Resources & FAQs
- Clinical Practice Guidelines for Surveillance Colonoscopy – in adenoma follow-up; follwoing curative resection of colorectal cancer; and for cancer surveillance in inflammatory bowel disease(2011) National Health & Medical Research Council (NHMRC). These guidelines are intended for use by all practitioners and health workers who require information about surveillance colonoscopy – in adenoma follow-up, following curative resection of colorectal cancer, and for cancer surveillance in inflammatory bowel disease.
- Guidelines for Referring Doctors: Information for referring doctors on the Open Access process and patient selection.
Frequently Asked Questions: responses from our team of gastroenterologists for questions from our referring doctors
What types of patients are suitable for Open Access Endoscopy?
In general any patient aged between 16 and 85 is suitable for open access endoscopy provided they do not have significant co-morbidities which could render the procedure or aftercare a risk to the patient. Patients outside that age band are considered for suitability on an individual basis. Patients with insulin dependent diabetes and those on anti-coagulant therapy present particular concerns and will often require a pre-procedural consultation prior to colonoscopy. Patients with BMI greater than 40 should have their open access procedures at a fully equipped hospital rather than day endoscopy center.
What tests should be performed for investigation of a positive FOBT?
There are two major types of Faecal Occult Blood Tests (FOBTs), chemical tests (gFOBTs)which detect faecal haem which perioxidises the reagent guaiac, and immunological tests (FITs)which detect faecal globin. As blood passes through the gastrointestinal tract the globin is digested so FITs are negative during upper gastrointestinal bleeding, but gFOBTs may remain positive. Chemical tests are 2-3 times less sensitive than immunological tests for detecting blood in the stool, and also less specific as other peroxidases in the diet may cause false positive gFOBTs. Chemical tests also require sampling from at least 3 consecutive stools to improve their sensitivity whereas FITs are sensitive with just 2 stool samples. For these reasons the National Bowel Screening Programme (NBCSP) uses the immunological test as the FOBT of choice. Guaiac based tests are still used in the Australian Rotary Health programme and in Bowelscan testing.
If a patient has a positive FIT as a participant in the NBCSP, the recommended test is a colonoscopy. An upper endoscopy is not necessary as this test does not detect bleeding from the UGIT.
How often are FOBTs positive in the NBCSP?
About 1 in 14 patients (7%) have a positive FOBT and most of these patients require further investigation as they are 12 times more likely to have colorectal cancer than patients with negative tests. In FOBT positive patients, 6% are found to have bowel cancer, 14% advanced adenomas, and 35% polyps. It is important to realise that a negative FOBT does not exclude cancer (it only detects blood, if present, in the stool, not polyps or cancer), so a symptomatic patient should be referred for colonoscopy without having a FOBT performed as a negative test may lull the patient or doctor into a false sense of security. Similarly it is recommended that patients already enrolled in surveillance programmes for follow-up of colonic polyps should not have regular FOBTs as a means of deciding whether to proceed with their follow-up investigation or not.
What is the rate of false positive FOBT (Faecal Occult Blood Tests) and how is this best approached?
The positive predictive value of the FOBT is 26.3%. This means that cancers and adenomas (including small adenomas) are detected 26% of the time that a positive FOBT is identified in average risk patients in a population. That value falls to 20% if you take out diminutiveadenomas. This does mean that a large proportion of the FOBTs are falsely positive. Having said that, there is strong evidence that colon cancer mortality is reduced by up to one third with a FOBT screening program. A positive test should be followed up by a colonoscopy if the patient has not had a screening colonoscopy in the immediate past (about two years). If an FOBT is positive and the most recent colonoscopy was two years prior, then I think that positive FOBT should trigger a further colonoscopy.
