SOP Open Access Endoscopy Updated30April

7/16/2019 SOP Open Access Endoscopy Updated30April

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2012

HOSPITAL TUANKU JAAFAR

SEREMBAN

NEGERI SEMBILAN

OPEN ACCESS ENDOSCOPE MALAYSIAReducing waiting time for endoscopy

Detecting Upper GI cancers early


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CONTRIBUTORS:

Dr. Mahadevan Deva Tata

Surgeon

Hospital Tuanku Jaafar

Seremban Negeri Sembilan

Prof. Dato' Dr. P. Kandasami

Professor of Surgery

IMU [Clinical School Seremban]

Honorary Consultant for Hospital Tuanku Jaafar

Dr. Ramesh Gurunathan

President

Malaysian Society of Gastroentrology and HepatologyAcademy of Medicine Malaysia

Dr. Jasiah Zakaria

Head of Surgery Department



Dr. Dharmendran Ratnasingam

Surgeon



Dr. Azrina Abu Bakar

Surgeon



Dr. Chik Ian



Dr Shirley Tang




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Mr. Chu Teck Hoe




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1. RATIONALE

Gastric cancer is the second most common cause of cancer-related death in the world. Detecting

this cancer early has been an uphill task for decades. Most of the patients with gastric cancer

present with advance diseases. Most often treatment modalities are narrowed towards palliative

procedures rather than curative. Detecting cancers early is vital to ensure better survival and

outcome of the surgery.

It is crucial that all endoscopist have a good knowledge on endoscopic appearance of early upper

gastrointestinal cancers especially stomach and esophageal cancers. This guideline is aimed to

standardize the endoscope techniques in OPEN ACCESS endoscope service. This guideline will

ensure to serve as a guide for the endoscopist who are involve in OPEN ACCESS endoscope

servicedoes the procedure using a systematic guide.

2. EARLY GASTRIC CANCER [EGC]

Early gastric cancer [EGC] is defined as a carcinoma confined to mucosa or sub mucosa,

regardless of nodal status. Detection of EGC is higher in regions where mass screening is done

routinely such as Japan. Macroscopically early stomach cancers [EGC] has been described as:

Protruding (type I)

Superficial (type II)

o Elevated (IIa)

o Flat (IIb)

o Depressed (IIc)

o Excavated (type III)

.


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Description of a lesion in the stomach

1. Site

2. size

3. shape

4. margin

5. floor

Classification of macroscopic subtype of early gastric cancers

[Adapted from Japanese Classification of Gastric Carcinoma - 2nd


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*Taken from ESGE recommendation for quality

control in astrointestinal endosco

3. OPEN ACCESS ENDOSCOPE TECHNIQUES AND QUALITY CONTROL

RECOMMENDATION

During an upper endoscope procedure it is crucial that the endoscopist examine the whole

esophagus, stomach and duodenum thoroughly. In some countries multiple images are taken as

a proof of completeness of procedure. Video images are also recorded to enable the endoscopist

to re-look the lesions after the procedure. Eight regions have been described by European

Society of Gastrointestinal Endoscopy [ESGE] recommendation for quality control in

gastrointestinal endoscopy. [Figure below]


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Open Access endoscope guideline recommends nine regions or stations that have been identified

for standardizing the endoscope procedure. This is to ensure accurate and effective detection of

mucosal lesion. Endoscopist need to examine the following region or stations where necessary

take images.


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Station 1:

Upper esophagus - about 20cm from the incisor teeth to get a forward view of the esophagus.

This region also is needed to be observed to look for upper esophageal lesion. Some of the upper

esophageal lesions can be missed either at the start of the endoscope procedure (when going

pass the cricopharyngeal constrictions) or at the end of the procedure when withdrawing the

scope too fast without looking at the upper esophagus. Using NBI endoscope may be useful look

for dysplastic area (pink color sign) or Intra-papillary capillary loop (IPCL) type III or more.

Station 2:

This region is at 2cm above the squamocolumnar junction [Z line]. This region is important to

identify. It is also important to note any abnormalities at this region; particularly in the case of

esophagitis or Barretts esophagus. In case of suspicious lesions or irregular Z line;

chomoendoscopy or NBI may be useful to assist accurate biopsy. Hiatus hernia is better identified

and described at this station.

Station 3:

Distension of stomach and viewing of greater curvature and upper part of the lesser curvature.

This is one of the region where lesions are frequently missed especially atrophic gastritis border.

This region should be viewed after inflation of the stomach. This is to ensure good visibility.

Lesser curvature needs to examine as well.

Station 4:

Angulus incisura in partial inversion. Positioning the endoscope in front of the angulus incisura

provides conformation that a complete examination of the antrum, angulus and fundus seen in

inversion has been performed.

Station 5:

Antrum. The whole of the antrum is visualized at this region, assuming that the angulus has just

been examined as described above. Use of NBI will be added benefit to visualize mucosal pattern

for intestinal metaplasia and atrophic gastritis.


