Comparing alternative follow-up strategies for patients with stable coeliac disease.

BACKGROUND: Once clinically stable, patients with coeliac disease should have annual follow-up. Lack of capacity in gastroenterology outpatient clinics mean alternatives are required. OBJECTIVES: We studied the effectiveness of follow-up deferred to general practitioners (GP-FU) and compared this with a neighbouring Trust where follow-up was through a dedicated nurse-led telephone clinic (T-FU). DESIGN: All patients with coeliac disease were posted a questionnaire examining patient satisfaction, adherence with gluten-free diet and calcium intake. RESULTS: 517 of 825 patients (62.7%) completed a postal questionnaire (median age 61, 72% female). 28% of GP-FU and 84% of T-FU patients received an annual review. Of those seen, 33% (GP-FU) and 53% (T-FU) were weighed (χ2 65.8, p<0.001), 44% and 63% had symptom review (χ2 81.1, p<0.001) and 33% and 51% had dietary adherence checked (χ2 60.6, p<0.001). Almost all patients considered their adherence with gluten-free diet (GFD) good or excellent, although the majority of patients failed to achieve the recommended daily intake of calcium. GP-FU patients were more likely to receive calcium±vitamin D supplements (77% vs 42%, χ2 88.2, p<0.001) and they were also more likely to receive appropriate vaccinations (67% vs 38%, χ2 17.6, p<0.001). CONCLUSIONS: Discharge of patients with coeliac disease to primary-care in many cases results in their complete loss to follow-up. When patients were reviewed, either by GP-FU and T-FU, many aspects of their care are not addressed. Whether this will result in late complications remains to be seen.

Can patients determine the level of their dysphagia?

AIM: To determine if patients can localise dysphagia level determined endoscopically or radiologically and association of gender, age, level and pathology. METHODS: Retrospective review of consecutive patients presenting to dysphagia hotline between March 2004 and March 2015 was carried out. Demographics, clinical history and investigation findings were recorded including patient perception of obstruction level (pharyngeal, mid sternal or low sternal) was documented and the actual level of obstruction found on endoscopic or radiological examination (if any) was noted. All patients with evidence of obstruction including oesophageal carcinoma, peptic stricture, Schatzki ring, oesophageal pouch and cricopharyngeal hypertrophy were included in the study who had given a perceived level of dysphagia. The upper GI endoscopy reports (barium study where upper GI endoscopy was not performed) were reviewed to confirm the distance of obstructing lesion from central incisors. A previously described anatomical classification of oesophagus was used to define the level of obstruction to be upper, middle or lower oesophagus and this was compared with patient perceived level. RESULTS: Three thousand six hundred and sixty-eight patients were included, 42.0% of who were female, mean age 70.7 ± 12.8 years old. Of those with obstructing lesions, 726 gave a perceived level of dysphagia: 37.2% had oesophageal cancer, 36.0% peptic stricture, 13.1% pharyngeal pouches, 10.3% Schatzki rings and 3.3% achalasia. Twenty-seven point five percent of patients reported pharyngeal level (upper) dysphagia, 36.9% mid sternal dysphagia and 25.9% lower sternal dysphagia (9.5% reported multiple levels). The level of obstructing lesion seen on diagnostic testing was upper (17.2%), mid (19.4%) or lower (62.9%) or combined (0.3%). When patients localised their level of dysphagia to a single level, the kappa statistic was 0.245 (P < 0.001), indicating fair agreement. 48% of patients reporting a single level of dysphagia were accurate in localising the obstructing pathology. With respect to pathology, patients with pharyngeal pouches were most accurate localising their level of dysphagia (P < 0.001). With respect to level of dysphagia, those with pharyngeal level lesions were best able to identify the level of dysphagia accurately (P < 0.001). No association (P > 0.05) was found between gender, patient age or clinical symptoms with their ability to detect the level of dysphagia. CONCLUSION: Patient perceived level of dysphagia is unreliable in determining actual level of obstructing pathology and should not be used to tailor investigations.

Incidence and predictive features of pharyngeal pouch in a dysphagic population.

Pharyngeal pouch patients often present with dysphagia and risk perforation when undergoing gastroscopy. Knowledge of pharyngeal pouch incidence and predictive demographic features in patients referred for dysphagia would help determine those patients who should have barium swallow as an initial investigation. The prospectively collected data of 2,797 consecutive referrals were analysed. Logistic regression determined significant variables for predicting pharyngeal pouches. Of the 2,430 patients investigated [mean age = 67.7 years, range 17-103; 48.2 % male], 49 (2.0 %) had a pharyngeal pouch [mean age = 79.8 years (range 58-93); 53.1 % male]. Significant predictors of pharyngeal pouch were pharyngeal level dysphagia (odds ratio [OR] 3.8-19.2), age over 65 years (OR 2.2-14.1), symptom duration over 12 weeks (OR 1.1-3.9), and no weight loss (OR 1.1-5.5). Only 18 patients (36.7 %) underwent surgery for their pouch. Midsternal dysphagia alone occurred in 16 % of all patients with pouches. From our results we conclude that pharyngeal pouches in a dysphagic population are more common than previously recognised. Patients aged over 65 years with pharyngeal level dysphagia for more than 12 weeks should have a barium swallow as their initial investigation.

