Gastroenterology - Introduction
The Gastroenterology Department at Basildon and Thurrock University Hospitals Foundation Trust is one of the largest sections within Basildon University Hospital. It offers both general gastroenterology and a variety of sub-speciality areas services. The department continues to provide the latest in diagnostics and treatments to ensure that patients obtain the best possible care. Over recent years it has become increasingly involved in a variety of multicentre national trials (‘Construct Trial’ for ulcerative colitis, ‘STOPAH’ trial in acute alcoholic hepatitis, ‘SEAFOOD’ for patients with colonic polyps).
The department have a dedicated GI ward (Edith-Cavell) within the hospital for the treatment of inpatients and a dedicated 4-room endoscopy unit.
There are 15 consultant and 7 nurse specialist clinics weekly offering a one-stop shop for upper GI cancer service, IBD, nutrition, pancreas and liver, as well as general or target gastroenterology referrals. Around 330 new patients are seen each month.
In addition weekly operational and educational meetings are held; two Multidisciplinary meetings (MDM) for upper GI cancer and one for Colorectal Cancers. Alternate weeks for IBD and liver MDM complete the timetable, along with a weekly nutrition MDM.
All the consultants contribute to outpatient and endoscopic work. In addition six will manage the gastroenterology inpatients, while the departments integrated operational planning ensures a cross-cover of all essential gastroenterology services throughout the year. Instead of a simple generic service this system has allowed specialist areas to develop and be fostered.
Each sub-specialty area has an assigned clinical lead to develop them strategically and integrate patient care with the other areas. These clinical areas are supported by nurse specialist teams in Nutrition, Upper gastrointestinal cancer, Inflammatory bowel disease, Liver and Bowel cancer screening who provide the continuity of care and patient access that is both mandatory and integral to high quality patient care.
The sub-speciality areas include
- Endoscopy
- Upper gastrointestinal cancers
- Liver
- Bowel cancer screening programme
- Inflammatory Bowel Disease
- Nutrition
- Pancreatology
Inflammatory Bowel Disease (IBD)
Following the recent review and subsequent recommendations on the care for irritable bowel disease sufferers by the department of health, it made a number of recommendations which the Trust has embraced to ensure a gold standard of care for the approximate1500 local patients seen with IBD.
The Trust employs series non-invasive or minimally invasive tests to diagnose, assess the severity of the disease and response to treatment ensuring that the patient is subjected to the minimal amount of discomfort
- Faecal calprotectin – assess disease activity
- MR enterography & Capsule endoscopy – assess small bowel
In-patients with chronic ulcerative colitis are offered a surveillance colonoscopy as per national guidance using chromo endoscopy, a dye spray technique to diagnose early changes of malignancy.
Regular reviews in clinic are supplemented by patient access to the IBD helpline which has been set up by the Trust and is accessible by both e-mail and by phone. It is run by a Specialist Nurse Practitioner and is designed to reduce the number of hospital visits/admissions.
A multidisciplinary team comprising of both medical and surgical members, meet fortnightly, to discuss complex patients ensuring that the best management of their condition is adopted. The department operates an integrated service with good physician/surgeon interface and are currently developing pathways for referral of IBD patients from community and on-going shared care with GPs.
On occasions a stand is placed in the outpatient area, offering support for IBD patients and assist in the understanding of how to manage their condition for both sufferers and their relatives.
There is a monthly IBD patient support group meetings; for more information, call Susan Harding, IBD Clinical Nurse Specialist on 0845 155 3111 ext 1499 or email susan.harding@btuh.nhs.uk
Pancreatology
In the UK, up to 45,000 people are living with chronic pancreatitis and around 12,000 people are diagnosed with acute pancreatitis each year*. Whilst in 2008 there were 8,085 newly diagnosed cases of pancreatic cancer in the UK**
In response to the high numbers of patients presenting with pancreatic disease ranging from acute and chronic pancreatitis to pancreatic cancer; Drs Lindo and Subhani set up one of the newest subspecialty services offered by the BTUH Gastroenterology department.
The service was developed February 2011 as a result of the complexity of the patients’ varying conditions being presented along with the special interests of the two consultants who run the service. It is unique to the immediate area with only Cambridge offering a similar set up.
This sub-speciality allows a focus on this difficult patient cohort as they require a multidisciplinary approach their care it enables nutritional needs, for example to be addressed.
In addition to managing complex in-patients with pancreatic pathology a dedicated multidisciplinary pancreatic clinic is held twice a month on the BTUH site for review and long term management of patients with pancreatic disorders.