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Region 6:

Duodenal bulb. This area can be examined by positioning the endoscope on the bulbar side of the

pylorus in order to see the entire bulb.

Station 7:

Second part of the duodenum. This confirms that a complete examination has been performed

with the end of the endoscope positioned near the papillary area.

Station 8:

Fundus in inversion. After viewing the angulus, fundus can be visualized in a distance before

pulling the scope nearer to the cardia (upper part). This view of the fundus in inversion allows

good visualization of the fundus as a whole. Posterior wall of the stomach can be best examined

during this procedure.

Station 9:

Cardia in inversion. An examination of the cardia in inversion at a close range allows good

visualization of the cardia and the lesions at the cardia and cardioesophageal junction.

4. BIOPSY TECHNIQUES AND DATA COLLECTION

Biopsies will be done if there are any suspicious lesions found in the stomach. To standardize the

number of biopsy taken, at least 4 biopsies for stomach lesions and esophageal lesions need to

be taken using standard biopsy forcep.

If there are no suspicious lesions seen during the OGDS; no biopsies will be taken. Rapid test for

helicobacter pylori (CLO test) or similar test must be performed for all high risk patients to

diagnose Helicobacter pylori.

The biopsies will be sent to the department of pathology of the respective hospitals to be

analyzed. Results of the biopsies will be kept at the respective hospital to be included into the


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Open Access database. A copy of histopathology report needs to be kept with the patients

endoscope finding sheet.

5. FOLLOW UP

After the OGDS, only patients with positive (cancers and other disease which cannot be managed

at Health centre to be decided by the endoscope centre/hospital) finding will be followed up at the

centre. Other patients will be given discharge note (the endoscope report with recommended

treatment) to the referral centre on recommendation to follow up. All result of the biopsy report

must be kept in the Open Access endoscope file.

Patients with other diagnosis such as non-ulcer dyspepsia, Helicobacter pylori related dyspepsia,

Cholelithiasis, GERD and etc should be managed according to the NICE guideline or any local

guidelines.

6. IMPORTANT CONSIDERATIONS

Open Access endoscopic service is a statement of revolution in fast track medical services with

great potential to improve patient health. However, several potential problems could arise if this

service is not used appropriately.

The issue that may arise includes inappropriate referral and poorly informed patients. The

indications and pre- endoscopic information about the patient should be adequately provided,

including underlying medical problems and drug history that may complicate an endoscopic

procedure. Detailed information should also be provided to the patient, informing them in detail

regarding the procedure, pre- procedure preparation, potential complications as well as

justifications and benefits expected from an endoscopic procedure. A proper informed consent is

compulsory to improve patient satisfaction towards the procedure and avoid unnecessary delay or

cancellation.


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PHYSICIAN INFORMATION LEAFLET

OPEN ACCESS Endos cop e Serv i ce in M a lays ia

-A move towards special ized health care closer to people -

OPEN ACCESS endoscope service in Malaysia

To identify high risk patients for Upper GI cancer

To eliminate barriers in the current referral system for endoscope

To reduce the waiting time for endoscope for high risk patients

To improve the outcome of Upper Gastrointestinal cancers

OPEN ACCESS endoscope service was first started in Negeri Sembilan. It was initiated byDepartment of Surgery of Hospital Tuanku Jaafar Seremban in 2006. This project was aimed to

detect Upper Gastrointestinal cancers early. This project won 2011 National Quality Assurance

award.

WHY OPEN ACCESS endoscope?

Dyspepsia is one of the most common presenting symptoms in public health centre.

This symptom is also according to published data commonly found in 60-90% of the Upper

Gastrointestinal cancer patients.

Making this discernible to identify high risk patients from general population.

For the last 3 years our center which is a referral center for upper GI cancers anddisorders seen more than 50 cancers involving stomach and esophagus. More than 80%of these patients present to us in advanced stages.

More than 85% of these patients have been treated at private clinics and health centers forsymptoms called gastritis.

The time delay from the first appearance of symptoms to the time of endoscope wasestimated to about 8 months

Using this system we are hoping to filter and shorten the referral process of endoscopyand detect gastric cancers early.

Subsequently to improve survival outcome of these patients.


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What is Open Access endoscope service?

Defined as the provision of a diagnostic endoscopic procedure by direct request of a medical

officer without prior hospital consultation, but including the provision of screening the

appropriateness of any referral. These have been widely practice in UK. OPEN ACCESS

endoscope is the first of its kind in Malaysia. We are using simple criteria called MARKs

Quadrant.

This means any medical officers in health centre can request for endoscope procedure for high

risk patients without prior hospital consultation. This will establish a barrier free referral system for

at risk patients for early endoscopy service.

