This issue...
Bridge overtroubled water?Millennium Issues ofGastroenterology inPerspective
Polishexperiencescreening in Polandhas now spread to58 centres
ESPCG continuesto growTen national groupmembers andindividual membersfrom a further ninecountries.
Endoscopywithout sedationHow I do it - apersonal view fromJohn Galloway
British Society ofGastroenterologyAnnual MeetingBirmingham21 March 2006
It is very good to see the launch ofGastroenterology in Primary Care,the journal of the Primary CareSociety for Gastroenterology.Congratulations to Editor RichardSpence, the Society’s ChairmanRichard Stevens and the PCSGCommittee for their energy inhitting the streets with thispublication at a time of greatchange and opportunity in the NHS.The publication of the January White
Paper on Care Outside Hospital re-
emphasises the primacy of primary care
in the provision of healthcare services
and, although we might have concerns
about where the money is coming from,
sets out new directions of travel for the
provision of services, many of which
have profound implications for the
provision of GI services by general
practitioners and their teams.
The PCSG has always tried to support
evidence-based management of
gastrointestinal problems and also to
support general practitioners actively
engaged in research, education and
service provision. In particular we have,
over many years, attempted to improve
the terms and conditions under which
GP endoscopists worked, in either
community or hospital settings, and the
work of GP endoscopists and
endoscopy nurses in providing more
endoscopy capacity outside hospital is
likely to become even more important
in the years ahead. Issues of
accreditation of endoscopists working
in the community will undoubtedly
arise, and the Society is set to play an
active role in this area too. Practice
based commissioning will give all of us
the opportunity to review our patients’
needs and, working together, improve
service provision, perhaps by
contracting for services with non-
traditional providers. Finally, the
continued expansion of the GPs with
Special Interests programme provides
an enabling framework for much of this
work, although PCTs and hospitals have
so far been slow to grasp the potential
value of general practitioners with
expertise in particular clinical areas in
helping them to set and develop
prescribing and management strategy
across whole PCTs and across the
interface between general practice and
the hospital.
So, 2006 looks like being an exciting
time for primary care gastroenterology
and we hope that our new publication
will reflect this excitement and provide
useful guidance and contacts for
everyone interested in this important
clinical area.
Professor Roger JonesPresident, PCSG
Welcome to the relaunched journal of thePrimary Care Society for Gastroenterology.
‘Gastroenterology in Primary Care’ will beproduced quarterly and report on news,developments and meetings in the field.
The journal will also serve as the
mouthpiece of the PCSG and, as well as
other content, carry reports of all our
meetings. This year we will be holding
our session at the British Society of
Gastroenterology meeting on the
afternoon of 21st March. Details of the
programme appear on the back page of
this issue. In addition we shall have our
Annual Scientific Meeting in October
and will be holding the definitive GP
G A S T R O E N T E R O L O G Y I N P R I M A R Y C A R E :
an exciting future
I N P R I MARY CAR E
MARCH 2006
endoscopists meeting in November.
Much is changing in the field of
endoscopy provision and I am pleased
to report that the society is being seen
as the definitive voice on the issues
surrounding the provision of endoscopy
services outside hospital.
The NHS is currently in a greater
state of change than at any time in its
history. Throughout this flux we have
the opportunity to define both the
scope and standards of our area of
special interest. I hope this journal will
be a major tool in achieving this.
