Gastroenterology
Rethinking upper GI referrals
Craig Vickery, a Consultant General and Upper Gastrointestinal Surgeon at West Suffolk NHS Foundation Trust, looks at how efficiency can be improved through the introduction of capsule sponge pathways. Around 64% of patients presenting with reflux symptoms can be managed without the need for an endoscopy by moving to this approach.
Endoscopy services are under increasing pressure from rising referral volumes, workforce shortages and even simply a lack of space. A particular area of growth is in the investigation of reflux symptoms, a common gastrointestinal (GI) complaint that can be a sign of serious underlying disease. Reflux is both a cause and a symptom of Barrett’s oesophagus, a precursor to oesophageal adenocarcinoma.1 However, thankfully, these more serious conditions are comparatively rare, with approximately five per cent of reflux referrals resulting in a Barrett’s diagnosis, and less than one per cent flagging oesophageal cancer.2
The
low diagnostic yield of the overall gastroscopy workload and the intense pressures faced by endoscopy departments are leading trusts to search for alternative ways to identify patients at higher risk. The upper GI surgery department at West Suffolk Hospital in Bury St Edmunds has successfully implemented capsule sponge testing into reflux diagnostics pathways, precisely to help overcome these challenges. This has resulted in more targeted triage of patients with reflux symptoms and helped to reserve endoscopy capacity for the patients most likely to have Barrett’s oesophagus and oesophageal cancer.
Managing reflux before referral Dyspepsia and reflux are some of the most common GI complaints seen in primary care in the UK, with dyspepsia accounting for between 1.2 and 4 per cent of all consultations.3 In many cases, symptoms can be effectively
managed under the care of a GP, initially with lifestyle advice and prescription of a proton pump inhibitor (PPI).4
diagnosis; the overall 10-year survival rate is only 12 per cent.7
Despite this, oesophageal cancer However, patients whose
symptoms persist despite treatment often require further investigation and referral to secondary care upper GI and endoscopy services. Similarly, those presenting with alarm symptoms, such as unexplained weight loss, raised platelet count or persistent nausea and vomiting, are referred directly through the suspected cancer pathway.5 Thankfully, reflux is rarely a sign of serious underlying pathology. Oesophageal cancer is one of the conditions primary care clinicians are most concerned about when assessing reflux symptoms, largely because the incidence – particularly of oesophageal adenocarcinoma – has increased in recent years.6
In addition, survival rates are poor, especially with late
The central challenge is identifying the small proportion of patients with Barrett’s oesophagus or cancer, while avoiding unnecessary invasive investigations for the much larger group with uncomplicated reflux.
is relatively uncommon in general practice, and the average full-time GP will encounter only one case every three to five years.8 Although the risk of disease is still there,
referral based purely on reflux symptoms alone has a low diagnostic yield. Across much of the country – and in West Suffolk before the introduction of the new pathway – many patients referred for reflux undergo a gastroscopy as a standalone investigation before being discharged back to primary care if no abnormal tissue is detected. While this approach is effective in excluding serious pathology, it often does little to address the underlying cause of symptoms. As a result, patients frequently present again to their GPs with persistent reflux, despite having received a normal endoscopy result. This traditional reflux investigation pathway
creates difficult challenges for both primary and secondary care. The central challenge is identifying the small proportion of patients with Barrett’s oesophagus or cancer, while avoiding unnecessary invasive investigations for the much larger group with uncomplicated reflux. At the same time, patients with uncomplicated
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