MARKs Quadrant symptoms based targeted screening tool. This tool was first developed in

Seremban in 2006. It was validated and tested in a prospective sample. MARKs quadrant

recently won young investigators award in the 2011 International Gastric Cancer Congress in

Seoul, Korea.

Figure above showing MARKs Quadrant targeted screening tool for Upper GI cancers

QUADRANT A: AGE QUADRANT B: RECENT UGIB( including m elena)

Score Score

< 40 yrs 2 Occurred more than 1 yearago

1

40 49 yrs 3 Occurred less than 1 year 5

50 yrs 5

Sector Total Sector Total

QUADRANT C: MODIFIEDALARM SYMPTOMS

QUADRANT D: DYSPEPSIA

Score Score

Anaemia 3 Intermittent, more than 1 year 1

Epigastric Mass /Fullness

3 Intermittent, less than 1 year 3

Persistent vomiting 3 Persistent for MORE than 2weeks

5

Significant LOW 3

Dysphagia 5

Early satiety / eating

less over a period oftime

3

Sector Total Sector Total


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How it works?

Once a patient scores 10 from any combination of the quadrant; he/she will be deemed high risk

and warrant an early endoscope appointment.

Call the respective endoscope centre near you (see OAE referral f low chart). We will give an

endoscope appt within 2 weeks. If the scope findings are positive for cancer we will continue the

management here. If it is negative send back the patient to your center with suggestion to follow

up. (Refer OAE fol low-up gu ide)

Intervention impact

The screening of symptomatic patients through Open Access endoscope has been reported to

achieve a higher incidence of Early Gastric Carcinoma [EGC].

In Birmingham, a policy of screening dyspeptic patients over the age of 40 years in the 1990s had

seen an improvement of detecting EGC from 1 to 26%. Curative resections had also increased in

parallel from 20 to 63% 11. Similar results have been confirmed in Leeds, with a 4% incidence of

EGC in 1970 increasing to 26% in 198010.

In Negeri Sembilan, Open Access Endoscope service was introduced in Oct 2006. From the 210

patient data; there were 18 (8.6%) stomach cancers were diagnosed during this period through

Open Access endoscope service. These include 2 early cancers (Stage 1 & II).

The rest of the patients scoped had either precancerous lesion of the stomach (n=144, 68.6%),

Benign lesion of the stomach (n=38, 18.1%) or normal scope (n=10, 4.8%). All patients has their

scopes done within 2 weeks. Compared to mean 15 weeks in the routine referral system.

References

1. Parkin DM. Global cancer statistics in the year 2000. Lancet Oncol 2001; 2:533543.

2. BC Cancer Agency, Oncology Nutrition November, 2004 Revised September 2005

3. National cancer registry 2003-2006.

4. Kandasami P et al. Gastric cancer in Malaysia: the need for early diagnosis. Med J

Malaysia. 2003

5. Yih K. Tan and John W.L. Fielding. Early diagnosis of early gastric cancer. European

Journal of Gastroenterology & Hepatology 2006, 18:821829.6. Goh KL. Clinical and epidemiological perspectives of dyspepsia in a multiracial Malaysian

population.J Gastroenterol Hepatol.2011 Apr;26 Suppl 3:35-8.
http://www.ncbi.nlm.nih.gov/pubmed/21443706http://www.ncbi.nlm.nih.gov/pubmed/21443706http://www.ncbi.nlm.nih.gov/pubmed/21443706http://www.ncbi.nlm.nih.gov/pubmed/21443706


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Summary

60%-90% of patients with early stomach cancers have dyspepsia.

Cancer can heal by acid suppression*

Makes the endoscopic identification impossible if the patient already been treated

with PPI

Healing of malignant ulcer in 4 weeks after PPI. (Wayman J N Engl J Med 1998;

338:19241925)

Bramble MG et al. delay in diagnosis of 26 weeks after PPI (Gut 2000; 46:464

467.)

Refrain from prescribing antacids or PPI esp. for patients over 50 years old with

dyspepsia before OGDS

Use MARKs Quadrant to identify high risk patients


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PATIENT INFORMATION LEAFLET

What is an OESOPHAGODUODENOSCOPY (OGDS)?

Upper endoscopy lets your doctor examine the lining of the upper part of your gastrointestinal

tract, which includes the esophagus, stomach and duodenum (first portion of the small intestine).Your doctor will use a thin, flexible tube called an endoscope, which has its own lens and light

source, and will view the images on a video monitor.

Why is it done?

Upper endoscopy helps your doctor evaluate your complaints that may be related to illness of theupper intestinal tract. It's the best procedure that would help doctors find out the cause of bleeding

from the upper gastrointestinal tract. It's more accurate than X-ray or CT scans for detecting

inflammation, ulcers and tumors of the esophagus, stomach and duodenum.


