This issue...

Bridge overtroubled water?Millennium Issues ofGastroenterology inPerspective

Polishexperiencescreening in Polandhas now spread to58 centres

ESPCG continuesto growTen national groupmembers andindividual membersfrom a further ninecountries.

Endoscopywithout sedationHow I do it - apersonal view fromJohn Galloway

British Society ofGastroenterologyAnnual MeetingBirmingham21 March 2006

It is very good to see the launch ofGastroenterology in Primary Care,the journal of the Primary CareSociety for Gastroenterology.Congratulations to Editor RichardSpence, the Society’s ChairmanRichard Stevens and the PCSGCommittee for their energy inhitting the streets with thispublication at a time of greatchange and opportunity in the NHS.The publication of the January White

Paper on Care Outside Hospital re-

emphasises the primacy of primary care

in the provision of healthcare services

and, although we might have concerns

about where the money is coming from,

sets out new directions of travel for the

provision of services, many of which

have profound implications for the

provision of GI services by general

practitioners and their teams.

The PCSG has always tried to support

evidence-based management of

gastrointestinal problems and also to

support general practitioners actively

engaged in research, education and

service provision. In particular we have,

over many years, attempted to improve

the terms and conditions under which

GP endoscopists worked, in either

community or hospital settings, and the

work of GP endoscopists and

endoscopy nurses in providing more

endoscopy capacity outside hospital is

likely to become even more important

in the years ahead. Issues of

accreditation of endoscopists working

in the community will undoubtedly

arise, and the Society is set to play an

active role in this area too. Practice

based commissioning will give all of us

the opportunity to review our patients’

needs and, working together, improve

service provision, perhaps by

contracting for services with non-

traditional providers. Finally, the

continued expansion of the GPs with

Special Interests programme provides

an enabling framework for much of this

work, although PCTs and hospitals have

so far been slow to grasp the potential

value of general practitioners with

expertise in particular clinical areas in

helping them to set and develop

prescribing and management strategy

across whole PCTs and across the

interface between general practice and

the hospital.

So, 2006 looks like being an exciting

time for primary care gastroenterology

and we hope that our new publication

will reflect this excitement and provide

useful guidance and contacts for

everyone interested in this important

clinical area.

Professor Roger JonesPresident, PCSG

Welcome to the relaunched journal of thePrimary Care Society for Gastroenterology.

‘Gastroenterology in Primary Care’ will beproduced quarterly and report on news,developments and meetings in the field.

The journal will also serve as the

mouthpiece of the PCSG and, as well as

other content, carry reports of all our

meetings. This year we will be holding

our session at the British Society of

Gastroenterology meeting on the

afternoon of 21st March. Details of the

programme appear on the back page of

this issue. In addition we shall have our

Annual Scientific Meeting in October

and will be holding the definitive GP

G A S T R O E N T E R O L O G Y I N P R I M A R Y C A R E :

an exciting future

I N P R I MARY CAR E

MARCH 2006

endoscopists meeting in November.

Much is changing in the field of

endoscopy provision and I am pleased

to report that the society is being seen

as the definitive voice on the issues

surrounding the provision of endoscopy

services outside hospital.

The NHS is currently in a greater

state of change than at any time in its

history. Throughout this flux we have

the opportunity to define both the

scope and standards of our area of

special interest. I hope this journal will

be a major tool in achieving this.

Richard StevensChairman, PSCG

CHAIRMAN’S MESSAGE JOURNAL OF THEPRIMARY CARESOCIETY FOR

GASTROENTEROLOGY

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Bridge overtroubled water?The theme of a primary care/secondary care bridge

chosen by the PCSG for the Millennium Issues ofGastroenterology in Perspective remains as appositeas ever and a strong bridge is now needed moreurgently than ever before.The exacerbation of the purchaser-provider split embedded in

Payment by Results (PBR) and Practice Based Commissing (PBC) will

have far reaching consequences. Added to this is the

top slicing by Strategic Health Authorities (SHAs) of

15% of total NHS local budgets to place with the

independent sector, where private providers of health

care are invited to bid for services hitherto largely

contained within the NHS. SHAs already have lists of

preferred providers drawn up and the bidding process

has started. Some GPs are looking at the feasibility of

Limited Liability Partnerships (LLPs) to try to retain

this budget with an “NHS” body, despite the private

partnership status. This major undertaking requires

investment of time and money. In other areas private

providers are looking to take over management of PCTs.

