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Is a pre-endoscopy interview necessary in open access endoscopy? An audit
A26
AGA ABSTRACTS
MUSCULOSKELETAL PROBLEMS IN PHYSICIANENDoscoPISTS VERSUS RHEUMATOLOGISTS: A SURVEY. A.S. Mee+, J Stratford +, J David*.
Departments of Gastroenterology + and Rheumatology*, Battle Hospital, Heading, UK. There are anecdotal reports that endoscopists may suffer from a variety of musculoskeletal problems. I65 consultant physician endoscopists and 160 consultant rheumatologists were sent a postal questionnaire requesting information on neck pain, X ray documented cervical spondylosis (if known), lateral epicondylitis, thumb extensor tenosynovitis, osteoarthritis of the carpo-metocarpal joint of the thumb and non-disc related low back pain. Endoscopists were asked to quantify approximate career numbers of upper gastrointestinal endoscopies, colonoscopies and ERCP's, whether or not the weight of the instrument was routinely increased by the use of a teaching arm and the proportion of work using video vs. fibreoptic instruments. There were 156/165 (95%) evaluable replies from the endoscopists (mean age 46.4 y, range 32-66). and 150/160 (94%) from the rheumatologists (mean age 44.6 y, range 30-65). Among the endoscopists 101 (65%) reported one or more problems compared with 118 (79%) rheumatologists. For endoscopists reporting a problem there was no correlation with their age, type of instrument used or addition of a teaching arm. Nevertheless, endoscopists performing the greatest number of procedures were significantly more likely to report a problem. For example the career total number of colonoscopies performed by 23 endoscopists reporting lateral epicondylitis ('tennis elbow') was 2830 compared with 2167 colonoscopies in 49 endoscopists with no problem (p<0.01).
GASTROENTEROLOGY, Vol. 108, No, 4
Domperidone vs. Cisapride: A CONTROLLED TRIAL WITH TWO PROKINETIC DRUGS IN DYSPESIA. ~ * , P.Staub °, B.Hammer**, A.Restellini °° and the OMEGA study group. *Ospedale Civico Lugano, °Cantonal Hospital Herisau, **Cantonal Hospital St.Gallen, °°Onex, Geneva. The HT4-agonist Cisapdde (CIS) and the peripheral D2-antagonist Domperidone (DOMP) have distinct prokinetic actions. We compared their clinical efficacy in dyspeptic patients. Patients & Methods: Patients presenting to their primary care physician with upper abdominal complaints of > than 1 month duration and without signs of organic disease were referred for upper gastrointestinal endoscopy (UGE). Those who had a normal UGE were allocated to the REFLUX-group (RG) (predominance of heartburn, acid regurgitation or retrosternal pain) or to the DYSPEPSIA group (DG) (predominance of epigastric pain or discomfort). The patients received in a double-blind randomized fashion tablets containing 10 mg of CIS or 20 mg of DOMP qid (RG) or lid (DG) for 1 month and were followed thereafter for further two months. They were considered responders to the treatment if the improvement was > than 2/3 of the initial symptoms' score; they were considered to have relapsed if the symptoms' score returned to > 1/2 of the initial value. Results were analyzed following the Last Observation Carried Forward (LOCF) method. Results: 172 patients, had an UGE and 127 were admitted to the study. 43 patients, were allocated to RG and 84 to DG. Both drugs were effective in reducing symptoms significantly. The response rates were clearly in favor of CIS in RG (p<0.05), but not in DG (See table). DOMP was significantly more effective against nausea. The benefit of both therapies was maintained to a large extent in the follow-up period.
RG DG
There is no overall increased risk of musculoskeletal problems in physician endoscopists compared with rheumatologists. However those endoscopists reporting a problem performed a greater number of procedures than those without problems.