Richard StevensChairman, PSCG
CHAIRMAN’S MESSAGE JOURNAL OF THEPRIMARY CARESOCIETY FOR
GASTROENTEROLOGY
Gastroenterology
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by non-selective non-steroidal anti-inflammatory drugs (NSAIDs) should berestricted to patients who require continued NSAID treatment and have anincreased risk to develop gastrointestinal complications. The increased riskshould be assessed according to individual risk factors, e.g. high age (>65 years ), history of gastric or duodenal ulcer or upper gastrointestinalbleeding. Side effects: Common: Headache, diarrhoea, constipation,flatulence, upper abdominal pain. Please refer to Summary of ProductCharacteristics for information on other side effects. Drug interactions:Protium® is metabolised in the liver via the cytochrome P450 enzyme system,however no clinically significant interactions have been observed in specific testswith antipyrine, caffeine, carbamazepine, diazepam, diclofenac, digoxin,ethanol, glibenclamide, metoprolol, naproxen, nifedipine, phenprocoumon,phenytoin, piroxicam, theophylline, warfarin and an oral contraceptive. As withother acid suppressants, the absorption of pH-dependent drugs such asketoconazole may be altered. Foods or antacids do not affect bioavailability ofProtium®. Basic NHS Price: 28 x 40 mg tablets £21.69, 28 x 20 mg tablets£12.31, 5 x 40 mg vials £26.57. Legal Category: POM. MarketingAuthorisation numbers: Protium® 40 mg – PL 20141/0002, Protium® i.v. – PL20141/0003, Protium® 20 mg – PL 20141/0001. Protium® is a registeredtrademark of ALTANA Pharma AG, Germany. Further information is available fromALTANA Pharma Ltd, Three Globeside Business Park, Fieldhouse Lane, Marlow,Bucks SL7 1HZ. Telephone 01628 646400. Last updated: December 2005.PAN214/040106/P
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Bridge overtroubled water?The theme of a primary care/secondary care bridge
chosen by the PCSG for the Millennium Issues ofGastroenterology in Perspective remains as appositeas ever and a strong bridge is now needed moreurgently than ever before.The exacerbation of the purchaser-provider split embedded in
Payment by Results (PBR) and Practice Based Commissing (PBC) will
have far reaching consequences. Added to this is the
top slicing by Strategic Health Authorities (SHAs) of
15% of total NHS local budgets to place with the
independent sector, where private providers of health
care are invited to bid for services hitherto largely
contained within the NHS. SHAs already have lists of
preferred providers drawn up and the bidding process
has started. Some GPs are looking at the feasibility of
Limited Liability Partnerships (LLPs) to try to retain
this budget with an “NHS” body, despite the private
partnership status. This major undertaking requires
investment of time and money. In other areas private
providers are looking to take over management of PCTs.
Through all this major change it is likely that there will be a
degree of destabilisation of some existing services. PBR and PBC are
by their nature opposing forces. Through PBR hospitals will try to
increase health resource group (HRG) activity for individual patients.
Forward looking Trusts my well try to draw elements of primary care
into this activity through “outreach” clinics. GP groups or consortia,
on the other hand, will use PBC to try to achieve savings by
regulating their referral patterns, and will unquestionably use the
services of GPSIs to provide a cheaper alternative service to
secondary care referral. Added to this, private providers may try to
pick off “cherries” from primary care, e.g. chronic disease
management, currently earning well under the Quality and
Outcomes Framework (QoF) points payments. They may also employ
“cheaper” professionals from elsewhere to deliver services -
American Physician Assistants are already working in the NHS.
British GPs and Consultants may have become over-priced in the
eyes of some policy makers.
These changes threaten the integrity of both primary and
secondary NHS care and it is more vital than ever that an effective
dialogue exists between the two. All the more surprising, therefore,
that the BSG “GI Service Review” completely fails to mention the
contribution made by GPs to the gastroenterology workforce
(section 4.2).
We are now seeing the fragmentation of the NHS that many had
assumed would always exist in its present breadth. Its preservation
as a comprehensive healthcare system, previously the envy of the
world, will only take place by cooperation between primary and
secondary care doctors at a level that has not been achieved up to
now. This cooperation needs to take place right across the new
models of working that emerge in the immediate future. What is
certain is that healthcare provision in Britain is going to look very
different in 2-3 years time.
Editor, Dr Richard Spence,GP and Endoscopist, Bristol
Dr Richard SpenceThe UEGW provided a very
interesting session on this subject. DrChristian Poeta from Tubingen inGermany spoke on problems of
reflux in neonates. As a neo-
natologist, his interest in the subject
was sparked by the fact that 19% of
infants admitted to US Paediatric
Hospitals are put on prokinetics
(cisapride or metoclopramide). Why?
Making the diagnosis at this
tender age is difficult since reflux is
so easily facilitated. Aggravating
factors are the frequent, high volume
feeds and the lower oesophageal
sphincter (LES) is “under water” most
of the time. Measurements show a
normal reflux rate of 3-5 episodes an
hour but the acid content is low. The
main abnormality in infants with
reflux disease (GERD) is a higher acid
content in the refluxate, although the
number of reflux episodes is not
increased and gastric emptying is
not delayed. Measuring intra-
oesophageal pH is also no good
because pH is >4 in 92% of preterm
infants.