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Your doctor might use upper endoscopy to obtain a biopsy (small tissue samples). A biopsy helps

your doctor distinguish between benign and malignant (cancerous) tissues or to test for

Helicobacter pylori, a treatable cause for gastric ulcers.

Upper endoscopy is used not only use to visualize the gastrointestinal tract, but this procedure

can also be used to provide treatment. Your doctor can pass instruments through the endoscope

to directly treat many abnormalities which may cause little or no discomfort. For example, your

doctor might stretch a narrowed area, remove polyps or treat bleeding.

What preparations are required?

An empty stomach allows for the best and safest examination, so you should have nothing to eat

or drink, including water, for approximately six hours before the examination. Your doctor will tell

you when to start fasting as the timing can vary.

Tell your doctor in advance about any medications you take; you might need to adjust your usual

dose for the examination. Discuss any allergies to medications as well as medical conditions,

such as heart or lung disease. It is advisable to refrain from smoking six hours prior to theprocedure.

What to Bring

CT, MRI and X-Rays if you have any.

Medications that you are taking.

Phone number of contact person who will pick you up.

Can I take my current medications?

Most medications can be continued as usual, but some medications can interfere with the

preparation or the examination. Inform your doctor about medications youre taking, particularly

aspirin products or antiplatelet agents, arthritis medications, anticoagulants (blood thinners such

as warfarin), clopidogrel, insulin or iron products. Also, be sure to mention any allergies you have

to medications.

What happens during upper endoscopy?

Your doctor might start by spraying your throat with a local anesthetic or by giving you a sedative

to help you relax. You'll then lie on your side, and your doctor will pass the endoscope through

your mouth and into the esophagus, stomach and duodenum. The endoscope doesn't interfere

with your breathing, Most patients consider the test only slightly uncomfortable, and many patients

fall asleep during the procedure.

What happens after upper endoscopy?

You will be monitored until most of the effects of the medication have worn off. Your throat might

be a little sore, and you might feel bloated because of the air introduced into your stomach during


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the test. You will be able to eat after you leave unless your doctor instructs you otherwise. Your

physician will explain the results of the examination to you, although you'll probably have to wait

for the results of any biopsies performed.

If you have been given sedatives during the procedure, someone must drive you home and stay

with you. Even if you feel alert after the procedure, your judgement and reflexes could be impaired

for the rest of the day.

The estimated time you will be here is 2 - 3 hours.

What are the possible complications of upper endoscopy?

Although complications can occur, they are rare when doctors who are specially trained and

experienced in this procedure perform the test. Bleeding can occur at a biopsy site or where a

polyp was removed, but it's usually minimal and rarely requires follow-up. Perforation (a hole or

tear in the gastrointestinal tract lining) may require surgery but this is a very uncommon

complication. Some patients might have a reaction to the sedatives or complications from heart or

lung disease.

Although complications after upper endoscopy are very uncommon, it's important to recognize

early signs of possible complications. Contact your doctor immediately if you have a fever after

the test or if you notice trouble swallowing or increasing throat, chest or abdominal pain, or

bleeding, including black stools. Note that bleeding can occur several days after the procedure.

If you have any concerns about a possible complication, it is always best to contact your doctor

right away.

IMPORTANT REMINDER:

This information is intended only to provide general guidance. It does not provide definitive

medical advice. It is very important that you consult your doctor about your specific condition.


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MAKLUMAT UNTUK PESAKIT

Apakah OESOPHAGODUODENOSCOPY (OGDS)?

Dengan mengunakan endoskopi (teropong), doktor anda boleh membuat pemeriksaan dalaman

saluran pencernaan anda, yang termasuk esofagus, perut dan duodenum (bahagian pertama

usus kecil). Doktor anda akan menggunakan saluran fleksibel (teropong) berkamera dan sumber

cahaya yang dipanggil endoskop, dan akan melihat imej saluran pencernaan anda akan

dipaparkan pada monitor video.


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Mengapa ia dilakukan?

Endoskopi membantu doktor mengenal pasti punca simptom anda yang mungkin berkaitan

dengan penyakit saluran pemakanan atas. Prosedur endoskopi adalah prosedur yang terbaik

dalam membantu doktor mencari punca pendarahan dari saluran pemakanan atas. Ia adalah

lebih tepat daripada sinar-X atau imbasan CT untuk mengesan radang, ulser dan tumor esofagus,

perut dan duodenum.Doktor anda mungkin menggunakan endoskopi atas untuk mendapatkan

biopsi (contoh tisu kecil). Biopsi membantu doktor anda membezakan antara tisu (kanser) yang

berjenis barah atau biasa atau untuk menguji jangkitan kuman Helicobacter pylori, punca dirawat

untuk ulser gastrik.Endoskopi bukan sahaja digunakan untuk memberi gambaran saluran usus,

tetapi prosedur ini juga boleh digunakan untuk memberi rawatan. Masalah pencernaan yang rumit

boleh dirawat dengan ketidak selesaan yang hanya sedikit atau tiada langsung. Sebagai contoh,

doktor anda mungkin melebarkan kawasan yang sempit, mengeluarkan polip atau merawat

pendarahan.