It is instructive to look at the outcomes of National Bowel Cancer Screening Program (NBCSP) in Queensland. Between 8/06 and 12/10, 552 400 kits were posted. The number returned was 183 000, of which 14 000 were positive. All patients with positive FOBT were offered screening at a QLD Health facility and 4800 accepted the offer. Amongst these 4800 individuals there were 210 colon cancers, and 3070 polyps of which about half were advanced (>1cm in diameter), i.e. a positive FOBT identified a significant polyp or cancer in 36% and any polyp or cancer in 68%. The false positive rate then for significant lesions was 64% and for any lesion, 32%. The figure of 26.3% mentioned above is a national figure and reflects the outcome in the screened population as a whole, including the majority who either did not return the test or did not attend for colonoscopy when indicated.
Does a coeliac patient require repeat endoscopies throughout their lifetime?
The short answer to this is, ‘No’. Having said that the traditional gold standard for diagnosing coeliac disease is the identification of subtotal villous atrophy on a small bowel biopsy, observing the histology return to normal on a strict gluten free diet and then demonstrating deterioration again once gluten is reintroduced into the diet. This approach is rarely taken in adults although at times in children this is necessary.
As a general rule if an adult has subtotal villous atrophy on small bowel biopsy, elevated tissue transglutaminase (TTG) antibodies and a good response to gluten elimination from their diet with resolution of symptoms and normalisation of antibodies and abnormal blood tests, then a repeat small bowel biopsy may not be necessary. If symptoms persist or blood tests remain abnormal, a repeat biopsy will be required to determine if the failure to respond is due to resistant Coeliac disease or other causes. Having said this, the most common cause for failed response is continued exposure to gluten. These patients need to be more fully investigated by a Gastroenterologist with thorough dietary history by a dietitian, review of the evidence for the diagnosis including HLA typing to determine if they have a compatible phenotype for Coeliac Disease and exclusion of other conditions such as small bowel lymphoma.
Guidelines for haemochromatosis
The diagnosis of haemochromatosis is based on clinical grounds, gene testing for mutations in the HFE gene, and an assessment of the degree of iron overload in the body as a whole. It is important to establish this stage of the disease in an individual patient and in particular whether there is significant liver injury or even cirrhosis. This may require liver biopsy when histology can be assessed, and iron concentration can be measured. More recently attempts have been made to gauge iron overload in the liver using MRI scanning, and the degree of fibrosis by FibroScan. However liver biopsy remains the most accurate means of assessing liver histology and iron loading. Decisions to do a liver biopsy depend on clinical judgement but is usually indicated when there is hepatomegaly, abnormal liver tests or when the serum ferritin is greater than 1000mcg/l.
Treatment aims to remove all the excess iron from the body and this requires a long series of venesections with monitoring of haemoglobin level regularly, and iron biochemistry intermittently. I find it ideal to reach a mild degree of iron deficiency as I am then certain all excess iron stores are removed. Once that has been achieved, venesection is required every three to four months in order to prevent iron re-accumulation and regular blood tests to monitor iron levels and haemoglobin. Patient with cirrhosis should have six monthly abdominal ultrasound and alpha fetoprotein because of the increased risk of hepatocellular carcinoma.
Does irritable bowel syndrome warrant an endoscopy?
Not everyone with potential irritable bowel syndrome requires extensive endoscopic investigation. By that I mean both upper GI endoscopy and small bowel biopsy and colonoscopy. A patient who is young and has symptoms that are very typical and who has no alarm symptoms together with normal biochemistry, normal haematology, normal inflammatory markers and normal TTG antibodies probably does not need to be further investigated. However alarm symptoms such as unusual abdominal pain that is progressive, evidence of gastrointestinal bleeding or weight loss would trigger further investigations.
In the older patient (for example someone over 50) the development of gastrointestinal symptoms that might initially suggest the irritable bowel syndrome should be further investigated whether or not there are alarm symptoms present because of the greater likelihood of pathology in the older age group than in the younger age group. This might even be in the absence of abnormalities in the various investigations mentioned above. There are of course exceptions to every rule. The irritable bowel syndrome is usually a condition that waxes and wanes over time so that the patient with progressive and worsening symptoms over some months does need to be investigated at whatever age they present and whatever the results of the above investigations are found to be.