• IS A PRE-ENDOSCOPY I N T E R V I E W NECESSARY IN OPEN ACCESS ENDOSCOPY? AN AUDIT. FH Mourad, TM Taylor, PD Fairclough, MJG Farthing. Digestive Diseases Research Centre, Medical College of St Bartholomew's Hospital, London, UK. Background and aim: Although well established in many hospitals, open access gastroscopy is still not available nationwide. It has been suggested that 'censorship' of general practitioners' (GP) referrals would be appropriate to avoid overinvestigation. The aim of this audit was to ascertain the value of a pre-endoscopy interview as a form of 'censorship' for open access gastroscopy. Subjects and Methods: We have established a 'one stop clinic' (OSC) where patients are first interviewed by a gastroenterologist directly before being endoscoped at the same visit. Patients are referred to this clinic either directly by general practitioners or by a consultant gastroenterologist after reading the general practitioner referral letter to the regular gastroenterology clinic, Results: Over a 22 month period, 272 patients attended this clinic: mean age 48.2y (range 18-82); M/F: 1/1. The time lapse between the referral and the clinic appointment was 3.8 weeks (range ld-5wks). General practitioners referred 137 pts directly to the OSC of whom 129 (95.4%) had a gastroscopy during their visit. Only 7 pts (5.8%) were not endoscoped although the GP specifically requested the examination. 135 pts were referred to the OSC after examining the GP's referral letter to the regular gastroenterology clinic: 109 pts (80.7%) in this group had a gastroscopy. Only 9 pts (14.5%) were not endoscoped although the general practitioner specifically requested one in his letter. The percentage of positive findings among all the gastroscopies performed in the clinic was 58% in each group. Thus, more than 90% of patients referred by general practitioners for gastroscopy are end0scoped even if they are first interviewed by a gastroenterologist. The rate of positive findings is similar to previously published data. Conclusion: This audit suggests that open access gastroscopy censorship in the form of a pro-endoscopy interview is not justified.
DOM CIS DOM ClS
Treatm.,d. 7 41% 48% 59% 51%
Treatm.,d. 28 64% 95% 76% 79%
F.-up, day 56 73% 90% 78% 79%
F.-up, day 84 73% 86% 78% 81%
Conclusions: Cisapride and Domperidone are effective in the treatment of dyspepsia; Cisapride is more effective than Domperidone in the Reflux-Group. The beneficial effect of both drugs is persisting after cessation of treatment. Supported by danssen Research Foundation, Baar, Switzerland
THE CLINICAL COURSE OF AUTOIMMUNE (CHRONIC ACTIVE) HEPATITIS (AIH). AJ Nicoll. liB Sewell, PW Angus and RA Smagwo0d.
Gastroenterology Unit, Austin and Heidelberg Repatriation Hospitals, Melbourne, Australia. The evolution and long term clinical outcomes of patients with AIH treated with immunosuppression have not been fully defined. This study examines the outcomes in 85 patients followed for up to' 40 years, with special emphasis on those patients developing "cholestatic" features. AIH patients were defined by liver biopsy and serological tests I . We have assessed clinical outcomes including the requirements for immuuosuppression; development of portal hypertension and encephalopathy; liver transplantation and mortality. Results There were 69 females and 16 males. Mean age at diagnosis was 43.5 years (range: 5-81 years) and duration of follow up was 8,8 years (range: 1 month-40 years, a total of 734 patient years). Evidence for any other contributing cause for liver disease eg. alcohoi, viral hepatitis, excluded the patient from study. Cirrhosis was present at diagnosis in nearly half the patients and 2/3 of all patients had portal hypertension within 6 years. One quarter had shown signs of encephaiopathy after 9 years. Seventy-four patients were treated with prednisolone (P) (mean maintenance dose: 14rag/day, range: 3mg60rag) one third of these received concomitant azathioprine (AZA) (range: 50-100mg/day), with good response in all but 4 patients, who required prompt transplantation. Complete withdrawal of P was attempted in 34 patiems and was successful in 2 on P plus AZA, and 11 on P alone (18% of treated group). Overall, mortality was 19% (31% males v 16% females), due primarily to liver failure, variceal haemorrhage and non-liver related causes. Three patients died of complicating liver carcinoma (at 1 and 2 years respectively, for the 2 cases of hepatocellular carcinoma, and at 14 years for a patient with cholangiocarcinoma). Poor prognostic features were the presence of portal hypertension, prednisolone maintenance dose >10mg/day, and male gender. Twelve patients underwent liver tlansplantation 10 years (3 months-23 years) post diagnosis. Twenty-five patients evolved "cholestatic" features (alkaline pbosphatase/GGT >4 fold rise; ALT/AST <2 fold rise), of whom 4 developed ERCP changes consistent with sclerosing cholangitis (PSC) on long term follow up. Response to immunosuppression and clinical outcomes of this subset of patients did not differ from those of the overall group. Conclusions (1) The overall clinical course of these AIH patients is comparable to those reported in other series. (2) Of special interest is the high frequency of patients developing cholestatic features, evolving in some to a picture indistinguishable from PSC. (3) Liver carcinoma is an important and {reviously under emphasised end point of AIH. Johnson et al Hepatulogy 1993; 18:998-1005.
