Gastroenterology team of the yearBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h1639 (Published 01 April 2015) Cite this as: BMJ 2015;350:h1639
- Nigel Hawkes, freelance journalist, London, UK
Scarred liver project
In Nottingham, a team from the university and the hospital trust led by Guruprasad Aithal and Neil Guha has transformed the diagnosis of chronic liver disease by identifying those at risk from GP records and inviting them to clinics held in GP practices where they are scanned to assess any scarring of their liver. The technique identifies twice as many patients with cirrhosis, the vast majority of whom had no symptoms and had normal liver function tests, illustrating, says Guha, the inadequacy of these widely used enzyme tests in flagging up chronic liver injury. The scan also detects early asymptomatic liver disease at a stage when it is still reversible.
“We screened over 20 000 patients in four GP practices, targeting factors such as diabetes and alcohol rather than liver enzymes,” he says. “All these patients were offered appointments for a scan, which is done by a trained nurse. We use a FibroScan, an ultrasound scanner, to measure the stiffness of the liver—it’s well established in secondary care but not in primary care, which is actually a better place to implement it.”
The 200 patients who had elevated scan readings were seen by consultant hepatologists, again in GP practices, and offered advice. The benefit is much earlier detection, a great improvement on identifying them only when they are admitted to hospital as an emergency, which was often the case in the past. The technique is inexpensive and money spent on the portable scanner is saved because fewer liver biopsies and outpatient visits are then needed. Patient response is extremely positive.
Inflammatory bowel disease—SSHAMP (Supported, Self help and Management Programme)
Better management of patients with inflammatory bowel disease was the target set by Luton and Dunstable Hospital. A paper based self management programme had run into problems, including patients disappearing from surveillance and only reappearing when they had developed cancer. The solution, says consultant Matthew Johnson, was a web based system using the Patients Know Best website. “The opening page is an index of symptoms, which patients complete, and behind that there is a calculator that scores them as green, orange, or red,” he says.
The website can be accessed by consultants to detect any deteriorating patients, enabling them to act in time to prevent unnecessary admissions and emergency appointments. Patients can use it for advice and information and to get support if they need it. “After three years’ experience with the first 425 patients, 16 had required advice on therapy, which was given over the phone. Only three had to come back to hospital for emergency outpatient appointments and we had had no hospital admissions,” Johnson says. “By the end of this year we expect to have 800 patients on the system.”
The scheme costs less, and has improved management of the condition and increased patient satisfaction, while freeing clinic capacity and providing a safe community based management system. “Very few patients are unwilling to try it,” Johnson says.
Management of paediatric chronic intestinal pseudo-obstruction
A rare but devastating condition that occurs in around one in 40 000 births—15 a year in the UK—was the challenge that faced gastroenterologists at Great Ormond Street Hospital in London. Children born with chronic intestinal pseudo-obstruction (CIPO) have abnormalities in the nerves or muscles of the intestinal tract and present with the symptoms of obstruction. Up to half need parenteral nutrition to keep them alive and are likely to undergo surgery to clear obstructions that don’t exist. Around 30% will die.
“Diagnosis is often delayed and children are given unnecessary or inappropriate treatment,” says Nikhil Thapar, consultant gastroenterologist at Great Ormond Street. “We believed that timely and accurate diagnosis and treatment would preserve bowel function and would ensure appropriate treatment for those found not to have CIPO, which turned out to be almost half.”
The national service provided by Great Ormond Street has reduced the time to diagnosis, and improved outcomes. Of the first 46 children seen, 24 were diagnosed with CIPO. The prognosis is better for those with stomas formed under the age of 5, 10 of whom have come off parenteral nutrition either partially or wholly. Another 22 were found not to have CIPO, nine of them avoiding surgery that might otherwise have been carried out. About 10% of the cases turned out to have fabricated or induced illness.
Intestinal failure team
Patients who suffer intestinal failure need parenteral feeding, which delivers nutrients intravenously to compensate for the failure of the normal digestive process. This can be done at home, once patients are trained in the technique. But in Wales in the 1990s such training was unavailable unless patients were willing to travel either to London or to Salford. A team at Cardiff and Vale Health Board, starting in 2004, commissioned a service for training in home parenteral nutrition for Welsh patients.
When the service started, there were 22 patients in Wales on home parenteral nutrition—now there are 106. “Training is vital because if you don’t use the full sterile technique you get fevers and have to be rushed into hospital,” says Barney Hawthorne, the consultant gastroenterologist who chaired the group responsible for commissioning the new service. “And each time a new line has to be put in, you run a risk of damage to the big veins.”
The scheme has been a success, with low rates of infection, an average of 0.43 catheter related infections per 1000 patient days. Patient satisfaction is high, with 97% pleased with the training they received, and costs are lower than when patients had to be sent to England for training.
Cite this as: BMJ 2015;350:h1639
The Gastroenterology Team of the Year award is sponsored by Takeda and Crohns and Colitis UK and The BMJ Awards are sponsored by MDDUS. The awards ceremony takes place on 6 May at the Park Plaza, Westminster Bridge. London. To find out more go to http://thebmjawards.bmj.com.