When is a capsule endoscopy indicated?
A capsule endoscopy is indicated when the patient has evidence of gastrointestinal blood loss and the site of bleeding is obscure. This could present as either overt gastrointestinal bleeding, or unexplained iron deficiency. A colonoscopy and upper GI endoscopy will have to have been performed, and have failed to show a potential source for blood loss. These two investigations do need to have been performed within six months of the proposed capsule endoscopy to generate a rebate of the cost of the capsule for the patient. Australia from the outset prospectively collected an extensive dataset on capsule endoscopy and this confirmed the clinical usefulness of this procedure. The yield from capsule endoscopy is higher than had been expected and this allowed the Medical Services Advisory Committee to fund this technology for these specific indications. Capsule Endoscopy is also funded for the further investigation of the small bowel in the polyposis syndromes under specific circumstances. An application has been submitted to MSAC for funding for Capsule Endoscopy in the further investigation of possible Crohn’s disease, again in certain specific instances.
Can you explain eosinophilic oesophagitis and the approaches to treatment?
We first recognised eosinophilic oesophagitis in paediatric medicine affecting boys more than girls and in that setting early data suggested that implementing an elimination diet to exclude foodstuffs such as peanuts, eggs, soy, cow’s milk, wheat and tree nuts was effective in about 75% of all children treated. This seems to be less effective in adults. However these elimination diets need to be applied with vigour and preferably with the assistance of a dietician. The second approach is to use topical glucocorticoids most frequently fluticasone which is administered using the metered dose inhaler but removing the spacer. The medication is sprayed onto the patient’s mouth at the back of the tongue and swallowed with a small amount of fluid. Obviously it is not inhaled. Budesonide has also been used as a viscous slurry. The addition of a proton pump inhibitor is often used although the relationship between gastro-oesophageal reflux disease and eosinophilic oesophagitis is somewhat unclear. There does at times seem to be overlap and the two approaches to treatment can be synergistic.
Can you provide clarification and recommendations for patients requiring endoscopy who are on Brilinta?
This question is really a more general question about which patients should cease and which patients should continue all forms of anti-coagulation prior to endoscopic procedures. The answer will depend on the individual patient, the reason the anti-coagulant or anti-platelet agent is administered and the nature and risks of the procedure contemplated. Specifically with upper GI endoscopy as a general principal I do not stop anti-platelet agents such as Brilinta. I would be reluctant to take many biopsies or embark on other interventions in that circumstance. The situation for colonoscopy and polypectomy is somewhat different and as a general principle I like to cease anti-platelet therapy prior to polypectomy particularly for the larger polyps. Brilinta reversibly binds to the ADP platelet receptor and its effect is largely lost by five days. Its excretion does not depend on renal function but it is dependent on hepatic metabolisms of some modification of that time may be necessary for very significant liver disease.
Does a coeliac patient require repeat endoscopies throughout their lifetime?
The short answer to this is no. Having said that the goal standard for diagnosing coeliac disease is the identification of subtotal villous atrophy on the small bowel biopsy, observing the histology return to normal on a strict gluten free diet and then demonstrating deterioration again once gluten is reintroduced into the diet. This approach is rarely taken in adults although at times in children this is necessary.
As a general rule if an adult has a biopsy showing subtotal villous atrophy and raised TTG antibodies and possibly a genetic profile that is appropriate in terms of their tissue antibodies and assuming the patient has a good response to gluten elimination from their diet based on resolution of symptoms, fall of antibodies to normal levels and a return of haematology and biochemistry to normal should they be abnormal initially that will be all that is necessary. The difficulty arises when it appears that there has not been a response either clinically or based on laboratory measures. Having said that the usual cause for failed response is the continued exposure to gluten but this type of patient can be difficult to work out. This would require careful history taking, review of the evidence for the diagnosis and probably the use of HLA typing as well.
Why do patients treated with Inflammatory Bowel Disease (IBD) still get symptoms?
