ENDOSCOPY
decompensation and liver cancer,” said Dr McPherson. “Treating patients with non- alcoholic steatohepatitis (NASH) to prevent the development of cirrhosis is critical. After diagnosis, patients with NAFLD must be staged to determine their current disease severity. Many staging algorithms are available and in my unit we recommend that patients with NAFLD are staged in primary care using the Fib-4 score. We recommend referral to our clinic for those with in increased Fib-4 score as these individuals are likely to need specialist management. “Further staging is conducted and those with increased liver stiffness may then undergo liver biopsy to accurately stage disease severity.”
According to Dr McPherson, weight loss is the most effective treatment for NAFLD and studies have shown that individuals who managed to lose more than 10% of body weight have significant improvements in liver fat, hepatic inflammation and liver fibrosis. “Therefore weight loss of more than 10% of body weight should be the goal for all patients,” he asserted. “Unfortunately only 10% of patients with NAFLD manage to sustain this degree of weight loss. Patients are much more likely to achieve weight loss if they’re seen in a specialist weight management clinic, so consider referring appropriate patients to these services. “All types of exercises improve NAFLD, even if individuals don’t lose weight, so encourage patients to participate in a suitable exercise programme. Many patients with NAFLD meet the NICE criteria for bariatric surgery, so consider referring appropriate patients for this procedure. As bariatric surgery is an excellent treatment for NAFLD. “Importantly, the majority of patients with NAFLD die a cardiovascular related death, rather than a liver related death, so modifying cardiovascular risk is vital in patients with NAFLD. All patients should be screened annually for diabetes, hypertension and Dyslipidemia and these conditions should be managed appropriately.” For patients with NAFLD and minimal fibrosis, Dr McPherson described lifestyle change and modification of cardiovascular risk as “the cornerstones of management” and added that other treatments are not usually required. “However, restaging patients every three years will help identify those who progress,” he noted. “Individuals with moderate to severe fibrosis are at significant risk of progressing to cirrhosis, so should be more actively managed. High dose
Clostridium difficile
vitamin E is available and randomised control trials have shown it significantly reduces hepatic inflammation. “There are now a multitude of randomised controlled trials of new drugs in NASH, so consider referring appropriate patients for these clinical trials. “Finally, for individuals who are found to have cirrhosis, remember to screen for cirrhosis related complications, as well as managing their underlying NAFLD.”
How to deliver a high quality colonoscopy
“Every patient referred for colonoscopy should be able to expect a very high quality experience,” asserted Siwan Thomas-Gibson, consultant gastroenterologist & endoscopist, St Mark’s Hospital.
“Colonoscopy is invasive, inconvenient
and often uncomfortable. As we know it requires dietary restriction, bowel purging, and although it is a safe procedure, it is associated with risks.”
Siwan believes that each endoscopist and their team should do their very best to optimise the experience for all patients, referring to it as “the gold standard investigation for assessment of the large bowel” and, in many cases, providing the opportunity for therapeutic intervention. “The British Society of Gastroenterology has published a set of key performance indicators and quality assurance standards for colonoscopy,” Siwan explained. “This, as well as the European equivalent from the ESGE, identifies the measures which should be recorded routinely – and which allow benchmarking between individuals and
We are familiar with a lot of the technical key performance indicators. However, improving performance by recommending aspirational targets is part of the BSG Endoscopy Quality Improvement Programme
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services. So what are the key components of colonoscopy technique? “We are familiar with a lot of the technical key performance indicators. However, improving performance by recommending aspirational targets is part of the BSG Endoscopy Quality Improvement Programme. “The National Endoscopy Database is an exciting innovation launched in 2018. This database hosted by JAG will work across all endoscopy reporting platforms and will collate data of endoscopies performed in the UK, in both NHS and private settings. Individual endoscopists will be able to reflect on their data in comparison to local colleagues and to national figures.” Siwan warned that the technical skill of colonoscopy is only one aspect of delivering a high quality experience, adding that non- technical skills and team-working are also crucial. “Latest JAG certification processes include an assessment of the endoscopic non-technical skills which have been identified as being important in providing safe, high quality colonoscopy,” she noted. “From referral to follow up there are multiple opportunities to improve the quality of patient experience. Analysing adverse events and errors – even those without consequence – and near misses, will provide opportunities to learn and prevent recurrent errors. A no-blame culture is imperative to optimise this. “JAG’s latest initiative to “Improve Safety
and Reduce Error in Endoscopy (ISREE)” is an exciting programme that has brought together a multidisciplinary group of experts. ISREE will develop training methodology in human factors, non-technical skills and team working - strategies to prevent and learn from error, and methods to improve from reporting errors. It will also investigate ways of supporting those endoscopists identified as having training needs. “It is an enthralling time to be involved in British endoscopy with so many opportunities to improve our ability to deliver high quality colonoscopy - even within the challenging NHS environment.”
SEPTEMBER 2018
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