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Gastroenterology Service, 2018
Introduction Endoscopic mucosal sampling remains an important aspect of diagnosing colonic pathol... more Introduction Endoscopic mucosal sampling remains an important aspect of diagnosing colonic pathology. There remains a wide variety of practice in biopsying the macroscopically normal colon in chronic diarrhoea. We combined recommendations from the BSG and ASGE guidelines and expert opinions from two review articles to set a local standard. Our standard was 2–4 biopsies from the right colon (caecum-transverse colon) and 2–4 from the left colon with compulsory rectal biopsy. Terminal ileum (TI) biopsies were deemed unnecessary if macroscopically normal. The aim was to audit the current practice and identify methods to reduce histopathology workload and financial implications. Methods We retrospectively audited all normal colonoscopies with diarrhoea as the indication using our endoscopy reporting tool over a 6 month period across two sites. Bowel Cancer Screening Programme, Inflammatory Bowel Disease assessment and surveillance procedures were excluded. Endoscopy reports were scrutinised to compare the indication, findings and biopsy series performed. We recorded the number of biopsies taken from each colonic segment: TI to rectum. In our Trust, each colonic segment biopsy was sent in separate formalin-based pots. The processing cost of each pot is £62 and approximates to 15 min of histopathology analysis time. Results 405 colonoscopies were performed. 27.9% (n=113) followed the standard. The most frequently performed series was 6 segmental biopsies per colonoscopy. A total of 3570 biopsies were taken; 22.3% were excess colonic biopsies and 6.4% were unnecessary TI biopsies. 84 procedures had inadequate biopsies; 20.2% (n=82) missed rectal biopsies and 0.5% (n=2) had insufficient biopsies taken to diagnose microscopic colitis. The incidence of microscopic colitis was 4.2% (n=17) with no change in pickup rate if our standards were applied. The total cost incurred was £1 10 670 and if our standard had been followed, the cost would be £1 00 440 in 6 months. This suggests an annual cost saving of over £20 000 in addition to saving the equivalent of 5 weeks of a pathologist’s time. Conclusions By adopting the new standards, our endoscopy and pathology units would make significant savings in cost and workload without reducing our diagnostic pick-up rate of microscopic colitis. In addition to re-educating endoscopists, we are exploring the use of multiwell cassettes or grouping all biopsies in one pot for analysis. References . Rees CJ, et al. UK key performance indicators and quality assurance standards for colonoscopy. Gut2016;65:1923–29. . Shepherd NA, Valori RM. The effective use of gastrointestinal histopathology: guidance for endoscopy biopsy in the gastrointestinal tract. Frontline Gastroenterology2014;5:84–7. . Bateman AC, Patel P. Lower gastrointestinal endoscopy: guidance on indications for biopsy. Frontline Gastroenterology2014;5:96–102.
Depression and dementia have a very intimate relationship and hence differentiating the two can b... more Depression and dementia have a very intimate relationship and hence differentiating the two can be technically challenging. Severe depression can masquerade as dementia and it is therefore extremely important to differentiate between these two as it can impact the management. A patient was admitted with acute confusion, poor mobility and poor oral intake and was initially treated for Urinary Tract Infection (UTI). However, as confusion remained fluctuant, patient was started on treatment for presumed encephalitis. Due to poor response treatment was withdrawn. Patient was then referred to gastroenterology department for consideration of enteral feeding due to malnourishment secondary to confusion and possibly dementia. However, on further assessment a psychiatric opinion was sought and as expected a diagnosis of severe depression was made and hence Electroconvulsive Therapy (ECT) was proposed. Patient made a remarkable recovery with ECT and was subsequently discharged to a rehab faci...
Gastroenterology Service, 2018
Introduction Endoscopic mucosal sampling remains an important aspect of diagnosing colonic pathol... more Introduction Endoscopic mucosal sampling remains an important aspect of diagnosing colonic pathology. There remains a wide variety of practice in biopsying the macroscopically normal colon in chronic diarrhoea. We combined recommendations from the BSG and ASGE guidelines and expert opinions from two review articles to set a local standard. Our standard was 2–4 biopsies from the right colon (caecum-transverse colon) and 2–4 from the left colon with compulsory rectal biopsy. Terminal ileum (TI) biopsies were deemed unnecessary if macroscopically normal. The aim was to audit the current practice and identify methods to reduce histopathology workload and financial implications. Methods We retrospectively audited all normal colonoscopies with diarrhoea as the indication using our endoscopy reporting tool over a 6 month period across two sites. Bowel Cancer Screening Programme, Inflammatory Bowel Disease assessment and surveillance procedures were excluded. Endoscopy reports were scrutinised to compare the indication, findings and biopsy series performed. We recorded the number of biopsies taken from each colonic segment: TI to rectum. In our Trust, each colonic segment biopsy was sent in separate formalin-based pots. The processing cost of each pot is £62 and approximates to 15 min of histopathology analysis time. Results 405 colonoscopies were performed. 27.9% (n=113) followed the standard. The most frequently performed series was 6 segmental biopsies per colonoscopy. A total of 3570 biopsies were taken; 22.3% were excess colonic biopsies and 6.4% were unnecessary TI biopsies. 84 procedures had inadequate biopsies; 20.2% (n=82) missed rectal biopsies and 0.5% (n=2) had insufficient biopsies taken to diagnose microscopic colitis. The incidence of microscopic colitis was 4.2% (n=17) with no change in pickup rate if our standards were applied. The total cost incurred was £1 10 670 and if our standard had been followed, the cost would be £1 00 440 in 6 months. This suggests an annual cost saving of over £20 000 in addition to saving the equivalent of 5 weeks of a pathologist’s time. Conclusions By adopting the new standards, our endoscopy and pathology units would make significant savings in cost and workload without reducing our diagnostic pick-up rate of microscopic colitis. In addition to re-educating endoscopists, we are exploring the use of multiwell cassettes or grouping all biopsies in one pot for analysis. References . Rees CJ, et al. UK key performance indicators and quality assurance standards for colonoscopy. Gut2016;65:1923–29. . Shepherd NA, Valori RM. The effective use of gastrointestinal histopathology: guidance for endoscopy biopsy in the gastrointestinal tract. Frontline Gastroenterology2014;5:84–7. . Bateman AC, Patel P. Lower gastrointestinal endoscopy: guidance on indications for biopsy. Frontline Gastroenterology2014;5:96–102.
Depression and dementia have a very intimate relationship and hence differentiating the two can b... more Depression and dementia have a very intimate relationship and hence differentiating the two can be technically challenging. Severe depression can masquerade as dementia and it is therefore extremely important to differentiate between these two as it can impact the management. A patient was admitted with acute confusion, poor mobility and poor oral intake and was initially treated for Urinary Tract Infection (UTI). However, as confusion remained fluctuant, patient was started on treatment for presumed encephalitis. Due to poor response treatment was withdrawn. Patient was then referred to gastroenterology department for consideration of enteral feeding due to malnourishment secondary to confusion and possibly dementia. However, on further assessment a psychiatric opinion was sought and as expected a diagnosis of severe depression was made and hence Electroconvulsive Therapy (ECT) was proposed. Patient made a remarkable recovery with ECT and was subsequently discharged to a rehab faci...