Open access upper gastrointestinal endoscopy

Upper gastrointestinal endoscopy at the korle bu teaching hospital, accra, ghana

SUMMARY OBJECTIVES

To study the indications for endoscopy, the endoscopic diagnosis and other lessons learnt.

METHODS

A retrospective and prospective audit of all upper gastrointestinal endoscopies performed in the Endoscopy Unit of the Korle-Bu Teaching Hospital from January 1995 to December 2002 was performed.

RESULTS

A total of 6977 patients, 3777 males and 3200 females with age range 1 year 8 months to 93 years were endoscoped. The mean age of males was 43.5 +/- 0.5 and females 43.7 +/- 0.6 years. Epigastric pain (42.5%), dyspepsia (32.8%) and haematemesis and melaena (14.2%) were the commonest reasons for endoscopy. Chronic duodenal ulcer (19.6%), acute gastritis (12.7%), duodenitis (10.2%), oesophagitis (7.5%) were the commonest diagnoses. Normal endoscopy was reported in 41.1% patients, and was higher in the younger age group compared to the older (R = 0.973, P<0.001). Nine hundred and ninety (14.2%) patients were endoscoped for haematemesis and melaena of which chronic duodenal ulcer (32.1%), gastritis/gastric erosions (12.8%), oesophageal varices (9.8%), carcinoma of the stomach (6.4%), and duodenitis (4.2%), were the commonest causes. No lesion was found in 20.6% of these patients. Urease test was positive in 75% of all biopsy specimen and 85% in chronic duodenal ulcer, gastritis and duodenitis.

CONCLUSION

The normal endoscopy rate is high and needs to be reduced in order to help prolong the lives of the endoscopes. Chronic duodenal ulcer is usually associated with H. pylori infection and is the commonest cause of upper gastrointestinal bleeding.

Evaluación de la eficacia diagnóstica de la consultoría entre internistas y médicos de familia para los pacientes con dispepsia

BACKGROUND AND OBJECTIVE

Our goal was to evaluate the efficacy of internal medicine consulting (CIM) in primary care (PC) for the care of patients with dyspepsia.

PATIENTS AND METHOD

Prospective case-control study of a population of 87,016 inhabitants during a 2 years period. We included patients with dyspepsia (319) jointly attended by a family physician (FP) and consulting internists (CI). The CI went weekly to the primary care center (PCC) to attend patients who would have been referred to the hospital outpatient clinic for specialized care (SC). As control group, 775 patients with dyspepsia were randomly and simultaneously chosen among a total of 29,317 first medical referrals during the period of the study.

RESULTS

5.36% of the consultations for SC were patients with dyspepsia (annual incidence of 183 patients/1,000 inhabitants). We observed a significant reduction in: mean time for SC (26.4 days; 22.4-30.4), mean number of tests per patient ordered by SC (0.77; 0.42-1.12), mean time for patient information on the tests ordered by SC (27.3 days; 18.7-35,9), mean time for the resolution of the process (27.3 days; 18.4-36.2) and rate of specialized follow-up visits (25.2%; 18.5-31.9); p < 0.005 in all cases. The resolution rate of the process (37.2%; 25.7-48.7) and the discharge rate (38.7%; 28.9-48.5) were significantly higher for CIM (p < 0.01 in both cases). The referral rate for SC showed a negative correlation (r = -0.97; p < 0.01) with the quality of the management; this rate related to the type of training, age and years of medical practice of the GPs. Satisfaction of patients with the CIM was very high.

CONCLUSIONS

The CIM with PC improves the efficacy of the specialized medical care of patients with dyspepsia.