Through all this major change it is likely that there will be a

degree of destabilisation of some existing services. PBR and PBC are

by their nature opposing forces. Through PBR hospitals will try to

increase health resource group (HRG) activity for individual patients.

Forward looking Trusts my well try to draw elements of primary care

into this activity through “outreach” clinics. GP groups or consortia,

on the other hand, will use PBC to try to achieve savings by

regulating their referral patterns, and will unquestionably use the

services of GPSIs to provide a cheaper alternative service to

secondary care referral. Added to this, private providers may try to

pick off “cherries” from primary care, e.g. chronic disease

management, currently earning well under the Quality and

Outcomes Framework (QoF) points payments. They may also employ

“cheaper” professionals from elsewhere to deliver services -

American Physician Assistants are already working in the NHS.

British GPs and Consultants may have become over-priced in the

eyes of some policy makers.

These changes threaten the integrity of both primary and

secondary NHS care and it is more vital than ever that an effective

dialogue exists between the two. All the more surprising, therefore,

that the BSG “GI Service Review” completely fails to mention the

contribution made by GPs to the gastroenterology workforce

(section 4.2).

We are now seeing the fragmentation of the NHS that many had

assumed would always exist in its present breadth. Its preservation

as a comprehensive healthcare system, previously the envy of the

world, will only take place by cooperation between primary and

secondary care doctors at a level that has not been achieved up to

now. This cooperation needs to take place right across the new

models of working that emerge in the immediate future. What is

certain is that healthcare provision in Britain is going to look very

different in 2-3 years time.

Editor, Dr Richard Spence,GP and Endoscopist, Bristol

Dr Richard SpenceThe UEGW provided a very

interesting session on this subject. DrChristian Poeta from Tubingen inGermany spoke on problems of

reflux in neonates. As a neo-

natologist, his interest in the subject

was sparked by the fact that 19% of

infants admitted to US Paediatric

Hospitals are put on prokinetics

(cisapride or metoclopramide). Why?

Making the diagnosis at this

tender age is difficult since reflux is

so easily facilitated. Aggravating

factors are the frequent, high volume

feeds and the lower oesophageal

sphincter (LES) is “under water” most

of the time. Measurements show a

normal reflux rate of 3-5 episodes an

hour but the acid content is low. The

main abnormality in infants with

reflux disease (GERD) is a higher acid

content in the refluxate, although the

number of reflux episodes is not

increased and gastric emptying is

not delayed. Measuring intra-

oesophageal pH is also no good

because pH is >4 in 92% of preterm

infants.

An important differential diagnosis

is cow’s milk allergy (can occur in

pre-term babies). Diagnosis is made

from blood eosinophilia, and

eosinophilic infiltrates can be

demonstrated in antral mucosa. The

conclusion was that GERD is a

serious problem for only few; reflux

is usually physiological; in the

presenter’s view there should be no

need for prolonged hospitalisation and

the use of prokinetics is unjustified.

A later speaker (Dr SylviaSalvatore, Varese, Italy) estimatesthat 5-9% of infants have

troublesome reflux and showed data

demonstrating a steady increase in

reflux through to teenage. The risk

for developing reflux appears to be

higher when it is present in infancy

and she suggested that adult GERD

may start in childhood and may be a

lifelong disease.

Even more alarming

was the presentation

from Dr FredericGottrand, Lille, Franceon the presence of

Barrett’s oesophagus in

children, 5 years being the

youngest reported age for

the condition. Diagnosis

depends on the finding of

intestinal metaplasia in

biopsies. Even adenocarcinoma

occurs; he described 14 patients

under the age of 25 years of whom

10 died. Biopsy recommendation

during endoscopy is the same as with

adults, ie 4 quad-rantic biopsies

every 1 cm of Barrett’s mucosa, and

then regular endoscopic surveillance.

(Clearly more “joined-up thinking” is

needed regarding the indications for

endoscopy in young adults presenting

with troublesome reflux symptoms).