Persediaan apa yang diperlukan?

Perut yang kosong membenarkan peperiksaan yang terbaik dan paling selamat, jadi anda harus

berpuasa (termasuk air), selama lebih kurang enam jam sebelum peperiksaan. Doktor anda akan

memberikan keterangan lanjut tentang berpuasa sebelum endoskopi.

Beritahu doktor anda terlebih dahulu tentang apa-apa ubat yang anda ambil, anda mungkin perlu

mengubah dos biasa anda untuk peperiksaan. Bincangkan sebarang alahan kepada ubat-ubatan

serta keadaan perubatan, seperti jantung atau penyakit paru-paru. Ia adalah dinasihatkan supaya

mengelakkan diri daripada merokok enam jam sebelum prosedur.

Apa yang perlu dibawa

CT, MRI dan X-Rays jika anda mempunyai sebarang. Ubat-ubatan yang anda ambil. Nombor

telefon orang kenalan yang akan menjemput anda. Bayaran adalah lebih kurang RM 30.

Bolehkah saya mengambil ubat-ubatan semasa saya?

Kebanyakan ubat-ubatan boleh diteruskan seperti biasa, tetapi sesetengah ubat boleh

mengganggu penyediaan atau peperiksaan. Maklumkan kepada doktor anda mengenai ubat-

ubatan yang anda ambil, terutamanya produk aspirin atau agen antiplatelet, ubat-ubatan artritis,

anticoagulants (pencair darah seperti warfarin), clopidogrel, insulin atau produk besi. Juga,

pastikan untuk menyatakan apa-apa alahan anda perlu kepada ubat-ubatan.


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Apakah yang berlaku semasa endoskopi atas?

Doktor anda mungkin bermula dengan menyembur tekak anda dengan ubat bius tempatan atau

dengan memberi anda ubat pelali untuk membantu anda berehat. Anda akan dipusing

menyebelah dalam keadaan baring, dan doktor anda akan memasukan teropong melalui mulut

anda dan ke dalam esofagus, perut dan duodenum. Endoskop itu tidak mengganggu pernafasan

anda, Kebanyakan pesakit menganggap ujian hanya sedikit tidak selesa, dan ramai pesakit

tertidur semasa prosedur.

Apa yang berlaku selepas endoskopi atas?

Anda akan dipantau sehingga kebanyakan kesan ubat-ubatan telah dipakai. Tekak anda mungkin

menjadi sakit sedikit, dan anda mungkin berasa yang mengembung kerana udara yang

diperkenalkan ke dalam perut anda semasa ujian. Anda akan dapat makan selepas anda

meninggalkan melainkan jika doktor mengarahkan sebaliknya. Doktor anda akan menerangkan

keputusan peperiksaan kepada anda, walaupun anda mungkin akan perlu menunggu keputusan

mana-mana biopsi yang dilakukan. Jika anda telah diberi sedatif semasa prosedur, seseorang

perlu memandu anda rumah dan tinggal bersama anda.

Anggaran masa anda akan berada di sini adalah 2 - 3 jam.

Apakah komplikasi yang mungkin endoskopi atas?

Walaupun komplikasi boleh berlaku, mereka jarang berlaku apabila doktor yang telah dilatih khas

dan berpengalaman dalam prosedur ini menjalankan ujian. Pendarahan boleh berlaku di tapak

biopsi atau polip telah dikeluarkan, tetapi ia biasanya kecil dan jarang memerlukan susulan. Luka

atau penembusan pada dinding saluran pemakan mungkin memerlukan pembedahan tetapi ini

adalah satu komplikasi yang sangat jarang berlaku. Sesetengah pesakit mungkin mempunyai

reaksi kepada sedatif atau komplikasi jantung atau jangkitan paru-paru.Walaupun komplikasi

selepas atas endoskopi adalah sangat jarang berlaku, ia adalah penting untuk mengenal pasti

tanda-tanda awal komplikasi yang mungkin. Hubungi doktor anda dengan segera jika anda

demam panas selepas ujian atau jika anda mendapati masalah menelan atau meningkatkan

kerongkong, dada atau sakit perut, atau pendarahan, termasuk najis hitam. Sila ambil perhatian

bahawa pendarahan boleh berlaku beberapa hari selepas prosedur.Jika anda mempunyai

sebarang kemusykilan tentang komplikasi endoskopi, seeloknya hubungi doktor anda dengan

segera.


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PERINGATAN PENTING:

Maklumat ini adalah hanya untuk panduan am. Anda perlu berbincang dengan doktor anda

tentang keadaan khusus anda untuk maklumat lebih lanjut.


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?

?