The one-stop dyspepsia clinic--an alternative to open-access endoscopy for patients with dyspepsia

The most sensitive investigative tool for the upper gastrointestinal tract is endoscopy, and many gastroenterologists offer an open-access endoscopy service to general practitioners. However, for patients with dyspepsia, endoscopy is not always the most appropriate initial investigation, and the one-stop dyspepsia clinic allows for different approaches. We have audited, over one year, the management and outcomes of patients attending a one-stop dyspepsia clinic. All patients seen in the clinic were included, and for those not endoscoped the notes were reviewed one year after the end of the study to check for reattendances and diagnoses originally missed. Patients' and general practitioners' views of the service were assessed by questionnaire. 485 patients were seen, of whom 301 (62%) were endoscoped at first attendance. In 66 patients (14%), endoscopy was deemed inappropriate and only one of these returned subsequently for endoscopy. 118 patients (24%) were symptom-free when seen in the clinic and were asked to telephone for an appointment if and when symptoms recurred; half of these returned and were endoscoped. Oesophagitis and duodenal ulcer were significantly more common in this 'telephone endoscopy' group than in those endoscoped straight from the clinic. Overall, 25% of patients referred were not endoscoped. Important additional diagnoses were made from the clinic consultation. General practitioners and patients valued the system, in particular the telephone endoscopy service. 84% of general practitioners said they would prefer the one-stop dyspepsia clinic to open-access endoscopy.

General practitioner access to gastroscopy: is 'censorship' valuable?

An audit was carried out on the activities of a one stop clinic where patients referred by GPs for endoscopy are first interviewed by a gastroenterologist, directly before the procedure. Such a barrier to open access endoscopy did not seem to reduce the workload or the rate of normal examinations.

Prevalence of open-access gastrointestinal endoscopy in the United States

OBJECTIVE

Open-access endoscopy allows physicians who are not gastroenterologists to directly schedule patients for endoscopic procedures without having them first seen in the gastrointestinal clinic. We sought to determine the prevalence of open-access endoscopy in the United States and to examine endoscopists' attitudes toward the practice.

METHODS

Questionnaires were mailed to a random sample of 1500 members of the American Society for Gastrointestinal Endoscopy. Out of 1460 that apparently reached the endoscopist, 577 (39.5%) were returned and analyzed.

RESULTS

Of the endoscopists who responded, 60.5% said that they offered some form of open-access endoscopy. Open-access endoscopy comprised less than 10% of outpatient endoscopic practice for 48.2% of individuals who reported they offered the service; it comprised over 25% of practice in 19.8%. Of those doing it, the procedures offered on an open-access basis included esophagogastroduodenoscopy 86.0%, colonoscopy 76.5%, flexible sigmoidoscopy 94.3%, ERCP 7.7%, and endoscopic ultrasonography 4.3%. For endoscopists not offering open-access endoscopy, the most important reasons were concern about performing "not indicated" procedures (85.1 %), medical-legal issues (65.8%), and failure to believe in the concept of open-access endoscopy (59.6%). Attitudes toward open access endoscopy were significantly different among endoscopists who did and did not practice it.

CONCLUSIONS

Open-access endoscopy, offered by more than 60% of the American endoscopists who responded to our survey, has become an important method of health care delivery in this country.

Open access gastroscopy: second survey of current practice in the United Kingdom

In June 1990 a survey of members of the endoscopy section of the British Society of Gastroenterology showed that 47% of respondents were offering some form of open access gastroscopy (OAG). Only 10% offered true (non-censored) OAG. The survey was repeated in June 1994. The overall provision of OAG had risen to 74%, most of whom were offering true OAG. Censored OAG is still widely practised and characterised by referral letters to a consultant in contrast with the use of referral forms (p < 0.001). Referral forms are being increasingly used and are an effective way of capturing important data such as the patients' symptoms (100%), previous treatment (87%), non-steroidal anti-inflammatory drug or aspirin use (78%), suspected diagnosis (74%), and other medical conditions (72%). Forms were used to establish clinical responsibility with the general practitioner in 64% of units. Standardised referral and reporting forms were used by 27% of respondents. A perceived inability to cope with the expected workload was still the most commonly cited reason for not being able to offer OAG. Although 20% of units with a single handed endoscopist were able to offer OAG, this compared with 68% of units with two or more endoscopists (p < 0.001). Only three units indicated that an OAG service had had to be withdrawn, but a further 12 consultants (nine units) were now offering an age restricted service because of excessive workload. Two thirds of the respondents not offering OAG were hoping to do so in the near future. True OAG has increased from 10% to 41% in four years.

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