Digestive Diseases

1. Digestive Diseases • 13.00 REGISTRATION AND LUNCH • 13.30 Mr John Grabham: Rectal bleeding and colorectal cancer • 14.00 Mr Neil Smith: Enhancing recovery in GI surgery • 14.30 BREAK • 14.45 Dr Gary Mackenzie: Upper GI disease • 15.15 Dr Azhar Ansari: Inflammatory bowel disease • 15.45COFFEE BREAK • 16.00 Dr Jonathan Stenner: Hepatology • 16.30 Mr Paras Jethwa: Management of gallbladder disease • 17.00CLOSE

4. Website and extranetSurrey & Sussex Healthcare NHS Trust

5. http://www.sash.nhs.uk/our-services/digestive-diseases/

7. Message 1. The Digestive Diseases Department • A coherent team of sub-specialists • Provide a multi-disciplinary service • Clear internal and external audit and clinical governance pathways

8. Guidelines for TWR referral • Bleeding and diarrhoea >40 (>6/52) • Bleeding w/o anal symptoms >60 (>6/52) • Diarrhoea >60 (>6/52) • Abdominal or rectal mass • Iron-deficiency anaemia NOT FOBs

12. 62 day & 31 day targets Urgent GP referral Received by hospital 1st OPA @hospital ?? Further investigations MDT meeting Diagnostic investigations Clinical Diagnosis 1st definitive treatment Decision to treat Emergency Admission 31 Days 62 Days Time

13. Work-up of patients with suspected colorectal cancer • Colonoscopy & Biopsy • CT scan • CEA • MRI pelvis • EUS • MRI liver • PET scan

16. CT assessment of colonic 1*

17. Anterior rectal cancer invading uterus

21. Solitary liver metastasis

22. 6/12 post-right hepatectomy

25. 62 day & 31 day targets Urgent GP referral Received by hospital 1st OPA @hospital ?? Further investigations MDT meeting Diagnostic investigations Clinical Diagnosis 1st definitive treatment Decision to treat Emergency Admission 31 Days 62 Days Time

26. 62 day TWR referral to treatment

27. 31 days decision to treatment

28. Clinical Results • Resection rate • Peri-operative mortality • Major complications • Clear resection margins • Local recurrence Comparisons with ACPGBI database

29. Resection rate = 93% (cf 89.5%) Mortality rate = 7.2% (cf 7.5%) Anastomotic leakage = 4.8% (cf 4.9%) Positive CRMs = <1% (10%) Local recurrence for T1-3 = <1% (10%)

30. Message 2.Summary of Colorectal Cancer Service • Rapid, efficient service • Excellent clinical outcomes • Please continue to refer your patients

31. Rectal Bleeding Pathway

32. Causes of Rectal Bleeding • Haemorrhoids • Fissure-in-ano • Other benign ano-rectal pathology • Polyps • Cancer • Diverticular disease • Colitis

33. Haemorrhoids • Common >15% • Usually associated with perianal symptoms • Often associated with straining • High fibre • Bulking agents • Topical agents • Exclude serious pathology • Banding / injection – maximum twice

35. Rubber band ligation

36. Thrombosed external haemorrhoid

38. Stapled haemorrhoidectomy

39. Stapled haemorrhoidectomy

40. Fissure-in-ano • Common esp young adults • Anal spasm • Rectal bleeding and pain • Often assoc with straining • Difficult to examine

41. Fissure-in-ano

42. Sentinel Tag

43. Fissure-in-ano management • 6/52 GTN or Diltiazem ointment • ? Lignocaine, ?anxiolytic, ?stool softener • Clinical review – 1/20 underlying pathology • Need to visualise rectum

44. Anal Warts

45. Anal Cancer

46. Carcinoma sigmoid colon

48. Rationale for early flexible sigmoidoscopy in rectal bleeding • Haemorrhoids – common and may co-exist with other pathology; treatment unreliable • Fissure – difficult to examine; sometimes associated with serious pathology • Reassurance of “nothing serious” • Colonic disease – allows a reliable, safe, preliminary assessment

49. Message 3.Revised clinical algorithm Rectal bleeding Flexible sigmoidoscopy