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BIOPSY(HELICOBACTER

PYLORI)

-6

6

CT, MRI X-

BLOOD

THINNER


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---LIDOCANE

SPRAYINTRAVENOUS

SEDATION

24

BIOPSY

2- 3


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Detect

STOMACH CANCERSearly.


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Definitions

1. Dyspepsia - is defined as pain or discomfort centered in the upper abdomen (i.e. in or aroundthe midline)The Rome III definition.

Also defined as upper abdominal pain or discomfort that is episodic or persistent and often

associated with belching, bloating, heartburn, nausea or vomiting.

QUADRANT A: DYSPEPSIA

QUADRANT B:UGIB(including melena)

Score Score

Intermittent, more than 1

year

1 Occurred more than 1 year ago 1

Intermittent, less than 1 year 3 Occurred less than 1 year 5

Persistent for 2 weeks 5

QUADRANT C: Modified ALARM

Symptoms

QUADRANT D: AGE

Score Score

Anaemia 3 Less than 40 yrs 2

Epigastric Mass / Fullness 3 40 49 yrs 3

Persistent vomiting [>2wks] 3 50 yrs 5

Significant LOW 3 Total score:

[a score of 10 and above will warrant an

urgent ODGS]

Dysphagia 5

Early satiety 3

MARKs Quadrant


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2. MelenaThe term "melena" describes black, tarry, and foul-smelling stools or

"hematochezia" to describe red- or maroon-colored stools. Melena is a sign of

gastrointestinal bleeding.

3. Dysphagia- The difficult passage of food from the mouth to the stomach during one or more of

the three phases of normal swallowing, i.e. oral, pharyngeal, esophageal.

4. Persistent vomiting- continuous vomiting more 1 weeks without any underlying disease

diagnosed during the period and cannot be related to any particular disease process.

5. Anaemia- The lower limit of the normal range of hemoglobin should be used to

define anemia.

6. Unintentional significant* loss of weight- is a decrease in body

weight/significant+

weight lost that is not voluntary.

*significant weight loss: loss of 5% body weight in 30 days, 7.5% in 60 days, or 10% in 180 days

7. Epigastric mass- A mass at the epigastric region during routine examination

8. Non-variceal Upper GI bleed- Upper-gastrointestinal (GI) bleeding refers to GI blood loss

whose origin is proximal to the ligament of Treitz. Acute upper-GI bleeding (UGIB) can

manifest as hematemesis, "coffee ground" emesis, the return of red blood via a nasogastric

tube, and/or melena with or without hemodynamic compromise. Non variceal bleeding

corresponds to OGDS findings/ evidence of esophageal varices.

9. Early satiety- A feeling of abdominal fullness which limits the patients ability to eat more than a

very small amount of food or liquid at any one time. Patient/ individual claims eating less over a

period of time less more than 3 months.


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AFFIX NAME LABEL HERE

(if none, enter patient name, address, insurer)

Name: Age:

NRIC: Race:

Tel:

Hospi tal _______________

OPEN ACCESS Endoscope service referral formTo request for endoscope service [OGDS or colonoscopy]

please complete this form and for endoscope date

Call directly Send it with the patient to Department.,

hospital to get their appointments for endoscope

procedure or

Fax to attention to Open access

endoscope service, Department ,

hospital

*For referring doctors onlyPlease circle the appropriate scores below and refer to us

Oesophagogastroduodenoscope [OGDS]MARKs quadrant [circle the score where necessary]

QUADRANTA:DYSPEPSIA

QUADRANTB:RECENTUGIB(includingmelena)

Score Score1 Occurred morethan 1 year ago 13 Occurred lessthan 1 year 5for 2 weeks 5QUADRANTC:ModifiedALARM

Symptoms

QUADRANTD:AGEScore Score3 < 40 yrs 2Mass / Fullness 3 40 49 yrs 33 50 yrs 5LOW 3 Total score:ysphagia 53

Referring doctor:

.

Name:__________________________ Phone:Fax:

*Patients with score of 10 and above will be scopedwithin __ weeks

Endoscope serviceOPEN ACCESS

Appointment date:

Important notice

Open Access endoscopic service is fast track endoscopereferral service under Ministry of Health Malaysia. This

service is aimed to reduce waiting time for endoscope for

high risk gastric cancer patient.

However, several potential problems could arise if this

service is not used appropriately; which include

inappropriate referral and poorly informed patients.

The MARKs quadrant score and pre- endoscopic

information about the patient should be accurately provided

by the referring doctors; including underlying medical

problems and drug history to ensure this service benefit

those who really need it.

Exclusion criteria for Open Access endoscope:-

1. Those who have already diagnosed with Upper

Gastrointestinal cancers.2. Individuals who had previous endoscope done less

than one year and/or under follow up.

3. Acute upper gastrointestinal bleeding.4. Emergency cases (yellow & red cases) in the

Accident and Emergency department.

