Braemar GP Seminar (i) Capsule endoscopy (ii) CRC screening Graeme - - PowerPoint PPT Presentation

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Braemar GP Seminar (i) Capsule endoscopy (ii) CRC screening Graeme - - PowerPoint PPT Presentation

Apr 10, 2023 267 likes •781 views

Braemar GP Seminar (i) Capsule endoscopy (ii) CRC screening Graeme Dickson BSc(hons) MB BS MRCP(UK) FRACP Clinical Director of Gastroenterology, Waikato Public Hospital & Tawa Street Clinic, Glenview Wireless Capsule Endoscopy

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SLIDE 1

Braemar GP Seminar

(i) Capsule endoscopy (ii) CRC screening

Graeme Dickson

BSc(hons) MB BS MRCP(UK) FRACP Clinical Director of Gastroenterology, Waikato Public Hospital & Tawa Street Clinic, Glenview

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SLIDE 2

Wireless Capsule Endoscopy

  • Procedure
  • Indications

– Obscure bleeding – Crohn’s – Small bowel polyps

  • Contraindications
  • Complications
  • Outcomes
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SLIDE 3

M2A capsule (11mm x 26mm, 3.7gm)

  • 1. Optical dome
  • 2. Lens holder
  • 3. Lens
  • 4. Illuminating LEDs
  • 5. Imager
  • 6. Battery
  • 7. Transmitter
  • 8. Antenna

Capsule endoscopy

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SLIDE 4
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SLIDE 5

Viewing

  • 60,000 images
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SLIDE 6
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SLIDE 7

Obscure Bleeding

  • normal UGI & Colonoscopy
  • historical approach
  • Enteroscopy
  • access to only10-20% of small

bowel (4-5m long)

  • 38-75% detection rate
  • small risk of complications
  • but therapeutic options
  • Small bowel X-ray
  • uncomfortable
  • sensitivity 5%
  • Red Cell Scan
  • sensitivity 30-86%
  • requires 150ml bleeding/24hrs
  • approximate site
  • Angiography
  • 750ml/24hours
  • therapeutic option
  • Surgical enteroscopy
  • gold standard
  • 70-100% sensitivity
  • but morbidity/mortality/cost
  • last resort
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SLIDE 8

Capsule for obscure GI bleeding

no lesion 38% vascular 36% ulceration 15% blood 6% tumour 1% polyp 3%

  • ther

1%

Pennazio

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SLIDE 9

Angiodysplasia

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SLIDE 10

Obscure bleeding

  • Age 77
  • Warfarin
  • Prosthetic valve
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SLIDE 11

Crohn’s disease

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SLIDE 12

Peutz Jeghers

  • Aged 18 & 26

6 polypectomies

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SLIDE 13

Contraindications 1.Dysphagia 2.Small bowel

  • bstruction

Complications

  • Capsule retention
  • 2%
  • RFs

– NSAIDs – Crohns – Radiation

  • Patency capsule
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SLIDE 14

Outcomes

  • Positive studies

– Obscure bleeding

  • High yield if performed early (<1mth)
  • Allows Rx of lesions found which reduces further

bleeding

  • Negative studies

– Obscure bleeding

  • 80% have no further bleeding at 1 yr
  • 95% have no major pathology found
  • Therefore, no further Ixs needed
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SLIDE 15

Availability

Public

  • 30 capsules per year
  • Obscure GI bleeding

– recurrent

  • Crohn’s
  • Polyposis syndromes

Private

  • Reimbursed by

insurers

  • Costs

– Capsule: $3578 – Capsule with patency study: $4247

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SLIDE 16
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SLIDE 17

CRC screening

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SLIDE 18

CRC in NZ

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SLIDE 19

Stage affects survival

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SLIDE 20

CRC screening

  • CRC prevention

– Colonoscopy – CT colonography – Flexible sigmoidoscopy

  • CRC detection

– Faecal occult bloods (FIT)

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SLIDE 21

Colonoscopy

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SLIDE 22

Colonoscopy – the problems

  • 1. Interval (missed) cancers
  • 2. Complications

– Perforation (1/1000)

  • 3. Patient preference

– Uncomfortable, requires sedation

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SLIDE 23

Interval cancers

CRC between planned colonoscopies

  • Tandem colonoscopies show 22%

adenoma miss rate

  • 2 to 6% miss rate for CRC
  • Rt side colon
  • Flat lesions
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SLIDE 24

Interval cancers – bowel prep

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SLIDE 25

Interval cancers – flat polyps

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SLIDE 26

Interval cancers - technique

“…You see but you do not observe…”

  • 1. Caecal intubation rate
  • 2. Withdrawal time
  • 3. Adenoma detection rate
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SLIDE 27

Screening colonoscopy – not for trainees

Risk factors for interval cancer

1)Biology – flat, rt sided 2)Poor bowel prep 3)Poor technique 4)Non-Gastroenterologist

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SLIDE 28

CT colonography

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SLIDE 29

CT colonography

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SLIDE 30

Flexible Sigmoidoscopy

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SLIDE 31

Faecal Immunochemical Test (FIT)

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SLIDE 32

CRC screening – what do you choose?