An important differential diagnosis
is cow’s milk allergy (can occur in
pre-term babies). Diagnosis is made
from blood eosinophilia, and
eosinophilic infiltrates can be
demonstrated in antral mucosa. The
conclusion was that GERD is a
serious problem for only few; reflux
is usually physiological; in the
presenter’s view there should be no
need for prolonged hospitalisation and
the use of prokinetics is unjustified.
A later speaker (Dr SylviaSalvatore, Varese, Italy) estimatesthat 5-9% of infants have
troublesome reflux and showed data
demonstrating a steady increase in
reflux through to teenage. The risk
for developing reflux appears to be
higher when it is present in infancy
and she suggested that adult GERD
may start in childhood and may be a
lifelong disease.
Even more alarming
was the presentation
from Dr FredericGottrand, Lille, Franceon the presence of
Barrett’s oesophagus in
children, 5 years being the
youngest reported age for
the condition. Diagnosis
depends on the finding of
intestinal metaplasia in
biopsies. Even adenocarcinoma
occurs; he described 14 patients
under the age of 25 years of whom
10 died. Biopsy recommendation
during endoscopy is the same as with
adults, ie 4 quad-rantic biopsies
every 1 cm of Barrett’s mucosa, and
then regular endoscopic surveillance.
(Clearly more “joined-up thinking” is
needed regarding the indications for
endoscopy in young adults presenting
with troublesome reflux symptoms).
Finally, Dr Marc Benninga,Amsterdam, Holland discussed the
safety of acid-suppressing drugs in
children, showing that PPIs heal
severe GORD and resolve symptoms
and have a high margin of safety.
Concerns have been expressed that in
neonates there might be a risk
rarely of neutropenia precipitating
bacteraemia. In Holland cisapride is
still allowed for the under 3s and is
often co-prescribed with a PPI. I heard
about Sandifer’s syndrome for the
first time (where the child develops
abnormal head and neck postures in
response to gross acid reflux).
Dr Anders Paerregaard,Copenhagen, chaired the session
and expressed the concern that many
still feel regarding the actual
longterm consequences of acid
suppression.
EDITORIALUEGW REPORTOesophageal reflux diseasein infancy and childhood
Dr Galloway is a GP endoscopist,treasurer of the PCSG and
RCGP representative on JAG
15- 20 years ago nearly all upper GIendoscopy was performed with sedationand local throat anaesthesia. Sedationusually included a cocktail of intravenousdiazepam and pethidine with an averagedose of 10mg and 50 mg respectively.This would heavily sedate most patientsand few would have much memory of theprocedure. Patients would sleep forseveral hours afterwards and not bepermitted to operate machinery or driveuntil the next day because of the longhalf life of diazepam.This tendency to heavy sedation allowed the
endoscopist to spend a long time carrying out the
procedure on an uncomplaining patient.
Occasionally patients would be over sedated and
require ventilation and administration of reversing
agents. The hypoxia that occurred was not fully
appreciated until pulse oximetry was routinely
used and this lead to progressively lighter sedation
with short acting midazolam alone and the term
light conscious sedation was born. This means that
the patient should be conscious, responsive and
calm. This lighter level of sedation demands greater
speed and dexterity from the endoscopist. The
mortality associated with gastroscopy of 1 in 2000
reported by Amanda Quine in 1995 was in part
related to the sedation techniques used in the past.
Endoscopy outside the hospitalWhen I started endoscopy outside hospital in
1994 I had to weigh up the risks of even light
conscious sedation and opted only to offer
endoscopy without intravenous sedation, using
only local anaesthetic throat spray. I felt in
practice there was little difference in the patient
experience between light sedation and no
sedation. Those patients who are intolerant of
the procedure may become disinhibited with
small doses of midazolam making the procedure
more difficult for the endoscopist.
Original fibreoptic gastroscopes were large in
diameter and the image was poor compared to
modern day videoscopes. Intubation was more
traumatic, often done blind and the whole
procedure would take longer to get adequate
views. Duodenal intubation was also traumatic
as the pylorus had to be entered by force in
many cases. The introduction of fibreoptic and
later videoscopes of a diameter slightly less than
10mm radically facilitated the procedure. In
particular, intubation with a narrow endoscope,
performed under direct vision was easier and
improved image quality, giving panoramic views
of the upper GI tract leading to faster
procedures. Most diagnostic upper GI
endoscopy with a single biopsy for a CLO test
should not take more than 3-4 minutes and this
is one reason why sedation is less necessary.
