and distension.

• Other NG12 specified symptoms with a FIT >100ug/gm who have not had a colonoscopy in the previous three years. • Symptoms deemed by specialist GI surgeons/ gastroenterologists at the point of triage, to merit urgent intervention. 2. For prioritised endoscopy or colonic imaging: (CTC, plain CT or colon capsule endoscopy) •

NG12 specified symptoms, with a FIT 10-100ug/gm.

• Other NG12 specified symptoms with a FIT >100ug/gm who have had a colonoscopy requiring no further investigation in the previous three years. 3. For patients to be safety-netted on a patient tracking list • NG12 specified symptoms, with a FIT <10ug/gm.

The utilisation of colonic imaging (colonoscopy, CTC or colon capsule endoscopy) for further investigation will depend on local capacity, clinical prioritisation and patient factors. Where colon capsule endoscopy is used, robust data collection and follow up processes must be in place.

While many patients with a FIT <10ug/gm will not require endoscopy, patients should not be discharged from the 2WW pathway on the basis of a FIT test alone, except in existing FIT pioneer service evaluation sites that were piloting the use of FIT before the COVID-19 outbreak.

Safety netting

Patients that do not require immediate investigation should be held on a patient tracking list (PTL) held by MDT co-ordinators for further management.

Appropriate safety netting should be put in place for these patients, to allow for a further clinical assessment should their symptoms change. Additional administrative support will be needed to coordinate and manage this process.

Patients for whom further investigation is deferred should be reassured that:

• their FIT result indicates that further tests are needed but this result is not usually caused by cancer

• due to the coronavirus (COVID-19) pandemic, their appointment for further tests will be booked at a later date. The patient should be given clear information about who to contact if they develop new symptoms or if their existing symptoms worsen. GPs should check that accurate contact information is held for all patients being held on a PTL and record the clinical safety netting advice given.

2WW Lower GI Referral

Any age Anal/rectal/abdo mass

Abdo pain AND

w

t loss

≤50

Rectal bleeding AND 1 or more

Fe def anaemia

Wt loss

CBH˟

Abdo pain

≥ 50Rectal bleeding

And 1 or more

CBH˟

Fe def anaemia

≥50

Abdo pain OR wt loss

≤ 60

CBH˟

OR fe def anameia

≥ 60

non fe def anaemia

FIT

≥ 10

Consider GI

referral

or advise & guidance

i

f concerns/persistent symptoms

Consider repeat FIT in 3m & if remains <10 bowel ca can be excluded

FIT testing has a very high

negative predictive value for

colorectal cancer

˂

10

Based on NICE NG12. Section 1.3 Lower GI tract cancer

Lower GI Suspected Cancer – Recognition & Referral

FIT

Triage with FIT – Timing

>100ug/gm – 2WW investigation

>10 <100ug/gm – Urgent investigation

<

10ug/gm – Safety netted W/L

˟CBH – Change in bowel habit – please specify how bowels have changed.

To constipation – Ix by CTVC/CT

abdo

To diarrhoea – Ix by colonoscopy

Asymptomatic Iron Deficiency

Anaemiaa

nd iron deficiency without anaemiaferritin <13 (female) or <30 (male)

Iron supplementation (3 months ferrous sulphate 200mg TDS or equivalent)Recheck Hb

and ferritin 3 monthly for 12 monthsFIT >10o

r >50y or strong FH of CRC

No further action required

Premenopausal

Female:FIT TTG

FIT <10 and <50y and no FH CRC

FBC

FerritinB12 and folateTTGHaemoglobinopathy screen (if indicated)

Urine dipFITFaecal calprotectinMale or post-menopausal female

Anaemia

resolves

Anaemia

persists

or recurs

Refer 2ww Gastro

Suggested Suspected and Symptomatic Referrals

Suspected Cancer

Please only use this section if you suspect the patient has colorectal cancer

Yes

Any Age with anal, rectal or abdominal mass

>=40 years with abdominal pain and weight loss

<50 years with rectal bleeding and more than one of:

Iron deficiency anaemia

Weight loss

Change in bowel habit

Abdominal pain

>=50 years with unexplained rectal bleeding

>= 60 with CIBH to:

diarrhoea

constipation

>= 60 with IDA

(Or low ferritin with no anaemia)

>= 50 with abdominal pain or weight loss and

FIT >10

<= 60 with IDA and

FIT>10

<= 60 with CIBH to:

Diarrhoea

Constipation

And

FIT >10

>= 60 years with any anaemia and

FIT >10

FIT has a very high negative predictive value for colorectal cancer.

If FIT <10 consider repeating after 3 months and if still <10 colorectal cancer can be excluded

Dyspepsia Guidelines 2020 – Supporting notes

 EndoscopyWhere community endoscopy is not available refer to secondary careThis indication will currently be triaged as a Category 3 and patients will be placed on the routine endoscopy waiting list

 H.PyloriTreat according to local guidelines Advice and GuidanceConsider discussion with local gastroenterology where there are any concerns or where patient symptoms not responding