This section deals with gastroscopy guidelines for inpatients; upper GI bleeds; indications for diagnostic gastroscopy; flexible sigmoidoscopy guidelines; colonoscopy guidelines; ERCP guidelines and antibiotic prophyylaxis for endoscopic procedures.
The Luton and Dunstable Endoscopy Unit has a longstanding history of high standard timely endoscopy. The unit always strives to be flexible, fitting in urgent patients as soon as possible. However, we always aim to follow best practice and this also ensures performing procedures only where it is appropriate to do so. Requests are vetted as soon as possible after they are made on ICE by a Consultant Endoscopist and if there is insufficient information to justify the request or concern that the procedure is not in the best interest of the patient, the request will be rejected and an ICE mail sent to the referring doctor and referring consultant with an explanation of the concerns.
This information will also be visible on ICE using “View Patient Requests” and then “View order” – any comments made when the request was rejected will be available in the “additional information” section. Further information on the endoscopy unit, including all the relevant documentation, is available on the endoscopy section of the intranet. Please note:
- All requests for gastroscopy, flexible sigmoidoscopy and colonoscopy (both inpatient and outpatient) should be made on ICE. If you are requesting procedures for patients to be done as an outpatient it is essential that you also print off the information leaflet about the procedure and the slip that tells the patient to go to the booking office to make an appointment for their procedure before leaving the hospital or to ring the endoscopy booking office the next working day to arrange the appointment and give these to the patient before they leave the hospital. If the patient books their appointment before leaving the hospital it means they can take all the relevant instructions home with them and can therefore be fitted in at short notice if other patients cancel procedures. If you do not do this, then any procedure will be delayed as it is often difficult for the booking clerks to contact the patient as phone numbers on iPMS are not always correct.
- All requests for oesophageal / pyloric dilatation, oesophageal / pyloric stent insertion, ERCP and bronchoscopy should be made to the appropriate consultant by yellow board.
- Requests for PEG insertion should be made using the Nutrition tab on the service provider section on ICE. Such patients will then be reviewed by the nutrition team who will assess the patient and the appropriateness of the procedure in the first instance and then liaise with endoscopy about the timing of the procedure.
- If patients are not able to give informed consent for the proposed procedure, you need to ensure that an assessment of mental capacity and consent form 4 are completed. If these have not been done, then the endoscopy staff will not be able to schedule the procedure.
- The inpatient Gastroscopy request on ICE should be used. As soon as the decision to request a procedure has been made the patient should be given a gastroscopy information sheet and endoscopy consent form (these can be accessed by using the “more information” buttons on the relevant section of the ICE request and printed off from there, or via the endoscopy section of the intranet).
- Patients should be given adequate time to be able to weigh up the information and make an informed decision about giving their consent to the procedure. The procedure is done either using local anaesthetic spray or with conscious sedation using low doses of midazolam.
Patients with significant upper GI bleeds
should be referred for Gastroscopy as soon as possible
- If a patient is admitted on a weekday before 4pm, contact the endoscopy unit as soon as possible to see if the patient can be added to the end of the list.
- Patients admitted after this or at a weekend will have a gastroscopy the next working day morning. Please keep patients NBM and contact the Endoscopy Unit as soon as possible the following morning to check when the procedure can be fitted in (the unit is open from 7.30am on weekdays and 8.30am on Saturdays). Patients should not have any food for 6 hours before a procedure, but can drink clear fluids until 2 hours before.
- All patients coming down for a procedure MUST have intravenous access.
- Patients should be haemodynamically stabilised before the procedure and transfused if necessary such that their Hb is > 80g/l.
- Patients with an obvious Mallory-Weiss tear, particularly young patients, do not necessarily need an endoscopy.