AGA ABSTRACTS
MUSCULOSKELETAL PROBLEMS IN PHYSICIANENDoscoPISTS VERSUS RHEUMATOLOGISTS: A SURVEY. A.S. Mee+, J Stratford +, J David*.
Departments of Gastroenterology + and Rheumatology*, Battle Hospital, Heading, UK. There are anecdotal reports that endoscopists may suffer from a variety of musculoskeletal problems. I65 consultant physician endoscopists and 160 consultant rheumatologists were sent a postal questionnaire requesting information on neck pain, X ray documented cervical spondylosis (if known), lateral epicondylitis, thumb extensor tenosynovitis, osteoarthritis of the carpo-metocarpal joint of the thumb and non-disc related low back pain. Endoscopists were asked to quantify approximate career numbers of upper gastrointestinal endoscopies, colonoscopies and ERCP's, whether or not the weight of the instrument was routinely increased by the use of a teaching arm and the proportion of work using video vs. fibreoptic instruments. There were 156/165 (95%) evaluable replies from the endoscopists (mean age 46.4 y, range 32-66). and 150/160 (94%) from the rheumatologists (mean age 44.6 y, range 30-65). Among the endoscopists 101 (65%) reported one or more problems compared with 118 (79%) rheumatologists. For endoscopists reporting a problem there was no correlation with their age, type of instrument used or addition of a teaching arm. Nevertheless, endoscopists performing the greatest number of procedures were significantly more likely to report a problem. For example the career total number of colonoscopies performed by 23 endoscopists reporting lateral epicondylitis ('tennis elbow') was 2830 compared with 2167 colonoscopies in 49 endoscopists with no problem (p<0.01).
GASTROENTEROLOGY, Vol. 108, No, 4
Domperidone vs. Cisapride: A CONTROLLED TRIAL WITH TWO PROKINETIC DRUGS IN DYSPESIA. ~ * , P.Staub °, B.Hammer**, A.Restellini °° and the OMEGA study group. *Ospedale Civico Lugano, °Cantonal Hospital Herisau, **Cantonal Hospital St.Gallen, °°Onex, Geneva. The HT4-agonist Cisapdde (CIS) and the peripheral D2-antagonist Domperidone (DOMP) have distinct prokinetic actions. We compared their clinical efficacy in dyspeptic patients. Patients & Methods: Patients presenting to their primary care physician with upper abdominal complaints of > than 1 month duration and without signs of organic disease were referred for upper gastrointestinal endoscopy (UGE). Those who had a normal UGE were allocated to the REFLUX-group (RG) (predominance of heartburn, acid regurgitation or retrosternal pain) or to the DYSPEPSIA group (DG) (predominance of epigastric pain or discomfort). The patients received in a double-blind randomized fashion tablets containing 10 mg of CIS or 20 mg of DOMP qid (RG) or lid (DG) for 1 month and were followed thereafter for further two months. They were considered responders to the treatment if the improvement was > than 2/3 of the initial symptoms' score; they were considered to have relapsed if the symptoms' score returned to > 1/2 of the initial value. Results were analyzed following the Last Observation Carried Forward (LOCF) method. Results: 172 patients, had an UGE and 127 were admitted to the study. 43 patients, were allocated to RG and 84 to DG. Both drugs were effective in reducing symptoms significantly. The response rates were clearly in favor of CIS in RG (p<0.05), but not in DG (See table). DOMP was significantly more effective against nausea. The benefit of both therapies was maintained to a large extent in the follow-up period.
RG DG
There is no overall increased risk of musculoskeletal problems in physician endoscopists compared with rheumatologists. However those endoscopists reporting a problem performed a greater number of procedures than those without problems.