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SLIDE 33

CRC screening – what do you choose?

  • Colonoscopy -10 yrly from age 50

– Quality (prep; technique; operator)

  • CT Colonography – 5yrly
  • Flex Sig – 5 yrly
  • FIT – 2yrly
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SLIDE 34

CRC screening in NZ – Family History

PUBLIC Depends on DHB

  • Waikato
  • NZGG moderate/high
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SLIDE 35

Familial Colorectal Cancer

  • What is their risk of developing CRC?

– Average risk at 75yrs=5% – 1 FDR risk=10% (slightly increased) – 1 FDR<55 or 2 FDRs risk=25% (moderate) – 1 FDR<55 & another FDR/SDR (high) OR 1 FDR & 2 SDRs (high) OR HNPCC/FAP/MSI on tumour histology

  • Can you refer them for a colonoscopy at WPH?

– High=yes – Moderate=yes – Low=not resourced

www.nzgg.org.nz

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SLIDE 36

CRC screening in NZ – Family History

PUBLIC Depends on DHB

  • Waikato
  • NZGG moderate/high

PRIVATE Depends on Insurer

  • Southern Cross

– 1 FDR

  • Sovereign/Tower

– No cover

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SLIDE 37

CRC screening in NZ – No family history

PUBLIC

  • National Pilot FOBs
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SLIDE 38

National Colorectal Cancer screening

  • Waitemata pilot (2011-2015)
  • Age 50-74
  • FOB (FIT) every 2 years
  • Colonoscopy if positive
  • Resource shortage
  • Waikato

– FOB peroxidase dropped – No screening yet

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SLIDE 39

CRC screening in NZ – No family history

PUBLIC

  • National Pilot FOBs

PRIVATE

  • Pos FOB – accepted

by all insurers

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SLIDE 40
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SLIDE 41
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SLIDE 42

Why is it needed?

  • Clostridium difficile

– 178,000 cases USA – 2.3% MR – 3.2 billion dollars hospital costs

  • Treatment

– Stop Abx – Metronidazole/Vancomycin +/- probiotics

  • Recurrence

– 15 to 30% – 40% chance 2nd recurrence, 65% 3rd recurrence

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SLIDE 43

Methods

  • Consented
  • Similar protocols

– Stop Abx 2/3 days prior to FMT – Donor stool <8hrs old – Mixed in saline, injected through colonoscope – 300:700mls injected to TI/caecum

  • Donors

– Exclusions (Abx, infectious or GI disease) – Tested (HBV, HCV, HIV, stools)

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SLIDE 44

Cure

  • Primary

– Resolution of diarrhoea <90days = 91% (70/77)

  • Secondary

– 4/7 responded to 2wks Vancomycin – 2 failed and had 2nd FMT – 1 in a hospice was not retreated and died – Resolution with a 2nd course Abx = 98% (76/77)

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SLIDE 45

Follow-up

  • Antibiotics post FMT

– 30/77 required Abx for other conditions (1-8 courses) – 8/30 recurrent CDT – No recurrence in those who didn’t receive Abx

  • Satisfaction

– 97% happy to have again. 53% prefer FMT to ABx

  • Other conditions

– 2 had improvement in allergies – 4 developed new problems (Sjogrens, ITP, RhA)

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SLIDE 46

Discussion

  • RFs: Elderly, hospitalised, antibiotics
  • Altered intestinal microbiome
  • Re-established with donor faeces
  • Secondary cure high- Abx became effective
  • 90% cure rates not unusual
  • Rapid symptom relief
  • Durable: CDT free at >5yrs

– Persistent donor flora mths after FMT (bacterioides)

  • Recurrence- all late recurrence 2ry ABx
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SLIDE 47
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SLIDE 48
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SLIDE 49
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SLIDE 50

Private Cover

Southern Cross Sovereign Tower Pos FOB Yes Yes Yes FHx CRC NZ Guidelines No (*Yes) No