5. In-patients from the hospitals.

6. Patients who are admitted for complication of

upper gastrointestinal malignancies.

7. Patient with severe medical illness which may behazardous for the procedure.

On the reverse side, most frequently asked questions have

been answered to assist the referring doctors while

explaining regarding this service to the patients and forpatients and family memebers to read after they are given

this form.

Medical history

Medical illness:.. Drug allergies: NO YESIs the patient on clopidogel NO YES Is the patient on warfarin? NO YES Is the patient on heparin? NO YESHas patient been instructed to stop warfarin 3-5 days prior to the procedure: NO YES NA

Current medications: .

* I f the patient has any medical i ll ness or condition that may compli cate the endoscope procedure; kindly inform the

endoscope centr e.


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MAKLUMAT UNTUK PESAKIT (PATIENT INFORMATION LEAFLET)

Apakah OESOPHAGODUODENOSCOPY (OGDS)?

Doktor anda akan menggunakan saluran fleksibel (teropong) berkamera dan sumber cahaya

yang dipanggil endoskop, dan akan melihat imejdan memeriksa saluran pencernaan (esofagus,

perut dan duodenum (bahagian pertama usus kecil) anda.

Mengapa ia dilakukan? Endoskopi membantu doktor mengenal pasti punca simptom anda

yang mungkin berkaitan dengan penyakit saluran pemakanan atas. Doktor anda mungkin

menggunakan endoskopi atas untuk mendapatkan biopsi (contoh tisu kecil). Biopsi membantudoktor anda membezakan antara tisu (kanser) yang berjenis barah atau biasa atau untuk

menguji jangkitan kuman Helicobacter pylori, punca dirawat untuk ulser gastrik.

Persediaan apa yang diperlukan? Perut yang kosong membenarkan peperiksaan yang

terbaik dan paling selamat, jadi anda harus berpuasa (termasuk air), selama lebih kurang enam

jam sebelum peperiksaan. Doktor anda akan memberikan keterangan lanjut tentang berpuasa

sebelum endoskopi.

Beritahu doktor anda terlebih dahulu tentang apa-apa ubat yang anda ambil, anda mungkin

perlu mengubah dos biasa anda untuk peperiksaan. Bincangkan sebarang alahan kepada ubat-

ubatan serta keadaan perubatan, seperti jantung atau penyakit paru-paru. Ia adalah

dinasihatkan supaya mengelakkan diri daripada merokok enam jam sebelum prosedur.

Apa yang perlu dibawa? CT, MRI dan X-Rays jika anda mempunyai sebarang.

Ubat-ubatan yang anda ambil. Nombor telefon orang kenalan yang akan menjemput anda.

Bayaran adalah lebih kurang RM..

Bolehkah saya mengambil ubat-ubatan semasa saya? Kebanyakan ubat-ubatan boleh

diteruskan seperti biasa, tetapi sesetengah ubat boleh mengganggu penyediaan atau

peperiksaan. Maklumkan kepada doktor anda mengenai ubat-ubatan yang anda ambil,

terutamanya produk aspirin atau agen antiplatelet, ubat-ubatan artritis, anticoagulants

(pencair darah seperti warfarin), clopidogrel, insulin atau produk besi. Juga, pastikan untuk

menyatakan apa-apa alahan anda perlu kepada ubat-ubatan.

Apakah yang berlaku semasa endoskopi atas? Doktor anda mungkin bermula dengan

menyembur tekak anda dengan ubat bius tempatan atau dengan memberi anda ubat pelali

untuk membantu anda berehat. Anda akan dipusing menyebelah dalam keadaan baring, dan

doktor anda akan memasukan teropong melalui mulut anda dan ke dalam esofagus, perut dan

duodenum. Endoskop itu tidak mengganggu pernafasan anda, Kebanyakan pesakit

menganggap ujian hanya sedikit tidak selesa, dan ramai pesakit tertidur semasa prosedur.

Apa yang berlaku selepas endoskopi atas? Anda akan dipantau sehingga kebanyakan kesan

ubat-ubatan telah dipakai. Tekak anda mungkin menjadi sakit sedikit, dan anda mungkin

berasa yang mengembung kerana udara yang diperkenalkan ke dalam perut anda semasa

ujian. Anda akan dapat makan selepas anda meninggalkan melainkan jika doktor mengarahkan

sebaliknya. Doktor anda akan menerangkan keputusan peperiksaan kepada anda, walaupun

anda mungkin akan perlu menunggu keputusan mana-mana biopsi yang dilakukan.

Jika anda telah diberi sedatif semasa prosedur, seseorang perlu memandu anda rumah dan

tinggal bersama anda.