• IS A PRE-ENDOSCOPY I N T E R V I E W NECESSARY IN OPEN ACCESS ENDOSCOPY? AN AUDIT. FH Mourad, TM Taylor, PD Fairclough, MJG Farthing. Digestive Diseases Research Centre, Medical College of St Bartholomew's Hospital, London, UK. Background and aim: Although well established in many hospitals, open access gastroscopy is still not available nationwide. It has been suggested that 'censorship' of general practitioners' (GP) referrals would be appropriate to avoid overinvestigation. The aim of this audit was to ascertain the value of a pre-endoscopy interview as a form of 'censorship' for open access gastroscopy. Subjects and Methods: We have established a 'one stop clinic' (OSC) where patients are first interviewed by a gastroenterologist directly before being endoscoped at the same visit. Patients are referred to this clinic either directly by general practitioners or by a consultant gastroenterologist after reading the general practitioner referral letter to the regular gastroenterology clinic, Results: Over a 22 month period, 272 patients attended this clinic: mean age 48.2y (range 18-82); M/F: 1/1. The time lapse between the referral and the clinic appointment was 3.8 weeks (range ld-5wks). General practitioners referred 137 pts directly to the OSC of whom 129 (95.4%) had a gastroscopy during their visit. Only 7 pts (5.8%) were not endoscoped although the GP specifically requested the examination. 135 pts were referred to the OSC after examining the GP's referral letter to the regular gastroenterology clinic: 109 pts (80.7%) in this group had a gastroscopy. Only 9 pts (14.5%) were not endoscoped although the general practitioner specifically requested one in his letter. The percentage of positive findings among all the gastroscopies performed in the clinic was 58% in each group. Thus, more than 90% of patients referred by general practitioners for gastroscopy are end0scoped even if they are first interviewed by a gastroenterologist. The rate of positive findings is similar to previously published data. Conclusion: This audit suggests that open access gastroscopy censorship in the form of a pro-endoscopy interview is not justified.
DOM CIS DOM ClS
Treatm.,d. 7 41% 48% 59% 51%
Treatm.,d. 28 64% 95% 76% 79%
F.-up, day 56 73% 90% 78% 79%
F.-up, day 84 73% 86% 78% 81%
Conclusions: Cisapride and Domperidone are effective in the treatment of dyspepsia; Cisapride is more effective than Domperidone in the Reflux-Group. The beneficial effect of both drugs is persisting after cessation of treatment. Supported by danssen Research Foundation, Baar, Switzerland
THE CLINICAL COURSE OF AUTOIMMUNE (CHRONIC ACTIVE) HEPATITIS (AIH). AJ Nicoll. liB Sewell, PW Angus and RA Smagwo0d.
Gastroenterology Unit, Austin and Heidelberg Repatriation Hospitals, Melbourne, Australia. The evolution and long term clinical outcomes of patients with AIH treated with immunosuppression have not been fully defined. This study examines the outcomes in 85 patients followed for up to' 40 years, with special emphasis on those patients developing "cholestatic" features. AIH patients were defined by liver biopsy and serological tests I . We have assessed clinical outcomes including the requirements for immuuosuppression; development of portal hypertension and encephalopathy; liver transplantation and mortality. Results There were 69 females and 16 males. Mean age at diagnosis was 43.5 years (range: 5-81 years) and duration of follow up was 8,8 years (range: 1 month-40 years, a total of 734 patient years). Evidence for any other contributing cause for liver disease eg. alcohoi, viral hepatitis, excluded the patient from study. Cirrhosis was present at diagnosis in nearly half the patients and 2/3 of all patients had portal hypertension within 6 years. One quarter had shown signs of encephaiopathy after 9 years. Seventy-four patients were treated with prednisolone (P) (mean maintenance dose: 14rag/day, range: 3mg60rag) one third of these received concomitant azathioprine (AZA) (range: 50-100mg/day), with good response in all but 4 patients, who required prompt transplantation. Complete withdrawal of P was attempted in 34 patiems and was successful in 2 on P plus AZA, and 11 on P alone (18% of treated group). Overall, mortality was 19% (31% males v 16% females), due primarily to liver failure, variceal haemorrhage and non-liver related causes. Three patients died of complicating liver carcinoma (at 1 and 2 years respectively, for the 2 cases of hepatocellular carcinoma, and at 14 years for a patient with cholangiocarcinoma). Poor prognostic features were the presence of portal hypertension, prednisolone maintenance dose >10mg/day, and male gender. Twelve patients underwent liver tlansplantation 10 years (3 months-23 years) post diagnosis. Twenty-five patients evolved "cholestatic" features (alkaline pbosphatase/GGT >4 fold rise; ALT/AST <2 fold rise), of whom 4 developed ERCP changes consistent with sclerosing cholangitis (PSC) on long term follow up. Response to immunosuppression and clinical outcomes of this subset of patients did not differ from those of the overall group. Conclusions (1) The overall clinical course of these AIH patients is comparable to those reported in other series. (2) Of special interest is the high frequency of patients developing cholestatic features, evolving in some to a picture indistinguishable from PSC. (3) Liver carcinoma is an important and {reviously under emphasised end point of AIH. Johnson et al Hepatulogy 1993; 18:998-1005.