*http://www.bupa.co.uk/individuals/health-information/directory/p/pancreatitis
Endoscopy
Endoscopy is the largest single area in Gastroenterology with all seven consultants and two nurse specialists performing procedures. The Basildon endoscopy unit was a new development in July 2009 with 4 state of the art procedure rooms, decontamination and teaching facilities.
Helen Mould (Endoscopy lead nurse) and Tracey Sawkins (Senior endoscopy sister) lead a dedicated team of 40 staff operating the unit 6 days a week 8am – 7pm with additional emergency work on Sundays. The weekend lists increase both our capacity also and patient choice for procedures.
The unit performs around 8500 gastrointestinal endoscopy / year with a 10-15%% expansion year on year.
| Per year | Wait urgent case | Wait routine case | |
| Gastroscopy | 3700 | ||
| Colonoscopy | 3500 | ||
| Flexible sigmoidoscopy | 1000 | < 2 weeks | < 6 weeks |
| ERCP | 280 | 1 week | 2 weeks |
“Timeliness” targets for urgent and routine procedures have been met continuously for 6 years.
Standard endoscopic practice is rigorously audited for efficacy, safety and comfort. This has resulted in very high scores against benchmarks such as colonoscopy completion rates (93% compared 85% recorded as No or minimal discomfort. A long running quality group headed by the Director and Endoscopy Lead nurse handle any patient concerns.
6-monthly patient satisfaction surveys continue to record extremely positive feedback.
In addition to standard endoscopic equipment the unit has a variety of specialised endoscopes
- Nasal gastroscopes
- Therapeutic gastroscope
- Magnifying colonoscopy
- Ultrathin paediatric colonoscope.
These allow the unit to tackle more complex cases and offer a higher level of service.
Specialist endoscopic procedures include:
- Endoscopic mucosal resection (EMR) of polyps and occasionally early cancers that would otherwise require surgery. Dr Subhani receives regional referrals for this specialised procedure.
- PEG and PEGG (direct puncture) are placed by Endoscopist and Nurse specialists. Importantly this work is fully integrated with the excellent nutrition team to provide support after the procedure.
- Video capsule endoscopy for assessment of small bowel not visualisable by endoscopy
- Oesophageal, pyloric, duodenal, biliary or colonic stenting for palliation of cancers
- The unit has a policy of staying abreast with new endoscopic technologies and often among the first units in the country to use them
As well as the procedures the endoscopy unit offers a very tight and hopefully seamless integration with a variety of teams. The BCSP, upper GI cancer, IBD and liver nurse specialist teams are all housed within the unit and are immediately on hand to liaise with patients as necessary. The nutrition team although based outside the unit are always available. In the return these teams can arrange urgent endoscopies on their patients minimising any delays.
Bowel cancer Screening programme
In 2008 the Trust was awarded the Bowel screening programme centre for South Essex. This covers 60 -75 year olds within our catchment area of 780,000 people.
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The programme is based in the endoscopy unit and as well as the consultants includes 4 specialist screening practitioners (nurse specialists), programme manager and administrative assistant.
Home testing kits are sent to eligible people every two years. All patients who are positive on their kits are assessed by the dedicated specialist screening practitioners in clinic spread across South Essex. They are then invited for colonoscopy by one of our four accredited screening colonoscopists at Basildon hospital. In fours years the programme has removed over 2500 polyps and identified 200 cancers in patients earlier than they would have been otherwise, improving patient outcomes.
Capsule Endoscopy
This is a device that is designed to look at the small bowel in a minimally invasive way. It is a camera small enough for a patient to swallow (the size of a large vitamin tablet); despite its size it comprises of a colour camera, battery, light source and transmitter.
The camera travels through the digestive system transmitting two pictures per second pictures to a data recorder attached to belt which the patient wears around the waist. The process is completed in approximately eight hours after which the data can be downloaded to a computer for evaluation
The camera is disposed of naturally
It is ideal for diagnosing the causes of
- Unknown iron deficiency anaemia
- Small bowel bleeding
- Crohn’s disease
- Small bowel tumours (currently a detection rate of 2% is being experience)
The Trust currently undertakes between 110-120 capsule endoscopies and these are increasing. The benefits of the new method, which avoids radiation, provides an excellent tool in the diagnostics of gastroenterology as compared to the reliance on radiology which was unreliable in identifying obscure gastrointestinal bleeding
Other advantages include
- Identifying small bowel lesions and avoiding repeat appointments
- Assist in the diagnosis and allow for effective management for IBD, by identifying any problems with the small bowel
- Greater detection in small bowel cancer
The Gastroenterology Department will accept direct referrals for this service
Nutrition
NICE compliant nutritional care is directed and overseen by the Nutrition Steering Group, with reporting mechanisms to the Board of Executive Directors. Maintaining CQC (Care Quality Commission) Essential Standards supporting Outcome 5 are paramount to providing good nutritional care to patients at Basildon University Hospital.