- If a patient is admitted with a severe upper GI bleed and requires a gastroscopy out of hours, you should:
- discuss this with and obtain agreement from the consultant in charge of the patient
- contact the duty Endoscopist (the rota is posted on the door of the endoscopy unit, in the main theatre and in EAU). Gastroscopy will then be arranged as soon as possible. At present there is only endoscopy nursing cover for out-of-hours gastroscopy from 6am-6pm at the weekend, but no overnight cover when procedures would be supported by the theatre staff.
- Inform the surgical SpR on call
Patients with low risk upper GI bleeds:
These patients can usually be discharged to return for an outpatient gastroscopy – see the Ambulatory Care Pathway
Symptoms suggestive of upper gastrointestinal cancer:
- Unexplained upper abdominal pain and weight loss
- Upper abdominal mass with or without dyspepsia
- Persistent vomiting & weight loss
- Unexplained worsening of dyspepsia
- Patients aged ≥55 years with unexplained & persistent recent-onset dyspepsia (after stopping treatment with PPIs)
- Abnormal or suspicious findings on barium studies, CT or US scanning
- Patients with haematemesis and/or melaena
- To confirm healing of oesophageal or gastric ulcer
- Persistent long term reflux, odynophagia or dyspepsia unresponsive to 6 weeks treatment in primary care
- Coeliac disease diagnosis (& follow up of non-responders)
- Surveillance of Barrett’s oesophagus
- To take small bowel biopsies to investigate malabsorption or enteropathy
- In patients with an adenocarcinoma of unknown primary after discussion at MDT
- Surveillance for gastric dysplasia or in patients with a strong family history of gastric carcinoma
- Surveillance or screening in patients with FAP because of the risk of duodenal polyps
- Surveillance for oesophago-gastric varices in patients with suspicion of portal hypertension (eg, decompensated liver disease, cirrhosis on liver biopsy or equivalent non-invasive testing, presence of varices on abdominal imaging)
Routine endoscopic investigation of patients of any age presenting with dyspepsia and without alarm signs is not necessary. The Luton dyspepsia guidelines are also available on the intranet (under Endoscopy / Policies and Procedures / Luton dyspepsia guidelines).
- Consider managing previously investigated patients without new alarm signs according to previous endoscopic findings.
- Consider the possibility of cardiac or biliary disease as part of the differential diagnosis.
Relative contra-indications to Gastroscopy
- INR >3.5 (biopsies will not be taken, increased risk of bleeding)
- Recent MI – endoscopy should not be performed within 4 weeks of an MI unless there is a strong indication or the results are likely to significantly alter management
- Severe COPD with hypoxaemia
- Pregnancy – endoscopy should be avoided in the first trimester if at all possible
- Relief of bolus obstruction
- Placement of feeding tubes, such as NJ tube or PEG insertion*
- Oesophageal or pyloric dilation**
- Insertion of oesophageal, pyloric or duodenal stent**
* Requests for PEG insertion should be made using the Nutrition tab on the service provider section on ICE.
** Requests for placement of NJ tube, oesophageal or pyloric dilatation and the insertion of stents should be sent by a standard yellow board to the appropriate consultant and the relevant nurse specialist informed.
Usual day and time of list
Where procedure done
Placement of Naso-jejunal tube
Miss S Cheslyn-Curtis
Mr D Whitelaw
Jacqui Arnold-Jellis (bleep 278)
Insertion of PEG tube
Dr R Gao
(but can also be done by other consultants if required)
Jacqui Arnold-Jellis (bleep 278)
Helen Chin (bleep 046)
(but can also be done at other times if required)
Oesophageal or pyloric dilation
Dr M Johnson
Mr P Jambulingam
Alternate Wednesday am
X-ray OR endoscopy
Oesophageal, pyloric or duodenal stent insertion
Dr M Johnson
Mr P Jambulingam
Alternate Wednesday am
- The inpatient flexible sigmoidoscopy request on ICE should be used.
- As soon as the decision to request a procedure has been made the patient should be given a flexible sigmoidoscopy information sheet and endoscopy consent form (these can be accessed by using the “more information” buttons on the relevant section of the ICE request and printed off from there, or via the endoscopy section of the intranet) – they should have adequate time to be able to weigh up the information and make an informed decision about giving their consent to the procedure.