Finally, Dr Marc Benninga,Amsterdam, Holland discussed the

safety of acid-suppressing drugs in

children, showing that PPIs heal

severe GORD and resolve symptoms

and have a high margin of safety.

Concerns have been expressed that in

neonates there might be a risk

rarely of neutropenia precipitating

bacteraemia. In Holland cisapride is

still allowed for the under 3s and is

often co-prescribed with a PPI. I heard

about Sandifer’s syndrome for the

first time (where the child develops

abnormal head and neck postures in

response to gross acid reflux).

Dr Anders Paerregaard,Copenhagen, chaired the session

and expressed the concern that many

still feel regarding the actual

longterm consequences of acid

suppression.

EDITORIALUEGW REPORTOesophageal reflux diseasein infancy and childhood

Dr Galloway is a GP endoscopist,treasurer of the PCSG and

RCGP representative on JAG

15- 20 years ago nearly all upper GIendoscopy was performed with sedationand local throat anaesthesia. Sedationusually included a cocktail of intravenousdiazepam and pethidine with an averagedose of 10mg and 50 mg respectively.This would heavily sedate most patientsand few would have much memory of theprocedure. Patients would sleep forseveral hours afterwards and not bepermitted to operate machinery or driveuntil the next day because of the longhalf life of diazepam.This tendency to heavy sedation allowed the

endoscopist to spend a long time carrying out the

procedure on an uncomplaining patient.

Occasionally patients would be over sedated and

require ventilation and administration of reversing

agents. The hypoxia that occurred was not fully

appreciated until pulse oximetry was routinely

used and this lead to progressively lighter sedation

with short acting midazolam alone and the term

light conscious sedation was born. This means that

the patient should be conscious, responsive and

calm. This lighter level of sedation demands greater

speed and dexterity from the endoscopist. The

mortality associated with gastroscopy of 1 in 2000

reported by Amanda Quine in 1995 was in part

related to the sedation techniques used in the past.

Endoscopy outside the hospitalWhen I started endoscopy outside hospital in

1994 I had to weigh up the risks of even light

conscious sedation and opted only to offer

endoscopy without intravenous sedation, using

only local anaesthetic throat spray. I felt in

practice there was little difference in the patient

experience between light sedation and no

sedation. Those patients who are intolerant of

the procedure may become disinhibited with

small doses of midazolam making the procedure

more difficult for the endoscopist.

Original fibreoptic gastroscopes were large in

diameter and the image was poor compared to

modern day videoscopes. Intubation was more

traumatic, often done blind and the whole

procedure would take longer to get adequate

views. Duodenal intubation was also traumatic

as the pylorus had to be entered by force in

many cases. The introduction of fibreoptic and

later videoscopes of a diameter slightly less than

10mm radically facilitated the procedure. In

particular, intubation with a narrow endoscope,

performed under direct vision was easier and

improved image quality, giving panoramic views

of the upper GI tract leading to faster

procedures. Most diagnostic upper GI

endoscopy with a single biopsy for a CLO test

should not take more than 3-4 minutes and this

is one reason why sedation is less necessary.

Informed consentInformed consent is a very important part of

gastroscopy. I send out an explanation leaflet

with the consent form to the patient once I have

received a referral. Patients can read through

the leaflet before booking their appointment

and discuss the procedure with a qualified

health professional involved with the service.

This is a valuable way of allaying fears before-

hand and filters out any patient who feels they

would be unsuitable for an unsedated procedure.

The unsedated patientThere is a slight difference in technique for the

unsedated patient. The group of patients willing

to have the procedure done without sedation

are to a certain extent self selecting but most

can be persuaded if their fears and anxieties are

overcome beforehand with a full explanation of

the procedure. Anxieties are usually about

whether they will be able to breathe normally,

choking and gagging and whether the

procedure will be painful. Some patients are

more worried about what will be found and this

has to be addressed too. I reassure the patient

that there will be no pain, they will be able to

breathe normally and gagging will be

minimised by the throat spray and limited

usually to the first few seconds of intubation.