28% of patients admitted to hospital have or are at risk of developing malnutrition as a cause or consequence of their disease processes. Identifying these patients and providing appropriate and timely intervention is an overriding principle of care.
The Nutrition Support Team is multi-disciplinary with representation from medicine, nursing, dietetics, pharmacy and speech therapy. The remit of the team is to develop and sustain a culture of providing safe, cost-effective, evidence based artificial nutrition support.
Services include
- Assessment of nutritional requirements and appropriateness of enteral or parenteral nutrition
- Assessment of suitable enteral or parenteral access devices
- Enteral Nutrition
- Tube feeding (Naso-gastric and naso jejunal)
- Gastrostomy (Percutaneous endoscopic and Radiological)
- Surgical feeding jejunostomy
- Management of high output stoma with electrolyte imbalances and monitoring - Parenteral nutrition
- In-patient
- Home parenteral nutrition (HPN)
- Home intravenous electrolyte replacement
- Enteral Nutrition
- Attendance to Multi-disciplinary meetings offering advice and specialist knowledge
- Upper GI Cancer MDM
- Liver MDM
- Motor Neurone Disease MDM
- Nutrition MDM
A monthly out-patient clinic is held for enteral patients needing specialist follow up, and 8 HPN clinics to monitor patients receiving home parenteral nutrition.
Hepatology
Basildon and Thurrock Hospital Hepatology Service was established around 10 years ago and introduced a dedicated liver clinic for the treatment of patients.
This has enabled to the team to standardise the management of patients with advanced chronic liver disease (cirrhosis) and ensure a consistent approach to their treatment plans
The speciality has expanded and currently holds 3 consultant clinics and 2 nurse specialist clinics per week, with between 50 - 60 patients seen each week with conditions such as:
- general hepatology
- abnormal LFTs
- asymptomatic liver “lesions”
- acute jaundice
- chronic viral hepatitis.
The viral hepatitis service manages both Hepatitis B and C and have recently restructured and expanded this service In anticipation of increased demand following the NICE approval of triple therapy agents for the treatment of Hepatitis C virus (HCV) infected patients.
Basildon Hospital will now be one of the few trusts able to offer triple therapy for HCV patients in the East of England SHA region and will likely allow the Trust to offer a pan-Essex service in the foreseeable future.
The department has strengthened their research and clinical networks with centres such as the Royal Free Hospital (RFH) liver and transplant unit, as part of a wider goal to improve hepatology services here at Basildon. This should lead to pre and post liver transplant care being offered locally to our patients with the obvious benefit of improved access, reduced travel and earlier review for an otherwise challenging group of patients.
The liver team are very proactive in research and publish extensively in the fields of academic and clinical hepatology, hepatobiliary and general gastroenterology. Recent Trust involvements in important clinical studies are outlined below:
- Enrolling patients for the ‘Stopah Trial’; a nationwide randomised control study looking at the comparative benefits of steroids versus pentoxifylline in the management of alcoholic steatohepatitis , a condition with a high mortality without specific treatment
- Enrolling Basildon patients to a RFH study involving the implantation of a novel subcutaneous pump to alleviate diuretic resistant ascites in those with decompensated liver disease. This is likely to be a significant step forward in the management of such patients, especially those deemed unsuitable for either a Transjugular Portosystemic Shunt (TIPS) or Transplantation.
- Enrolling patients for a RFH randomised controlled study assessing the potential benefit of probiotics (Lactobacillus Casei Shirota) for the Prevention of Infection in Cirrhosis
It is felt essential to involve Basildon patients in such activities to further drive improvements in the quality of care and access too liver services for patients and primary care partners alike.
The liver team are in the process of establishing an alcohol dependency service in partnership with local primary care commissioning bodies and psychiatric services. It is anticipated that such provision will provide a more targeted and cost-effective care for this increasingly isolated patient group; more details will be made available in due course
Sarah Tarff, the Nurse Lead for Hepatology, has over the last few years developed strong links with the substance abuse agencies in community, such as CDAS a Blood born virus agency to identify patients earlier and provide hospital based support to those that require it.