Informed consentInformed consent is a very important part of
gastroscopy. I send out an explanation leaflet
with the consent form to the patient once I have
received a referral. Patients can read through
the leaflet before booking their appointment
and discuss the procedure with a qualified
health professional involved with the service.
This is a valuable way of allaying fears before-
hand and filters out any patient who feels they
would be unsuitable for an unsedated procedure.
The unsedated patientThere is a slight difference in technique for the
unsedated patient. The group of patients willing
to have the procedure done without sedation
are to a certain extent self selecting but most
can be persuaded if their fears and anxieties are
overcome beforehand with a full explanation of
the procedure. Anxieties are usually about
whether they will be able to breathe normally,
choking and gagging and whether the
procedure will be painful. Some patients are
more worried about what will be found and this
has to be addressed too. I reassure the patient
that there will be no pain, they will be able to
breathe normally and gagging will be
minimised by the throat spray and limited
usually to the first few seconds of intubation.
Because great care is taken not to rush, most
patients are pleasantly surprised. I emphasise
that concentrating on slow regular breathing is
very helpful as it reduces the gag reflex and
helps the patient to focus. (It opens the pharynx
and usually keeps the epiglottis out of the way
-swallowing and choking close the passage).
Handling of the endoscope.The endoscopist should guide the endoscope
with the right hand and not leave this to the
assistant. The left hand alone should manipulate
both wheels and the valves. The right hand
should rarely leave the insertion tube, except for
taking biopsies. Keeping control of the insertion
tube and its economy of gentle movement are
probably the most important tips for a
successful unsedated procedure.
Both wheels and valves manipulated with theleft hand
Preparing the patientI usually spray the patient’s throat in a separate
room from where the procedure is performed. I
ask the patient to lie down on an examination
couch and explain that the throat spray has a
banana flavour which helps to disguise the bitter
taste of xylocaine. I explain that the throat spray
will make the throat numb for about 10 to 15
minutes and that the procedure will last about
3-5 minutes. I ask the patient to allow the spray
to build up in a pool in the back of their mouth
and not to swallow until I have finished spraying.
I usually use about 10 puffs of spray and warn
the patient that they will feel a warm sensation as
the local anaesthetic starts to work. Having
sprayed their throat and having taken away any
dentures I escort the patient into the endoscopy
room and introduce them to the two nurses who
will look after them throughout the procedure.
The endoscopyTalking to the patient throughout the procedure
with encouraging words is essential as is giving
them a running commentary of progress and
how much longer it will take. The patient is
Endoscopy witHOW I DO IT - A PERSONAL V
asked to lie on their left side and one nurse is
positioned at their head and one at their side to
hold their right hand and assist me in taking
biopsies. Before intubation, I shield the patient’s
eyes from the endoscope and then place it in
their mouth and wait for a few seconds to get a
good view of the back of the tongue and soft
palate. The dialogue starts with me explaining
that I am advancing the scope over the tongue
and that they may feel a slight gag reaction but
not to worry as it will be short lived. I advance a
little further asking the patient to concentrate
on their breathing as I go beyond the soft palate
into the pharynx and visualise the larynx. I then
advance the scope towards the back of the
larynx and intubate the upper oesophagus,
sometimes asking the patient to take a swallow
if the scope is not advancing freely.
Aim the endoscope toward the area markedXXXX to intubate the oesophagus
This is the end of the most difficult part of the
procedure for the patient and it is worth telling
them this for reassurance. I also pause now for
the patient to compose themselves and regulate
their breathing while I wash away any sputum
or lubricating jelly from the lens.
I proceed down the oesophagus into the
stomach insufflating very little air to minimise
gas bloat and belching as this can be
uncomfortable and upsetting for the patient. I
will always try to aspirate any fluid from the
stomach at this stage to reduce the risk of reflux
during the procedure. I only insufflate enough
air to visualise the pylorus so that I can intubate
the duodenum and then reassure the patient
that there will be no more pushing of the
endoscope. Intubation of the duodenum can be
unpleasant as sometimes the endoscope has to
be pushed through a closed pylorus and if the
stomach is too full of air it can result in
uncontrollable belching followed by a spell of
gagging. I take any duodenal biopsies at this
stage without too much further scope
thout sedationVI EW FROM JOHN GALLOWAY
manipulation and then pull back into the
antrum to take a CLO test if necessary. It is easy
to retrovert the endoscope at this stage as
sufficient air will have been insufflated to get a
good view of the cardia. I tend to take any lesion
biopsies on the way out minimising the need to
move the endoscope any more than necessary.