Improved clinical outcomes and efficacy with a nurse-led dysphagia hotline service.

BACKGROUND: A nurse practitioner-led dysphagia service was introduced to improve appropriateness of investigations. OBJECTIVE: To determine the clinical outcomes and efficacy of this service. DESIGN AND PATIENTS: A 7-year prospective audit of the first 2000 patients referred for investigation of dysphagia. SETTING: Royal Cornwall Hospitals NHS Trust. INTERVENTION: An innovative nurse practitioner-led telephone dysphagia hotline (DHL) assessment service for all patients and consultant review following investigation prior to discharge. OUTCOMES: Clinical outcomes, service efficiency and cost effectiveness. RESULTS: 2000 patients (median age 70 years, 48% male) were referred in less than 7 years, 1775 being managed fully through the DHL. 67% patients had gastroscopy only, 13% barium swallow only and 8.8% both and 11.2% had no investigation. Reflux was the commonest cause (41.3%), 9% had peptic stricture, 10% malignancy 1.9% pharyngeal pouches and 0.8% achalasia. The did not attend rate was reduced from 3.9% to 1.1% and 151 patients either refused or did not require investigation saving a potential £53 040. Although some patients with pharyngeal pouches had gastroscopy as initial investigation, no complications resulted. CONCLUSIONS: The nurse practitioner-led DHL service has improved efficiency and resulted in a safe prompt service to patients.

Predictive value of symptoms and demographics in diagnosing malignancy or peptic stricture.

AIM: To determine which features of history and demographics predict a diagnosis of malignancy or peptic stricture in patients presenting with dysphagia. METHODS: A prospective case-control study of 2000 consecutive referrals (1031 female, age range: 17-103 years) to a rapid access service for dysphagia, based in a teaching hospital within the United Kingdom, over 7 years. The service consists of a nurse-led telephone triage followed by investigation (barium swallow or gastroscopy), if appropriate, within 2 wk. Logistic regression analysis of demographic and clinical variables was performed. This includes age, sex, duration of dysphagia, whether to liquids or solids, and whether there are associated features (reflux, odynophagia, weight loss, regurgitation). We determined odds ratio (OR) for these variables for the diagnoses of malignancy and peptic stricture. We determined the value of the Edinburgh Dysphagia Score (EDS) in predicting cancer in our cohort. Multivariate logistic regression was performed and P < 0.05 considered significant. The local ethics committee confirmed ethics approval was not required (audit). RESULTS: The commonest diagnosis is gastro-esophageal reflux disease (41.3%). Malignancy (11.0%) and peptic stricture (10.0%) were also relatively common. Malignancies were diagnosed by histology (97%) or on radiological criteria, either sequential barium swallows showing progression of disease or unequivocal evidence of malignancy on computed tomography. The majority of malignancies were esophago-gastric in origin but ear, nose and throat tumors, pancreatic cancer and extrinsic compression from lung or mediastinal metastatic cancer were also found. Malignancy was statistically more frequent in older patients (aged >73 years, OR 1.1-3.3, age < 60 years 6.5%, 60-73 years 11.2%, > 73 years 11.8%, P < 0.05), males (OR 2.2-4.8, males 14.5%, females 5.6%, P < 0.0005), short duration of dysphagia (≤ 8 wk, OR 4.5-20.7, 16.6%, 8-26 wk 14.5%, > 26 wk 2.5%, P < 0.0005), progressive symptoms (OR 1.3-2.6: progressive 14.8%, intermittent 9.3%, P < 0.001), with weight loss of ≥ 2 kg (OR 2.5-5.1, weight loss 22.1%, without weight loss 6.4%, P < 0.0005) and without reflux (OR 1.2-2.5, reflux 7.2%, no reflux 15.5%, P < 0.0005). The likelihood of malignancy was greater in those who described true dysphagia (food or drink sticking within 5 s of swallowing than those who did not (15.1% vs 5.2% respectively, P < 0.001). The sensitivity, specificity, positive predictive value and negative predictive value of the EDS were 98.4%, 9.3%, 11.8% and 98.0% respectively. Three patients with an EDS of 3 (high risk EDS ≥ 3.5) had malignancy. Unlike the original validation cohort, there was no difference in likelihood of malignancy based on level of dysphagia (pharyngeal level dysphagia 11.9% vs mid sternal or lower sternal dysphagia 12.4%). Peptic stricture was statistically more frequent in those with longer duration of symptoms (> 6 mo, OR 1.2-2.9, ≤ 8 wk 9.8%, 8-26 wk 10.6%, > 26 wk 15.7%, P < 0.05) and over 60 s (OR 1.2-3.0, age < 60 years 6.2%, 60-73 years 10.2%, > 73 years 10.6%, P < 0.05). CONCLUSION: Malignancy and peptic stricture are frequent findings in those referred with dysphagia. The predictive value for associated features could help determine need for fast track investigation whilst reducing service pressures.