There are a number of reasons for this. It is obviously important to be sure that the Inflammatory Bowel Disease is completely controlled by the medications administered. That can be a little difficult in the case of Crohn’s Disease, particularly where it affects the small bowel, but there are ways to do that. One useful test that is appearing at the present time is a faecal calprotectin. Royal Brisbane performs this for us at the present time, but there is an application to MSAC for funding of this test in the long term.
However, the issue is more often that the disease does seem to have settled yet symptoms persist. Professor Peter Gibson at Monash has had a great interest this area, together with a dietician attached to his unit, Sue Shepherd, and has investigated this phenomenon for some years now. It was out of that question that the concept of FODMAPS arose. These, as you may be aware, are Fermentable Oligo-, Di-, Mono-saccharides And Polyols. These are constituents of many foodstuffs, especially fruits and vegetables, and probably account for the symptoms of looseness, distension and gas that persist in some patients after adequate treatment of Inflammatory Bowel Disease. They are a potential cause of such symptoms in a proportion of patients with IBS as well. Other triggers for irritable bowel symptoms are no less likely to affect those with treated inflammatory bowel disease either, so there is a third potential explanation. A low FODMAP diet booklet can be obtained from the Monash University dept of medicine website.
What review period do you recommend for patients with previously identified polyps?
Unfortunately, there is no simple answer to this question. Follow-up recommendations vary widely across countries, specialties, expert committees and “expert” guidelines!
The Gastroenterological Society of Australia and the American Gastroenterological Association recommend:
- One to two small tubular adenomas with low grade dysplasia – follow up in five years.
- Adenomas greater than 1cm, more than two polyps, polyps with any villous component, or more than low grade dysplasia – follow-up three years.
- Sessile serrated adenomas (SSA) follow-up three years.
Others believe five years is too long for tubular adenoma follow-up. In practice the issue is much more complex. Factors such as family history, length of colon, quality of bowel preparation, age, and co-morbidities all have to be taken into consideration.
Particularly with sessile polyps the difficulty of removal and the degree of certainty that the polyp has been totally removed are very important.
There are a series of clinical and histological factors which determine if polypectomy is adequate treatment for a malignant polyp or if surgery is required.
A number of special syndromes (FAP, HNPCC, Flat Adenoma Syndrome, Familial Giant Hyperplastic Polyps Syndrome etc), all have their own special follow-up programs.
We do not routinely recommend follow-up for patients over 80. However, if they remain in good health at this age follow-up is reasonable.
There are different opinions about hyperplastic polyps. 2-4mm rectal hyperplastic polyps are of little significance. Larger hyperplastic polyps are followed on a 3-10 year basis depending upon the number size and other factors.
How do you approach resistant Helicobacter pylori?
There are a number of accepted first line treatment combinations for H. pylori eradication. A regime of a PPI + Amoxycillin + Clarithromycin for 7 – 14 days is the most commonly used. For patients allergic to penicillin a cephalosporin, metronidazole or tetracycline can be substituted. There is now a high level of metronidazole resistance.
It is critical to discuss treatment carefully with the patient. They must clearly understand the risks including allergic reactions and C.difficile induced pseudomembranous colitis. They need to understand treatment eradication success rates and realize missing any medication dose will seriously increase the likelihood of treatment failure.
If first-line therapy has failed, consider possible reasons. Has the patient taken ALL OF EVERY medication prescribed? If side effects have caused compliance failure, then further treatments containing the drug causing the side effects will also fail.
Are further attempts at eradication justified? Patients presenting with MALT lymphoma, family history of gastric carcinoma, current or a past history of peptic ulcer, the need for long term PPI therapy, and requirement for blood thinning or longterm NSAID use certainly require eradication. An elderly person with none of the above does not. C.difficile infection can be a devastating illness in the elderly. This risk outweighs likely benefits in older patients without major risk factors. It is often useful to outline side effects and success rates of further attempts versus risks of non eradication and let the patient decide.