Before leaving the stomach it is easy to get
panoramic views to make sure no lesions are
missed. I will also deflate the stomach before
leaving which makes the patient more
comfortable. Oesophageal biopsies can be taken
on the way out, again minimising movement of
the endoscope. Withdrawal is done gently
making sure the endoscope is straight so as not
to cause any trauma on extubation.
The patient should be reassured all the time. I
give a running commentary and tell them what
to expect at every point. Progress should be
reported - signalling when you are half done,
three quarters done, nearly finished and that
they may feel a slight tug as you take a biopsy
but no pain. If the patent belches, coughs or gags
reassure them that it is okay and not to worry.
After taking biopsies, especially in the
oesophagus, warn the patient that they may
taste a little blood.
After the procedure I ask the patient to rest
on their back for a minute or two and let them
wipe away any saliva with a tissue. Then I escort
them back to a consulting room and give them
a full explanation about the findings and further
management. I tell them that the numbness in
the throat will wear off in a fewminutes following
which they will be able to have a cold drink.
Because they have had no sedation there is no
restriction in their activities for the rest of the day.
Ultraslim gastroscopeA recent acquisition to my department has been
a Pentax ultra slim gastroscope. This is only 6
mm in diameter and has a tiny cross sectional
area. This endoscope has some important
advantages but there are disadvantages as well.
The image is comparable to a standard 9 mm
gastroscope but because of its size water
droplets from the washer are slower to clear
from the lens. Insufflation is slower because of
the smaller air channel. The endoscope is narrow
enough to pass through the nostril but I find
that this is more uncomfortable than through
the mouth and still favour the latter as a route
of intubation. The small size is very well
tolerated in the throat but lack of rigidity can
lead to curling up in the pharynx if there is any
muscular spasm. I have overcome this by
applying the locks on the up/down control until
the endoscope is in the upper oesophagus. .
The diameter of the endoscope allows it to
pass through strictures with ease and intubation
of the pylorus is remarkably comfortable for the
patient. The endoscope cannot remove large
amounts of liquid quickly and biopsies are smaller,
although using disposable forceps with long
alligator jaws and a locating prong give good
results. The flimsiness of the endoscope means
that a highly contractile stomach takes control
and pushes it about more, prolonging the
procedure. Also incarcerated hiatus hernias and
cup and spill deformities are difficult to reduce
and navigate for the same reasons.
Ultra slim endoscopes are not so robust.
Already I have had a guide wire break and the
narrow channels have retained a cleaning brush
which required a rebuild of the endoscope -
luckily under guarantee. Pentax assure me that
the ultra slim endoscopes do not return to the
repair department any more frequently than
standard diameter endoscopes but common
sense dictates that such fine instruments needs
careful handling by the operator and support staff.
I would hate to be without the ultra slim
endoscope now, but if I had a choice I would
stick with the 9 mm model as it is more robust
and endoscopy is usually faster with a more
controllable instrument. But, I have re-scoped a
few patients who were intolerant of the
procedure before and they have been much
happier with the ultra slim endoscope.
Ultra slim gastroscopes are about 25% of thecross sectional area compared to a 9 mm scope
ConclusionsI feel that most upper GI endoscopy can be
performed without intravenous sedation. The
procedure has to be highly interactive to
achieve the high success rate that I enjoy of
98% completion. Patients are self selecting so
this success rate would not be the same for all
comers. It is less consuming of resources and
does away with the need for recovery beds and
attached staff. It is safe as most complications
of upper GI endoscopy are sedation related.
@
www.Dr Huw Thomas, GP,Minehead
The DAVE project - Digital Atlas ofVideo Education (gastroenterology). www.thedaveproject.org This is a collection of teaching tools
which include video endoscopy clips
supported by radiological and surgical
images which is free to use for non
commercial purposes. Users can
submit their own clips.
BMJ learningwww.bmjlearning.comThis site has some interesting online
courses in all areas including
gastroenterology. It is free to BMA
members and has interesting new
modules on C.Difficile and IBS -
updates in management.
Users can build up a portfolio of
completed courses and print
certificates ready for the annual
appraisal visits!