Because great care is taken not to rush, most

patients are pleasantly surprised. I emphasise

that concentrating on slow regular breathing is

very helpful as it reduces the gag reflex and

helps the patient to focus. (It opens the pharynx

and usually keeps the epiglottis out of the way

-swallowing and choking close the passage).

Handling of the endoscope.The endoscopist should guide the endoscope

with the right hand and not leave this to the

assistant. The left hand alone should manipulate

both wheels and the valves. The right hand

should rarely leave the insertion tube, except for

taking biopsies. Keeping control of the insertion

tube and its economy of gentle movement are

probably the most important tips for a

successful unsedated procedure.

Both wheels and valves manipulated with theleft hand

Preparing the patientI usually spray the patient’s throat in a separate

room from where the procedure is performed. I

ask the patient to lie down on an examination

couch and explain that the throat spray has a

banana flavour which helps to disguise the bitter

taste of xylocaine. I explain that the throat spray

will make the throat numb for about 10 to 15

minutes and that the procedure will last about

3-5 minutes. I ask the patient to allow the spray

to build up in a pool in the back of their mouth

and not to swallow until I have finished spraying.

I usually use about 10 puffs of spray and warn

the patient that they will feel a warm sensation as

the local anaesthetic starts to work. Having

sprayed their throat and having taken away any

dentures I escort the patient into the endoscopy

room and introduce them to the two nurses who

will look after them throughout the procedure.

The endoscopyTalking to the patient throughout the procedure

with encouraging words is essential as is giving

them a running commentary of progress and

how much longer it will take. The patient is

Endoscopy witHOW I DO IT - A PERSONAL V

asked to lie on their left side and one nurse is

positioned at their head and one at their side to

hold their right hand and assist me in taking

biopsies. Before intubation, I shield the patient’s

eyes from the endoscope and then place it in

their mouth and wait for a few seconds to get a

good view of the back of the tongue and soft

palate. The dialogue starts with me explaining

that I am advancing the scope over the tongue

and that they may feel a slight gag reaction but

not to worry as it will be short lived. I advance a

little further asking the patient to concentrate

on their breathing as I go beyond the soft palate

into the pharynx and visualise the larynx. I then

advance the scope towards the back of the

larynx and intubate the upper oesophagus,

sometimes asking the patient to take a swallow

if the scope is not advancing freely.

Aim the endoscope toward the area markedXXXX to intubate the oesophagus

This is the end of the most difficult part of the

procedure for the patient and it is worth telling

them this for reassurance. I also pause now for

the patient to compose themselves and regulate

their breathing while I wash away any sputum

or lubricating jelly from the lens.

I proceed down the oesophagus into the

stomach insufflating very little air to minimise

gas bloat and belching as this can be

uncomfortable and upsetting for the patient. I

will always try to aspirate any fluid from the

stomach at this stage to reduce the risk of reflux

during the procedure. I only insufflate enough

air to visualise the pylorus so that I can intubate

the duodenum and then reassure the patient

that there will be no more pushing of the

endoscope. Intubation of the duodenum can be

unpleasant as sometimes the endoscope has to

be pushed through a closed pylorus and if the

stomach is too full of air it can result in

uncontrollable belching followed by a spell of

gagging. I take any duodenal biopsies at this

stage without too much further scope

thout sedationVI EW FROM JOHN GALLOWAY

manipulation and then pull back into the

antrum to take a CLO test if necessary. It is easy

to retrovert the endoscope at this stage as

sufficient air will have been insufflated to get a

good view of the cardia. I tend to take any lesion

biopsies on the way out minimising the need to

move the endoscope any more than necessary.

Before leaving the stomach it is easy to get

panoramic views to make sure no lesions are

missed. I will also deflate the stomach before

leaving which makes the patient more

comfortable. Oesophageal biopsies can be taken

on the way out, again minimising movement of

the endoscope. Withdrawal is done gently

making sure the endoscope is straight so as not

to cause any trauma on extubation.

The patient should be reassured all the time. I

give a running commentary and tell them what

to expect at every point. Progress should be

reported - signalling when you are half done,

three quarters done, nearly finished and that

they may feel a slight tug as you take a biopsy

but no pain. If the patent belches, coughs or gags

reassure them that it is okay and not to worry.