- The procedure is done either without sedation, with Entonox or with conscious sedation using low doses of Midazolam. Patients should be given a phosphate enema (written up on the drug chart) on the ward about 60 minutes before the scheduled procedure time.
If a procedure is requested as an outpatient, the patient will be given / sent the appointment in writing with all the necessary instructions and documentation. This will include instructions on how to give themselves a phosphate enema at home. Indications for Diagnostic Flexible Sigmoidoscopy (BSG 2013)
- Investigation of diarrhoea with or without bleeding in acutely ill patients
- Investigation of rectal bleeding in absence of altered bowel habit (≥ 40 years; fresh bleeding not mixed with stool)
- < 40 years with persistent and/or recurrent bleeding with or without change in bowel habit
- Investigation of equivocal radiological abnormalities in the rectum or sigmoid colon
- Within the Flexible Sigmoidoscopy bowel cancer screening programme (starting at L&D mid 2014)
- Surveillance of rectal stump in FAP
- Surveillance by pouchoscopy for patients with IPAA (ileal pouch anal anastomosis) (for IBD or FAP)
- Evaluation for an anastomotic recurrence in rectosigmoid carcinoma
- Decompression of sigmoid volvulus if decompression with a flatus tube has failed
Contraindications for flexible sigmoidoscopy (see also contraindications for gastrosocopy)
- Acute severe diverticulitis
Please note: the information obtained at flexible sigmoidoscopy is often limited by poor bowel preparation. If you think this is likely to be an issue, please discuss with the endoscopy unit in advance.
- Where a colonoscopy would be more appropriate
Colonoscopy is rarely necessary to perform as an inpatient. Not only do patients require bowel preparation, but it is also a longer procedure and hence more difficult just to fit in at the end of a list. To request a colonoscopy for an inpatient, please use the inpatient colonoscopy request on ICE making it clear why this needs to be done as an inpatient. Unless there are compelling reasons to organise this as an inpatient, most patients will be given / sent an outpatient appointment with all the necessary instructions and documentation, including the bowel preparation. Colonoscopy is usually done under conscious sedation using a combination of Pethidine, Midazolam and / or Entonox.
If a colonoscopy is required as an inpatient, this should be discussed with one of the Endoscopy consultants. Under these circumstances the patient should be given a colonoscopy information sheet and endoscopy consent form (these can be accessed by using the “more information” buttons on the relevant section of the ICE request and printed off from there, or via the endoscopy section of the intranet) – they should have adequate time to be able to weigh up the information and make an informed decision about giving their consent to the procedure. It is also essential that the patient is prescribed bowel preparation well in advance and encouraged to take this as prescribed with sufficient oral fluid. If there is any doubt that the bowel preparation has been successful, the patient should also be given a phosphate enema on the ward 60 minutes before the scheduled procedure time.
For frail elderly patients and those with significant co-morbidity, it is essential to be sure that colonoscopy is an appropriate investigation and consider whether a less invasive investigation such as a CT scan would give the required information.
