In general any patient aged between 16 and 84 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 with insulin dependent diabetes and those on anti-coagulant therapy, who are otherwise heathy, are suitable for Open Access Endoscopy; and the appropriate management of these patients will be discussed with the GIE gastroenterologist and all relevant parties. Patients with BMI greater than 40 should have their open access procedures at a fully equipped hospital rather than day endoscopy centre.

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.

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.

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.

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.

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.

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.

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.

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.

This question is really 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. 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. NOACs reversibly binds to the ADP platelet receptor and its effect is largely lost by five days. Their 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.

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.

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.

Unfortunately, there is no simple answer to this question. Follow-up recommendations vary widely across countries, specialties, expert committees and “expert” guidelines!

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.

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:-

There is no universally agreed answer.  My own view is that if:

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.

Self-diagnosed wheat intolerance and “gluten reactions” have become very common indeed almost fashionable!

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:-

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.

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.

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.