20 YEARS IN GAST ROENT E ROLOGY
breakthrough for diagnostic investigations, by controlling and slowing down the movement of the pill-sized camera within the body to improve visualisation and guide navigation.7
In addition, the introduction
of artificial intelligence (AI) assisted upper gastrointestinal endoscopy has gone a long way to help overcome inter-operator variability, by aiding endoscopists in the accurate detection and diagnosis of lesions and early cancers.8
Too much of a good thing However, endoscopy is not without its limitations. The procedure is invasive and expensive, costing an average of £436 per patient for endoscopy and biopsy of the upper gastrointestinal tract for patients over 19 years of age on the NHS.9
In practice,
endoscopists also report that this method requires a significant level of expertise in order to make a conclusive decision when investigating conditions such as gastritis.10 The greatest concern with endoscopy
is the overwhelming backlog of referrals that have amassed over the last few years. In 2015, the UK Government announced its Be Clear on Cancer national campaign to raise awareness of oesophago-gastric cancers, encouraging patients with symptoms of reflux to visit the GP in order to detect cancer sooner.11
There is much discussion in the industry about the benefits of implementing non-invasive, case-selection methods to diagnose upper gastrointestinal conditions before endoscopy, drawing from a large evidence base and experience from other countries, and functional serology is presenting itself as a viable and realistic option.
services and postponing non-essential appointments indefinitely. This exacerbated the already dire backlog of referrals, creating huge waiting lists, which quickly overwhelmed endoscopy services with both new and existing patients when appointments reopened. Clinics are slowly beginning to recover from this wave of referrals and work through the myriad of cases, but patients are still often waiting weeks at a time before receiving a diagnosis, decreasing patient satisfaction and retention. It can also be challenging for clinicians
Although this was
a much-needed initiative, it resulted in a massive increase in demand for gastroscopy services, which were inundated with concerned patients referred from primary care. Outpatient appointments nearly doubled, from 2005 to 2017, and patients were waiting more than the 18-week standard for hospital appointments, largely owing to an increase in referrals.12 Fast forward to 2020 and the world was struck by the COVID-19 pandemic, temporarily closing all routine endoscopy
in primary care to determine when to send a patient for endoscopy, as some conditions – such as atrophic gastritis – might not present with distinguishable symptoms early in development. As a result, patients often don’t qualify for endoscopy according to the predefined criteria until a later, less treatable stage. On the other hand, there are also many instances of patients being referred too soon, when gastroscopy cannot identify significant disease within the gastric mucosa, resulting in a low diagnostic yield. This often means that those with potentially fatal cases of gastrointestinal disorders may not be diagnosed until a
very late stage – typically through the presentation of alarm symptoms – or even missed. This complexity in diagnosis goes some way to explaining the abysmal five- year survival rate of just 21% for gastric cancer patients.13
This leaves a distinct void in the patient care pathway, with no clear way to distinguish high-risk patients from low/ negligible risk patients, with some referred unnecessarily, while others are referred far too late, adding to the pressure on already overwhelmed services.
Earlier interventions This shortfall in the diagnostic pathway has forced a change in approach, and gastroenterology is now transitioning to implement more non-invasive and point- of-care diagnostic tests to streamline the patient care pathway for those most at risk. Efforts are being made to introduce these test methods prior to endoscopy, in order to alleviate the burden on overstretched services. The British Society of Gastroenterology (BSG) published a set of guidelines in 2019 clearly stating that the key to early detection of gastric adenocarcinoma is to non-invasively detect pre-cancerous conditions before endoscopy.14
The identification of H. pylori as a precursor for gastric cancer and precancerous conditions, including atrophic gastritis, has been an important step to help fill this gap in early cancer detection and prevention. This has enabled the introduction of H. pylori tests in primary care, with various assay formats – including serum, stool antigen, and urea breath tests – now available to identify an
H.pylori infection and pinpoint patients for eradication therapy. However, these tests need to be selected carefully and physicians need to be aware of the limitations of each,15
and H. pylori tests
alone are unable to detect damage to the gastric mucosa, meaning that they cannot identify patients at high risk of developing gastric adenocarcinoma.
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