After taking biopsies, especially in the

oesophagus, warn the patient that they may

taste a little blood.

After the procedure I ask the patient to rest

on their back for a minute or two and let them

wipe away any saliva with a tissue. Then I escort

them back to a consulting room and give them

a full explanation about the findings and further

management. I tell them that the numbness in

the throat will wear off in a fewminutes following

which they will be able to have a cold drink.

Because they have had no sedation there is no

restriction in their activities for the rest of the day.

Ultraslim gastroscopeA recent acquisition to my department has been

a Pentax ultra slim gastroscope. This is only 6

mm in diameter and has a tiny cross sectional

area. This endoscope has some important

advantages but there are disadvantages as well.

The image is comparable to a standard 9 mm

gastroscope but because of its size water

droplets from the washer are slower to clear

from the lens. Insufflation is slower because of

the smaller air channel. The endoscope is narrow

enough to pass through the nostril but I find

that this is more uncomfortable than through

the mouth and still favour the latter as a route

of intubation. The small size is very well

tolerated in the throat but lack of rigidity can

lead to curling up in the pharynx if there is any

muscular spasm. I have overcome this by

applying the locks on the up/down control until

the endoscope is in the upper oesophagus. .

The diameter of the endoscope allows it to

pass through strictures with ease and intubation

of the pylorus is remarkably comfortable for the

patient. The endoscope cannot remove large

amounts of liquid quickly and biopsies are smaller,

although using disposable forceps with long

alligator jaws and a locating prong give good

results. The flimsiness of the endoscope means

that a highly contractile stomach takes control

and pushes it about more, prolonging the

procedure. Also incarcerated hiatus hernias and

cup and spill deformities are difficult to reduce

and navigate for the same reasons.

Ultra slim endoscopes are not so robust.

Already I have had a guide wire break and the

narrow channels have retained a cleaning brush

which required a rebuild of the endoscope -

luckily under guarantee. Pentax assure me that

the ultra slim endoscopes do not return to the

repair department any more frequently than

standard diameter endoscopes but common

sense dictates that such fine instruments needs

careful handling by the operator and support staff.

I would hate to be without the ultra slim

endoscope now, but if I had a choice I would

stick with the 9 mm model as it is more robust

and endoscopy is usually faster with a more

controllable instrument. But, I have re-scoped a

few patients who were intolerant of the

procedure before and they have been much

happier with the ultra slim endoscope.

Ultra slim gastroscopes are about 25% of thecross sectional area compared to a 9 mm scope

ConclusionsI feel that most upper GI endoscopy can be

performed without intravenous sedation. The

procedure has to be highly interactive to

achieve the high success rate that I enjoy of

98% completion. Patients are self selecting so

this success rate would not be the same for all

comers. It is less consuming of resources and

does away with the need for recovery beds and

attached staff. It is safe as most complications

of upper GI endoscopy are sedation related.

@

www.Dr Huw Thomas, GP,Minehead

The DAVE project - Digital Atlas ofVideo Education (gastroenterology). www.thedaveproject.org This is a collection of teaching tools

which include video endoscopy clips

supported by radiological and surgical

images which is free to use for non

commercial purposes. Users can

submit their own clips.

BMJ learningwww.bmjlearning.comThis site has some interesting online

courses in all areas including

gastroenterology. It is free to BMA

members and has interesting new

modules on C.Difficile and IBS -

updates in management.

Users can build up a portfolio of

completed courses and print

certificates ready for the annual

appraisal visits!

Dr Richard SpencePOLAND

The Polish experience was presented by Prof Jaroslaw Regula(a good name for the job?). CRC screening commenced in Poland in

the year 2000 in a few centres, and has now spread to 58 centres,

with 50,148 people having been screened by the end of 2004. The

age group screened is 50-66 years, or 40-66 with positive family

history. Caecal intubation rate has increased from 85-91% and there

have been 51 complications including 5 perforations, but no deaths.

Pathology was found in 1:20 with 4-8% advanced adenomas

and 5% advanced neoplasia. Odds ratio for males to females is 1.8

so that men have nearly double the incidence of pathology

compared to women at the same age. So men may need CRC

screening earlier in life. “Colonoscopy is cheap in Poland” and is

the preferred screening method.