If there are compelling reasons to eradicate, then it is often best to go straight to the more expensive and (for the doctor!) tedious third line treatment. Unfortunately these drugs have to be obtained through the TGA Special Access Scheme.
You will need: – TGA Category B Special Access Form (Phone Tri-med 08 9388 1444)
Complete form and send to TGA
TGA will send you a letter; send this to Tri-med with payment. Treatment is DENOL + FURAZOLIDONE + AMOXYCILLIN
For what purpose would you order a barium swallow?
Barium studies of the upper GI tract are significantly less accurate than endoscopy for most upper gastrointestinal diseases and are recommended only in selected patients. Indications can include:-
- Suspected oesophageal dysmotility (order cine barium swallow indicating clinical suspicion of oesophageal dysmotility).
- Failed endoscopy. Rarely it may not be possible to insert the endoscope into the oesophagus. This can occur following surgery, radio therapy, caustic ingestion etc. Usually a guide wire can be passed under Xray control to allow dilatation. However, it may be considered advisable to outline the whole oesophagus before attempting dilatation.
- Contra indications to intravenous sedation. Rarely cardiac or respiratory disease can be a contra indication to intravenous sedation.
- Demonstrating anatomical relationships in a patient with a large paraoesophageal hiatus hernia.
- Non barium Xray contrast (e.g. gastrograffin) if oesophageal perforation is suspected.
- Defining anatomy preoperatively in large pharyngeal pouches.
In a patient with rectal bleeding when would you choose a flexible sigmoidoscopy versus a colonoscopy?
There is no universally agreed answer. My own view is that if:
- The blood is “cut finger” bright red, AND
- Is only ever seen on the toilet paper, OR
- Drips or sprays on to the bowel wall during defecation, then the lesion should be within 60cm of the anus and should be able to be seen at flexible sigmoidoscopy.
HOWEVER, if the patient:
- Is unsure of the bleeding details or is a poor historian, visually impaired “didn’t look” etc.
- Has other risk factors (e.g. family history, previous carcinoma of the colon, previous colonic polyps or inflammatory bowel disease).
- Is anxious about the possibility of carcinoma;
Then full colonoscopy is to be preferred. NB visualization of bleeding from a haemorrhoid does NOT prove that this is the source of PR bleeding . Digital examination and proctoscopy can precipitate haemorrhoidal bleeding.
What is your recommendation for patients who need to fly following their procedure?
For diagnostic endoscopy and colonoscopy there is no need for any flying restrictions. If polyps have been removed there is always some possibility of post Polypectomy haemorrhage. This risk can extend for up two weeks following Polypectomy but is most likely within the first 48 hours. In general we recommend avoiding domestic flights for 48 hours and international flights or any travel to remote areas for 7 to 10 days. However, this time line may need to modified depending on polyp size, difficulty of removal, co-morbidities, blood thinning agents etc.
How do you determine if a patient has gluten or wheat intolerance?
Self-diagnosed wheat intolerance and “gluten reactions” have become very common indeed almost fashionable!
Coeliac disease is a specific clear cut inflammatory reaction to gluten which is a component of Gliden in wheat flour. 90-95% of coeliac patients will have positive antibody tests. The best antibody tests are Tissue Transglutaminase Autoantibodies (TGAA) and Endomysial Antibodies (EMA). In children under two IgA antigliden antibody is more reliable. A SMALL BOWEL BIOPSY is necessary to make a definitive diagnosis.
A normal small bowel biopsy in a patient on a gluten free diet does NOT exclude coeliac disease. A small number of patients with normal small bowel biopsies will subsequently develop clinical coeliac disease (for details see The Gut Foundation web site (gut.nsw.edu.au).