Indications for Diagnostic Colonoscopy (BSG 2013)
Symptoms suggestive of colorectal cancer:
- ≥40 years with rectal bleeding with a change of bowel habit towards looser stools and/or increased stool frequency persisting 6 weeks or more
- Patients at any age with altered blood or blood mixed in stool
- ≥60 years with rectal bleeding persisting for 6 weeks or more without a change in bowel habit and without anal symptoms
- ≥60 years with a change in bowel habit to looser stools and/or more frequent stools persisting for 6 weeks or more without rectal bleeding
- Men of any age with unexplained iron deficiency anaemia
- Non-menstruating women with unexplained iron deficiency anaemia
- In patients with melaena after upper GI source was excluded
- In patients with emergency admission with rectal bleeding
- Clinically significant diarrhoea of unexplained origin (including microscopic colitis)
- Abnormal or suspicious findings in colon on barium enema, CT or virtual (CT) colonography
- Unexplained abnormalities of terminal ileum on small bowel imaging
- Persistent abdominal symptoms with raised CRP or faecal calprotectin
- Assessment of neo-terminal ileal recurrence of Crohns following right hemi-colectomy to determine need for medical therapy
- Assessment of extent and activity of known IBD
- To confirm mucosal response to treatment with biological agents in patients with Crohn’s disease
- Screening in patients with significant family history of, or other risk factors (such as uretero-sigmoidostomy or acromegaly) for colorectal cancer
- In patients with positive faecal occult blood tests as part of NHS national bowel cancer screening programme
- Surveillance of patients with IBD
- Surveillance after resection of colorectal cancer
- Surveillance after removal of adenomas and in patients with FAP
- After identification of adenomas at flexible or rigid sigmoidoscopy and for clearing the colon of synchronous neoplasia in patients with colorectal cancer
Colonoscopy is generally NOT indicated in the following circumstances
- Chronic stable irritable bowel or chronic abdominal pain (except in unusual cases where colonoscopy may be performed to exclude organic disease, particularly if symptoms unresponsive the therapy)
- Metastatic adenocarcinoma of unknown primary site, unless there are colonic signs or symptoms
- Upper GI bleeding or melaena with a documented upper GI source
Contraindications for colonoscopy (see also contraindications for gastrosocopy)
- Acute severe diverticulitis
- Under general anaesthesia
Requesting gastroscopy, flexible sigmoidoscopy and colonoscopy to be done as an outpatient
- Patient unable to take bowel preparation (which will involve drinking up to 4 litres of fluid in 24 hours)
- These requests should be made on ICE and the relevant information printed off and given to the patient before they go home.
- This should include a slip that asks the patient to go directly to the booking office to make their appointment before leaving the hospital (in which case they can pick up all the relevant paperwork and bowel preparation, if required) or to ring the endoscopy booking office to arrange a convenient appointment.
- Patients should be asked to go to the booking office to make their appointments before leaving the hospital whenever possible. If they do this they can pick up all the relevant paperwork and bowel preparation, if required.
- It is very important that patients understand that they need to contact the booking office to make the appointment. Any procedure is likely to be delayed if we have to try and get hold of them as we often end up having to write to them to ask them to contact us.
- If the request has not been vetted when the patient makes the appointment they will be given all the paperwork and told the booking office will contact them to confirm that the request has been approved.
- The endoscopy booking office is staffed 9am-5.30pm Monday to Friday and is situated on the ground floor opposite security.
ERCP is performed by Miss Cheslyn-Curtis and Mr Whitelaw. Patients should be referred using a yellow board. Patients admitted for ERCP follow an integrated care pathway which gives all the necessary information and guidance (available on the surgical wards and the endoscopy section of the intranet). If patients are scheduled to have an ERCP as an inpatient they should be given an ERCP information sheet and endoscopy consent form – they should have adequate time to be able to weigh up the information and make an informed decision about giving their consent to the procedure.
Indications for ERCP
- Obstructive jaundice thought to be due to biliary obstruction
- Clinical and biochemical or imaging data suggestive of pancreatic or biliary tract disease
- Stent placement across benign or malignant strictures, fistulae, postoperative bile leak, or large common bile duct stones
- Tissue sampling from pancreatic or bile ducts
THE BSG guidance is summarised in table 3 - in
Allison, M.C., Sandoe, J.A.T. et al (2009). Antibiotic prophylaxis in gastrointestinal endoscopy. GUT 58 pp.869-880
Luton & Dunstable antibiotic guidance:
- PEG insertion: Co-amoxiclav 1.2 g stat 30 minutes before the procedure OR Teicocoplanin 400mg iv stat if allergic to Pencillin
- ERCP: Ciprofloxacin 500mg po 2 hours before the procedure
Ambulatory care pathway