UK PLANSDr Alastair Watson from Liverpool presented the UK plans fora national CRC screening programme, due to roll out in 2006 and

based in 8 selected national centres. There is a belief that there is

a long development cycle from adenoma to cancer (5-25 years)

which was based on a few early papers.

Screening has 2 meanings: 1. opportunistic screening where the cost is low.2. population based screening where the cost is high.

Dr Watson says “I don’t believe any country in the world can afford

colonoscopy to screen the population”.

There are 6 available screening tools:1. Faecal occult blood (guiac)2. Faecal occult blood (immune)3. Flexible sigmoidoscopy4. Colonoscopy5. CT colography6. Faecal DNA test

The gold standard is to demonstrate a reduction in mortality

from CRC. To do this 10-15 years of follow-up are needed. Three

large studies have reported such reduction.

The percentage reductions in mortality were:Nottingham, UK 15%Funen, Denmark 18%Minnesota, USA 21%

Of the endoscopic procedures, flexible sigmoidoscopy detects

only 50% of proximal adenomas, but colonoscopy “has the

potential to kill someone”.

The planned UK programme is evidence-based and will be based

on faecal occult blood in the 60-69 age group, repeated every 2

years. If positive, colonoscopy will be offered “in 2 weeks”.

Recruitment will be from the national population database and

“bypasses primary care physicians - who are very busy people”.

Cost is estimated at £58 million in Year 1; colonoscopy workload

is estimated at 61,274 examinations, requiring 39 full time

“consultant colonoscopists”!

Colorectal cancer

screeningCOMPARING POLAND AND THE UK

GASTROENTEROLOGICAL RESOURCES ON THE WEB

Gastrohepwww.gastrohep.com This subscription service (£75 per year)

is an excellent resource for all matters

gastroenterological. It has excellent

summaries of recent published articles.

Remember all the PCSG publications

and other information is available at

the website: www.pcsg.org.uk

The Feldman GastroAtlas Onlineis also a good (free) resource for

slides for presentations etc. Access

www.gastroatlas.com - you have to

register but there is no charge.

PCSG Email ListThere is an active email list which is

open to all who are interested in

gasterenterological issues. It is free to

join - please encourage any GP’s or

nurses you meet to join the list. Go to

the website and click on the email list

button to join, or send an email to

pcsg-request@jiscmail.ac.uk The list

is moderated - so signing up will not

result in “spam” mail - and it is a great

medium to discuss a variety of issues.

Recent topics have included tariff

prices for endoscopic procedures,

commissioning endoscopy services,

and GPSI in Endoscopy. Archives of

past postings are also available at the

PCSG website.

@

www.

Endoscope decontaminationand patients at risk of vCJD.The Decontamination Working

Group of the BSG has met with

representatives from the CJD Incidents

Panel in order to agree the consensus

guidelines and practical advice to all

endoscopists in the avoidance of risk.

The updated BSG decontamination

guidelines are on the BSG website

(www.bsg.org.uk) and advise what to

do when endoscoping patients who

have received quantities of plasma

product concentrates prior to when

donors were tested for vCJD (primarily

but not exclusively haemophiliacs and

patients with immunodeficiency

syndromes). There are estimated to be

about 6500 of these patients in the UK,

and the vast majority have now been

told of their risk (and asked to take

certain public health precautions to

reduce the risk of spread to others).

Chairmen: Dr Richard Stevens and Professor Pali Hungin14.30 Is Helicobacter pylori yesterday’s news?Dr Bob Walt. Consultant gastroenterologist, University

Hospital, Birmingham

15.00 The Hepatitis C epidemic in the UK and EuropeProfessor William Rosenberg. Professor of Hepatology,

Southampton General Hospital

15.30 Pharmacological and non-pharmacologicaltreatments for irritable bowel syndromeProfessor Roger Jones. Professor of Primary Care, Kings

College London School of Medicine

JOURNAL OF THEPRIMARY CARESOCIETY FOR

GASTROENTEROLOGY

Event Diary

20-23 March 2006BSG ASM InternationalConvention Centre,Birmingham.PCSG session 2.30pmTuesday 21st March