Apakah komplikasi yang mungkin endoskopi atas? Walaupun komplikasi boleh berlaku,

mereka jarang berlaku apabila doktor yang telah dilatih khas dan berpengalaman dalam

prosedur ini menjalankan ujian. Pendarahan boleh berlaku di tapak biopsi atau polip telahdikeluarkan, tetapi ia biasanya kecil dan jarang memerlukan susulan. Luka atau penembusan

pada dinding saluran pemakan mungkin memerlukan pembedahan tetapi ini adalah satu

komplikasi yang sangat jarang berlaku. Sesetengah pesakit mungkin mempunyai reaksi kepadaubat sedatif atau komplikasi jantung atau jangkitan paru-paru. Walaupun komplikasi selepas

atas endoskopi adalah sangat jarang berlaku, ia adalah penting untuk mengenal pasti tanda-

tanda awal komplikasi yang mungkin. Hubungi doktor anda dengan segera jika anda demam

panas selepas ujian atau jika anda mendapati masalah menelan atau meningkatkan

kerongkong, dada atau sakit perut, atau pendarahan, termasuk najis hitam. Jika anda

mempunyai sebarang kemusykilan tentang komplikasi endoskopi, seeloknya hubungi doktor

anda dengan segera.

PERINGATAN PENTING: Maklumat ini adalah hanya untuk panduan am. Anda perlu berbincang

dengan doktor anda tentang keadaan khusus anda untuk maklumat lebih lanjut.

English

What is an OESOPHAGODUODENOSCOPY (OGDS)? Upper endoscopy lets your doctor

examine the lining of the upper part of your gastrointestinal tract, which includes the

esophagus, stomach and duodenum (first portion of the small intestine). Your doctor will use a

thin, flexible tube called an endoscope, which has its own lens and light source, and will view

the images on a video monitor.

Why is it done? Upper endoscopy helps your doctor evaluate your complaints that may be

related to illness of the upper intestinal tract. It's the best procedure that would help doctorsfind out the cause of bleeding from the upper gastrointestinal tract. Your doctor might useupper endoscopy to obtain a biopsy (small tissue samples). A biopsy helps your doctor

distinguish between benign and malignant (cancerous) tissues or to test for Helicobacter

pylori, a treatable cause for gastric ulcers.

What preparations are required? An empty stomach allows for the best and safest

examination, so you should have nothing to eat or drink, including water, for approximately six

hours before the examination. Your doctor will tell you when to start fasting as the timing can

vary. Tell your doctor in advance about any medications you take; you might need to adjust

your usual dose for the examination. Discuss any allergies to medications as well as medical

conditions, such as heart or lung disease. It is advisable to refrain from smoking six hours prior

to the procedure.

What to Bring ? CT, MRI and X-Rays if you have any. Medications that you are taking. Phone

number of contact person who will pick you up.

Can I take my current medications? Most medications can be continued as usual, but some

medications can interfere with the preparation or the examination. Inform your doctor aboutmedications youre taking, particularly aspirin products or antiplatelet agents, arthritis

medications, anticoagulants (blood thinners such as warfarin), clopidogrel, insulin or iron

products. Also, be sure to mention any allergies you have to medications.

and duodenum. The endoscope doesn't interfere with your breathing. Most patients consider

the test only slightly uncomfortable, and many patients fall asleep during the procedure.

What happens after upper endoscopy? You will be monitored until most of the effects of the

medication have worn off. Your throat might be a little sore, and you might feel bloated because

of the air introduced into your stomach during the test. You will be able to eat after you leave

unless your doctor instructs you otherwise. Your physician will explain the results of the

examination to you, although you'll probably have to wait for the results of any biopsies

performed.

If you have been given sedatives during the procedure, someone must drive you home and stay

with you. Even if you feel alert after the procedure, your judgement and reflexes could be

impaired for the rest of the day.

What are the possible complications of upper endoscopy? Although complications can

occur, they are rare when doctors who are specially trained and experienced in this procedure.

Bleeding can occur at a biopsy site or where a polyp was removed, but it's usually minimal and

rarely requires follow-up. Perforation (a hole or tear in the gastrointestinal tract lining) may

require surgery but this is a very uncommon complication. Some patients might have a reaction

to the sedatives or complications from heart or lung disease.

Although complications after upper endoscopy are very uncommon, it's important to recognize

early signs of possible complications. Contact your doctor immediately if you have a fever after

the test or if you notice trouble swallowing or increasing throat, chest or abdominal pain, or

bleeding, including black stools. Note that bleeding can occur several days after the procedure.

If you have any concerns about a possible complication, it is always best to contact your doctor

right away.

IMPORTANT REMINDER: This information is intended only to provide general guidance. It

does not provide definitive medical advice. It is very important that you consult your doctor

about your specific condition.

Chinese

?

?

biopsy

(Helicobacter pylori)

-6

6

CT, MRI X-,

blood thinner

---lidocane spray

Intravenous sedation

24

biopsy

SOP Open Access Endoscopy Updated30April

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Transcript of SOP Open Access Endoscopy Updated30April