Dr Richard SpencePOLAND
The Polish experience was presented by Prof Jaroslaw Regula(a good name for the job?). CRC screening commenced in Poland in
the year 2000 in a few centres, and has now spread to 58 centres,
with 50,148 people having been screened by the end of 2004. The
age group screened is 50-66 years, or 40-66 with positive family
history. Caecal intubation rate has increased from 85-91% and there
have been 51 complications including 5 perforations, but no deaths.
Pathology was found in 1:20 with 4-8% advanced adenomas
and 5% advanced neoplasia. Odds ratio for males to females is 1.8
so that men have nearly double the incidence of pathology
compared to women at the same age. So men may need CRC
screening earlier in life. “Colonoscopy is cheap in Poland” and is
the preferred screening method.
UK PLANSDr Alastair Watson from Liverpool presented the UK plans fora national CRC screening programme, due to roll out in 2006 and
based in 8 selected national centres. There is a belief that there is
a long development cycle from adenoma to cancer (5-25 years)
which was based on a few early papers.
Screening has 2 meanings: 1. opportunistic screening where the cost is low.2. population based screening where the cost is high.
Dr Watson says “I don’t believe any country in the world can afford
colonoscopy to screen the population”.
There are 6 available screening tools:1. Faecal occult blood (guiac)2. Faecal occult blood (immune)3. Flexible sigmoidoscopy4. Colonoscopy5. CT colography6. Faecal DNA test
The gold standard is to demonstrate a reduction in mortality
from CRC. To do this 10-15 years of follow-up are needed. Three
large studies have reported such reduction.
The percentage reductions in mortality were:Nottingham, UK 15%Funen, Denmark 18%Minnesota, USA 21%
Of the endoscopic procedures, flexible sigmoidoscopy detects
only 50% of proximal adenomas, but colonoscopy “has the
potential to kill someone”.
The planned UK programme is evidence-based and will be based
on faecal occult blood in the 60-69 age group, repeated every 2
years. If positive, colonoscopy will be offered “in 2 weeks”.
Recruitment will be from the national population database and
“bypasses primary care physicians - who are very busy people”.
Cost is estimated at £58 million in Year 1; colonoscopy workload
is estimated at 61,274 examinations, requiring 39 full time
“consultant colonoscopists”!
Colorectal cancer
screeningCOMPARING POLAND AND THE UK
GASTROENTEROLOGICAL RESOURCES ON THE WEB
Gastrohepwww.gastrohep.com This subscription service (£75 per year)
is an excellent resource for all matters
gastroenterological. It has excellent
summaries of recent published articles.
Remember all the PCSG publications
and other information is available at
the website: www.pcsg.org.uk
The Feldman GastroAtlas Onlineis also a good (free) resource for
slides for presentations etc. Access
www.gastroatlas.com - you have to
register but there is no charge.
PCSG Email ListThere is an active email list which is
open to all who are interested in
gasterenterological issues. It is free to
join - please encourage any GP’s or
nurses you meet to join the list. Go to
the website and click on the email list
button to join, or send an email to
[email protected] The list
is moderated - so signing up will not
result in “spam” mail - and it is a great
medium to discuss a variety of issues.
Recent topics have included tariff
prices for endoscopic procedures,
commissioning endoscopy services,
and GPSI in Endoscopy. Archives of
past postings are also available at the
PCSG website.
@
www.
Endoscope decontaminationand patients at risk of vCJD.The Decontamination Working
Group of the BSG has met with
representatives from the CJD Incidents
Panel in order to agree the consensus
guidelines and practical advice to all
endoscopists in the avoidance of risk.
The updated BSG decontamination
guidelines are on the BSG website
(www.bsg.org.uk) and advise what to
do when endoscoping patients who
have received quantities of plasma
product concentrates prior to when
donors were tested for vCJD (primarily
but not exclusively haemophiliacs and
patients with immunodeficiency
syndromes). There are estimated to be
about 6500 of these patients in the UK,
and the vast majority have now been
told of their risk (and asked to take
certain public health precautions to
reduce the risk of spread to others).