Wheat intolerance is a very non-specific reaction, undoubtedly there are some people who have a variety of symptoms including abdominal bloating, excess intestinal gas, abdominal cramps and diarrhoea which are precipitated by wheat ingestion. This appears to be an intolerance to the whole wheat flour protein not to gluten. Food intolerances in general are a very difficult area. If patients feel that their symptoms are reduced by a wheat free diet there is no reason not to follow one. They do not need to be on a gluten free diet. Unfortunately, food intolerances often change overtime. Serial elimination diet studies confirm this (for more information on food intolerances see the Gut Foundation website and the publication “Friendly Foods” by the Royal Prince Alfred Hospital, Sydney, Department of Dietetics).
Colonoscopy Withdrawal Time: How important is it?
One of the problems we have encountered with colonoscopy in the last thirty years has been the incidence of missed colon cancer during colonoscopy. We have failed to see as dramatic a reduction in the incidence of colon cancer as we would have liked to see. There have been intensive efforts in the last ten to fifteen years to try and improve our yield at colonoscopy. Namely:-
- We have realised the importance of careful bowel preparation, in particular split preparations which improve the quality of the prep and enhance visualisation of the mucosa;
- We have seen the progressive improvement in the quality of instruments we use, not just in the image itself but in the physical characteristics of the instrument and the progressive improvements in techniques we use to achieve full examination of the colon;
- We have recognised the existence of flat right-sided adenomas (sessile serrated adenomas) which can be quite difficult to detect; and
- We have recognised the importance of slow and careful withdrawal looking behind colonic folds on withdrawal.
Withdrawal time then is just one potential factor in increasing yield at colonoscopy and it is becoming more regularly reported. It is based on relatively recently published data that suggested an average withdrawal time of six minutes improved the yield of colonoscopy as compared with an average withdrawal time of less than that number. I personally report that number, but I regard it more important to spend time washing the colon, carefully analysing the mucosa with enhancing techniques such as dye spraying or Narrow Band Imaging, looking behind folds and re-examining areas that are known to be difficult to see well such as the right colon, behind flexures and in the sigmoid colon. Probably a better assessment of overall colonoscopy performance is the adenoma detection rate. This is also being measured by colonoscopists around the world and locally.
What would you recommend if a patient has rectal bleeding between routine colonoscopic examinations for polyp follow-up?
Any rectal bleeding has to be taken seriously, but the management in any particular situation must be individualised. If a patient has had a recent colonoscopy by an experienced proceduralist and has further bleeding, it may not require a repeat procedure. If the bleeding sounds anal in origin (bright red blood on the paper) and the patient had documented haemorrhoids at the last colonoscopy, it would be fairly safe to assume that these were the source of the bleeding. If the bleeding is persistent or causing the patient concern, then it would be wise to investigate this further. It is important to understand that no procedure is 100% accurate and even significant polyps or cancers can be missed by even experienced gastroenterologists. Sometimes such patients are best handled by requesting a referral for a consultation with a gastroenterologist rather than requesting a repeat colonoscopy.
If haemorrhoids are found at colonoscopy, are they treated at the time?
Open access patients referred for colonoscopy will not have haemorrhoids treated during their procedure. There are a number of reasons for this. Firstly there are a number of treatments available for treating haemorrhoids (topical medical treatment, sclerotherapy, banding, haemorrhoidectomy), and what treatment is used varies according to the clinical situation and the wishes of the patient. In addition there are potential complications of haemorrhoidal treatments which have to be discussed with the patient prior to administering treatment. As the patient has not had this explained to them prior to the procedure, it is therefore not advisable or possible to administer treatments without having gone through this consent process first. Generally speaking most patients having haemorrhoids treated should be referred to colorectal surgeons so that the treatment options, and the risks and complications can be discussed first.
Do patients with Bulimia need regular endoscopic surveillance?
Some patients with Bulimia sustain Mallory-Weiss tears and have oesphagitis from frequent vomiting. Any patient with Bulimia who has complications from their vomiting (eg haematemesis or chest pain) should be investigated appropriately by upper endoscopy, but only those patients who have damage to their oesophagus (severe ulceration or Barrett’s oesophagus) would need ongoing surveillance.