Advances in imaging with contrast MRI and contrast ultrasound are helping the clinicians to characterise a greater proportion of isolated liver lesions without the need for biopsy with a dedicated Hepatology MDT to discuss these cases.
A hepatocellular screening programme has been offered to our patients with advanced liver disease for nearly 10 years.
Endoscopic treatment of complications of liver disease including the variceal banding programme and histoacryl treatment of gastric varices takes place in-house.
Sarah Tarff offers an open access service for paracentesis from cirrhosis of troublesome ascites to patients.
A small proportion of our patients with continue to deteriorate and consideration for liver transplant will to be made. The team has had strong links for the last 10 years with both the Royal Free Hospital and Addenbrooke’s Liver transplant centres.
Upper GI Cancer Services
In line with Government recommendations (National Cancer Action Team, The Cancer Reform Strategy) the department provide a fully functional UGI MDT. The cancers included within the MDT are oesophageal, gastric, pancreatic, liver, bilary, neuroendocrine, lymphoma, sarcoma, GIST’s and some other rarer UGI cancers.
Referral pathways are via a 2 week wait, direct endoscopy referral, target referral, consultant upgrades and inpatient referrals.
All target patients are seen within 2 weeks via a One Stop clinic in outpatients, where the patient will have a gastroscopy in the morning. If cancer is suspected they are introduced to the UGI Clinical Nurse Specialist (UGI CNS) and given contact numbers to the UGI cancer team. At this point the UGI CNS team will take over co-ordination of care including:
- Collating histology and imaging results
- Entering the patient onto the UGI database and Somerset Database
- Ensuring the patient is discussed in a timely manner at UGI MDT
- Arrange consultation for results and management plan post UGI MDT preferably the same day with a CNS
- Support the patient throughout the pathway from diagnosis to death
- Ensuring the patient has a Key Worker and relevant information
- Offer an SOS Helpline for cancer patients and their families
- On confirmation of cancer patients are then discussed in the relevant MDT. All oesophageal and gastric patients are discussed via a live link with Broomfield Hospital (Tertiary referral Centre for UGI Cancer Surgery - curative). Curative surgery is performed by the Surgeons at Broomfield within a supportive MDT setting and for this period there is ‘shared care’.
Hepatobilary cases are discussed at local MDT and then referred to Royal London Hospital for Specialist MDT management plan. Curative patients have surgery at the Royal London Hospital but palliative chemotherapy is locally.
All chemotherapy and radiotherapy is held at Southend Hospital however, as the patient remains within BTUH’s care the patients’ follow ups are held at Basildon Hospital.
There is an Acute Oncology Service operating at Basildon Hospital to ensure that UGI oncology patients are seen within an hour on presenting to A/E and are reviewed by an Acute Oncology CNS, UGI CNS and an Oncology Consultant.
The MDT meetings are held twice a week – Monday is Specialist MDT with Broomfield and Wednesday is the local MDT. As a team we believe that an MDT is not just a meeting, it is the provision of providing continuity of high quality care for the cancer patient and their family. We consider that communication and information is key to providing a seamless pathway and as such have developed a very strong team to provide what we believe to be an excellent service to our patients.
As an MDT and part of the Essex Cancer Network the Trust is reviewed annually in relation to meeting targets, provision of high quality care, ‘Quality of Life’ issues and clinical performance. The Department’s Peer Review feedback and performance for the last 4 years has been outstanding and through rigorous monitoring and work programmes we constantly strive to improve the service.
Barrett’s Surveillance
Barrett’s oesophagus is a pre cancerous condition and some patients require monitoring to detect early cell changes to prevent cancer developing (BSG Guidelines).
The Upper GI CNS team co-ordinate the Barrett’s surveillance programme and also maintain a database on all Barrett’s patients. This is for audit purposes and to ensure that patients are entered on to the programme.
Newly diagnosed patients are seen in outpatients for a consultation regarding their diagnosis including the pre-cancerous risk, lifestyle, surveillance and treatment and written information given. Direct telephone access is given to all patients if they become symptomatic so that they can be assessed and gastroscopy arranged if required.
Patient’s on the surveillance programme are recalled every 2 years at present and are informed of their histology results verbally and in writing by the UGI CNS.
Any patients who have high grade dysplasia or above are discussed at the UGI MDT in order to formulate a management plan.