Chairmen: Dr Richard Stevens and Professor Pali Hungin14.30 Is Helicobacter pylori yesterday’s news?Dr Bob Walt. Consultant gastroenterologist, University
Hospital, Birmingham
15.00 The Hepatitis C epidemic in the UK and EuropeProfessor William Rosenberg. Professor of Hepatology,
Southampton General Hospital
15.30 Pharmacological and non-pharmacologicaltreatments for irritable bowel syndromeProfessor Roger Jones. Professor of Primary Care, Kings
College London School of Medicine
JOURNAL OF THEPRIMARY CARESOCIETY FOR
GASTROENTEROLOGY
Event Diary
20-23 March 2006BSG ASM InternationalConvention Centre,Birmingham.PCSG session 2.30pmTuesday 21st March
25 April 2006“Endoscopy in PrimaryCare” conference,De Vere Belfry,Warwickshire
13 October 2006PCSG (Primary CareSociety for Gastro-enterology) AnnualScientific Meeting andAGM, London, Contact:[email protected]
25-26 November2006GP EndoscopistsSymposium (TBC)
Gastroenterology in Primary Care Editor: Dr Richard Spence, [email protected] Web Editor: Dr Huw Thomas,[email protected] Produced by the Primary Care Society for Gastroenterology, Gable House, 40 High Street,Rickmansworth, Herts WD3 1ER Tel: 01923 712711 Fax: 01923 778131 [email protected] www.pcsg.org.uk
16.15 The PCSG Debate "Public plus private sector careis better than public sector care alone for NHS patientswith GI problems."Proposed by Dr Richard Smith, Chief Executive, United
Health Europe and former editor of BMJ. Seconded by Dr
Peter Evans, General Practitioner and director of Jubilee
Surgery Endoscopy Services Opposed by Dr Peter Fisher,
President of NHS Consultants Association and retired
consultant physician and gastroenterologist. Seconded by
Professor Elwyn Elias, BSG president 2005-2006.
17.30 Close
PRIMARY CARE SOCIETY FOR GASTROENTEROLOGYAt the British Society of Gastroenterology Annual Meeting, Birmingham, 21 March 2006
When a scope is used in such
patients, and the procedure is expected
potentially to contaminate instruments
with lymphoid tissue (biopsies,
diathermy and some balloon dilatation
techniques where the balloon is drawn
back into the biopsy channel); the scope
should be quarantined, and removed
from use except for further use in the
same patient. Endoscopy units could
consider retaining fully functional
endoscopes that are close to
decommissioning for potential use on
individuals at risk of vCJD
http://www.advisorybodies.doh.gov.uk/acdp/tseguidance/Index.htm
Towards better endoscopicdescription of refluxoesophagitis and Barrett’s.As well as the Los Angeles staging
system of oesophagitis, the inter-
national working group for the
NEWS SNIPPETS - Dr Huw Thomas
Classification of Oesophagitis (IWGCO)
is recommending Barrett’s is described
both by the distance that the
circumferential metaplasia and the
longest tongue extends above the top
of the gastric folds; ie. a patient who
has 4 cm of circumferential metaplasia
and a 2 cm tongue above this, Barrett’s
is recorded as Prague; C4 & M6.See Armstrong, D. Review article: towards consistency in the endoscopicdiagnosis of Barrett's oesophagus and columnar metaplasia. AlimentaryPharmacology & Therapeutics 2004 20(s5):40-47Lundell et al; Endoscopic assessment of oesophagitis: clinical andfunctional correlates and further validation of the Los Angelesclassification. Gut. 1999 Aug; 45(2):172-80.
Higher doses of mesalazinein UC?The recent ASCEND trial has recently
reported that mesalazine 4.8g/day was
significantly more effective than
2.4g/day, the currently used induction
dose in the UK.Hanauer SB et al. Delayed-Release Oral Mesalamine at 4.8 g/day(800mg Tablet) for the Treatment of Mderately Active UlcerativeColitis: The ASCEND II Trial. Am J Gastroenterol 2005; 100(11):1-8
ESPCG E U R O P E A N S O C I E T Y F O RPR IMARY CARE GASTROENTEROLOGY
Professor Greg Rubin, Professor of Primary Care, University of Sunderland
The ESPCG continues to grow, with 10 national group members, including the
PCSG, and individual members from a further 9 countries. It is actively involved in
promoting educational initiatives and research projects in general practice. Its most
recent project is a study of the diagnostic process for IBS in general practice, while
members have also been involved in the recent exercise to update the Maastricht
guidelines on H pylori management. Our key meetings are held at WONCA-Europe
and the UEGWmeetings. This year they will be held in Florence (27-30 Aug) and Berlin
(21-25 Oct) respectively. The Society’s AGM will be held during the Florence meeting.
All members of the PCSG are automatically members of the ESPCG. Our website at
www.espcg.org contains more information about our past and current activities.