25 April 2006“Endoscopy in PrimaryCare” conference,De Vere Belfry,Warwickshire

13 October 2006PCSG (Primary CareSociety for Gastro-enterology) AnnualScientific Meeting andAGM, London, Contact:secretariat@pcsg.org.uk

25-26 November2006GP EndoscopistsSymposium (TBC)

Gastroenterology in Primary Care Editor: Dr Richard Spence, richardspence@yahoo.com Web Editor: Dr Huw Thomas,fennington@fennington.demon.co.uk Produced by the Primary Care Society for Gastroenterology, Gable House, 40 High Street,Rickmansworth, Herts WD3 1ER Tel: 01923 712711 Fax: 01923 778131 secretariat@pcsg.org.uk www.pcsg.org.uk

16.15 The PCSG Debate "Public plus private sector careis better than public sector care alone for NHS patientswith GI problems."Proposed by Dr Richard Smith, Chief Executive, United

Health Europe and former editor of BMJ. Seconded by Dr

Peter Evans, General Practitioner and director of Jubilee

Surgery Endoscopy Services Opposed by Dr Peter Fisher,

President of NHS Consultants Association and retired

consultant physician and gastroenterologist. Seconded by

Professor Elwyn Elias, BSG president 2005-2006.

17.30 Close

PRIMARY CARE SOCIETY FOR GASTROENTEROLOGYAt the British Society of Gastroenterology Annual Meeting, Birmingham, 21 March 2006

When a scope is used in such

patients, and the procedure is expected

potentially to contaminate instruments

with lymphoid tissue (biopsies,

diathermy and some balloon dilatation

techniques where the balloon is drawn

back into the biopsy channel); the scope

should be quarantined, and removed

from use except for further use in the

same patient. Endoscopy units could

consider retaining fully functional

endoscopes that are close to

decommissioning for potential use on

individuals at risk of vCJD

http://www.advisorybodies.doh.gov.uk/acdp/tseguidance/Index.htm

Towards better endoscopicdescription of refluxoesophagitis and Barrett’s.As well as the Los Angeles staging

system of oesophagitis, the inter-

national working group for the

NEWS SNIPPETS - Dr Huw Thomas

Classification of Oesophagitis (IWGCO)

is recommending Barrett’s is described

both by the distance that the

circumferential metaplasia and the

longest tongue extends above the top

of the gastric folds; ie. a patient who

has 4 cm of circumferential metaplasia

and a 2 cm tongue above this, Barrett’s

is recorded as Prague; C4 & M6.See Armstrong, D. Review article: towards consistency in the endoscopicdiagnosis of Barrett's oesophagus and columnar metaplasia. AlimentaryPharmacology & Therapeutics 2004 20(s5):40-47Lundell et al; Endoscopic assessment of oesophagitis: clinical andfunctional correlates and further validation of the Los Angelesclassification. Gut. 1999 Aug; 45(2):172-80.

Higher doses of mesalazinein UC?The recent ASCEND trial has recently

reported that mesalazine 4.8g/day was

significantly more effective than

2.4g/day, the currently used induction

dose in the UK.Hanauer SB et al. Delayed-Release Oral Mesalamine at 4.8 g/day(800mg Tablet) for the Treatment of Mderately Active UlcerativeColitis: The ASCEND II Trial. Am J Gastroenterol 2005; 100(11):1-8

ESPCG E U R O P E A N S O C I E T Y F O RPR IMARY CARE GASTROENTEROLOGY

Professor Greg Rubin, Professor of Primary Care, University of Sunderland

The ESPCG continues to grow, with 10 national group members, including the

PCSG, and individual members from a further 9 countries. It is actively involved in

promoting educational initiatives and research projects in general practice. Its most

recent project is a study of the diagnostic process for IBS in general practice, while

members have also been involved in the recent exercise to update the Maastricht

guidelines on H pylori management. Our key meetings are held at WONCA-Europe

and the UEGWmeetings. This year they will be held in Florence (27-30 Aug) and Berlin

(21-25 Oct) respectively. The Society’s AGM will be held during the Florence meeting.

All members of the PCSG are automatically members of the ESPCG. Our website at

www.espcg.org contains more information about our past and current activities.