Digestive Diseases

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Digestive Diseases

• 13.00 REGISTRATION AND LUNCH
• 13.30 Mr John Grabham Rectal bleeding and
  colorectal cancer
• 14.00 Mr Neil Smith Enhancing recovery in GI
  surgery
• 14.30 BREAK
• 14.45 Dr Gary Mackenzie Upper GI disease
• 15.15 Dr Azhar Ansari Inflammatory bowel disease
• 15.45COFFEE BREAK
• 16.00 Dr Jonathan Stenner Hepatology
• 16.30 Mr Paras Jethwa Management of gallbladder
  disease
• 17.00CLOSE

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Website and extranetSurrey Sussex Healthcare
NHS Trust
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http//www.sash.nhs.uk/our-services/digestive-dise
ases/
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Message 1. The Digestive Diseases Department

• A coherent team of sub-specialists
• Provide a multi-disciplinary service
• Clear internal and external audit and clinical
  governance pathways

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Guidelines for TWR referral

• Bleeding and diarrhoea gt40 (gt6/52)
• Bleeding w/o anal symptoms gt60 (gt6/52)
• Diarrhoea gt60 (gt6/52)
• Abdominal or rectal mass
• Iron-deficiency anaemia
• NOT FOBs

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62 day 31 day targets
Urgent GP referral
Received by hospital
1st OPA _at_hospital
?? Further investigations
MDT meeting
Diagnostic investigations
Clinical Diagnosis
1st definitive treatment
Decision to treat
Emergency Admission
31 Days
62 Days
Time
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Work-up of patients with suspected colorectal
cancer

• Colonoscopy Biopsy
• CT scan
• CEA
• MRI pelvis
• EUS
• MRI liver
• PET scan

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CT assessment of colonic 1
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Anterior rectal cancer invading uterus
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Solitary liver metastasis
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6/12 post-right hepatectomy
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62 day 31 day targets
Urgent GP referral
Received by hospital
1st OPA _at_hospital
?? Further investigations
MDT meeting
Diagnostic investigations
Clinical Diagnosis
1st definitive treatment
Decision to treat
Emergency Admission
31 Days
62 Days
Time
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62 day TWR referral to treatment
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31 days decision to treatment
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Clinical Results

• Resection rate
• Peri-operative mortality
• Major complications
• Clear resection margins
• Local recurrence
• Comparisons with ACPGBI database

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• Resection rate 93 (cf 89.5)
• Mortality rate 7.2 (cf 7.5)
• Anastomotic leakage 4.8 (cf 4.9)
• Positive CRMs lt1 (10)
• Local recurrence for T1-3 lt1 (10)

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Message 2.Summary of Colorectal Cancer Service

• Rapid, efficient service
• Excellent clinical outcomes
• Please continue to refer your patients

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Rectal Bleeding Pathway
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Causes of Rectal Bleeding

• Haemorrhoids
• Fissure-in-ano
• Other benign ano-rectal pathology
• Polyps
• Cancer
• Diverticular disease
• Colitis

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Haemorrhoids

• Common gt15
• Usually associated with perianal symptoms
• Often associated with straining
• High fibre
• Bulking agents
• Topical agents
• Exclude serious pathology
• Banding / injection maximum twice

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Rubber band ligation
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Thrombosed external haemorrhoid
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Stapled haemorrhoidectomy
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Stapled haemorrhoidectomy
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Fissure-in-ano

• Common esp young adults
• Anal spasm
• Rectal bleeding and pain
• Often assoc with straining
• Difficult to examine

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Fissure-in-ano
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Sentinel Tag
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Fissure-in-ano management

• 6/52 GTN or Diltiazem ointment
• ? Lignocaine, ?anxiolytic, ?stool softener
• Clinical review 1/20 underlying pathology
• Need to visualise rectum

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Anal Warts
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Anal Cancer
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Carcinoma sigmoid colon
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Rationale for early flexible sigmoidoscopy in
rectal bleeding

• Haemorrhoids common and may co-exist with other
  pathology treatment unreliable
• Fissure difficult to examine sometimes
  associated with serious pathology
• Reassurance of nothing serious
• Colonic disease allows a reliable, safe,
  preliminary assessment

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Message 3.Revised clinical algorithm

• Rectal bleeding

Flexible sigmoidoscopy
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GPH ECN Booking Process

• Book patient into Rectal Bleeding Clinic
• Fax form to secretary
• Referral validated
• Information, instructions and enema sent to
  patient
• Procedure carried out promptly

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Summary

• Please refer to members of the Digestive Diseases
  Team
• Excellent clinical outcomes
• Please refer all rectal bleeding for flexible
  sigmoidoscopy