Gastroenterology
reflux have limited or no specialist input once they have been cleared by gastroscopy, leaving symptoms poorly controlled and patients anxious about their health.
Moving beyond endoscopy-first referrals There are more efficient alternatives to endoscopy-only pathways, which are often limited in capacity by a lack of effective triage. A good example of a more effective pathway is at the West Suffolk Hospital in Bury St Edmunds, where EndoSign capsule sponge testing is routinely used to triage reflux patients prior to endoscopy. Often referred to as a ‘pill-on-a- thread’, this device consists of a small capsule containing a compressed sponge attached to a thin thread. Patients swallow the capsule, which dissolves in the stomach after approximately seven minutes. The sponge is then gently withdrawn, collecting cells from the entire oesophageal lining as it passes upwards. These cells are analysed for biomarkers associated with dysplasia, Barrett’s oesophagus and cancer. The hospital first introduced capsule sponge
testing during the COVID-19 pandemic to reduce reliance on endoscopy, which had significant restrictions at the time as an aerosol generating procedure. The test has since become part of a wider structured model of care with the creation of a full pathway around it, benefiting all reflux cases and acting as a gateway to specialist assessment, education and follow-up rather than acting as a standalone diagnostic procedure. Patients referred from primary care with
predominantly gastric symptoms, such as nausea, bloating and abdominal pain, are sent directly for gastroscopy. However, those with reflux symptoms like heartburn first receive a 30-minute telephone appointment with a specialist nurse, during which a comprehensive history is taken. Depending on this assessment, patients may still be referred for gastroscopy, but a significant proportion are invited to the capsule sponge clinic. The clinic is managed by specialist nurses with experience in performing the test and advising patients on reflux management. While the capsule dissolves, nurses use that time to discuss symptoms with patients and provide practical lifestyle advice. Following the capsule sponge test, results
are reviewed by consultants, or by experienced nurses with consultant support if required. If no biomarkers for dysplasia, oesophageal adenocarcinoma or Barrett’s oesophagus are identified, patients are discharged to their GPs with lifestyle advice and, where appropriate, suggestions for changes to medication. By this point, patients will have had two nurse-led interactions and, in many cases, their reflux
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symptoms will have already improved if they have followed the advice received.
Reducing pressure while improving care The introduction of this pathway at West Suffolk Hospital has delivered significant benefits for both patients and service capacity. More than 200 patients undergo the capsule sponge test each year, and around 64 per cent of those presenting with reflux symptoms can be managed without the need for an endoscopy. This has substantially reduced pressure on endoscopy services, particularly as previously almost all reflux patients would have been referred directly for gastroscopy. In addition, the relative simplicity and non-
invasiveness of the procedure mean that many patients can have the test and get their results far more quickly than through conventional endoscopy pathways. In many cases, capsule sponge appointments can be offered within one week, compared with much longer waits for endoscopy. Results are typically returned within seven to 10 days, giving patients rapid reassurance or timely onward referral for further investigations. Patients also often find the capsule sponge test much easier to tolerate than endoscopic investigations, due to the less invasive nature of the procedure, and the quicker test time. These local findings are similar to those seen at a national level, with high patient satisfaction reported during the NHS England pilot project and the Cytoprime assessment; patients described a perception of respect and dignity due to the less invasive testing procedure, and they appreciated the reduced wait times compared to endoscopy.9,10
The pathway has also changed patient care for those who have been discharged after normal results. Under the previous endoscopy- first model, patients regularly returned to the department because their symptoms remained difficult to control in primary care. Since the nurse-led capsule sponge pathway was introduced four years ago, the department has not seen any patients return with the same symptoms. The team believes that this is a result of the pathway’s emphasis on lifestyle advice and the help with symptom management that patients receive from the specialist nurses. This is backed up by patient satisfaction surveys that show consistently positive feedback, with many patients reporting that the new pathway was the first chance they had for a complete discussion of their reflux symptoms and management.
A new model for Barrett’s surveillance While capsule sponge testing at West Suffolk Hospital has transformed the assessment of patients referred with reflux symptoms, its role does not end at diagnosis. The technology is also being used for ongoing surveillance of patients with Barrett’s oesophagus, reducing the reliance on repeated endoscopies while still ensuring effective monitoring. It is crucial that patients with Barrett’s oesophagus are regularly monitored because the condition increases the risk of oesophageal adenocarcinoma by approximately 30 times.11
In traditional
pathways, that surveillance is carried out by regular gastroscopies but, at the West Suffolk Hospital, while patients have their initial diagnosis of Barrett’s oesophagus confirmed by endoscopy and biopsy, they then have the
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