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2012

HOSPITAL TUANKU JAAFAR SEREMBAN NEGERI SEMBILAN

OPEN ACCESS ENDOSCOPE MALAYSIA


Reducing waiting time for endoscopy Detecting Upper GI cancers early

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 Hepatology Academy of Medicine Malaysia Dr. Jasiah Zakaria Head of Surgery Department Hospital Tuanku Jaafar Seremban Negeri Sembilan Dr. Dharmendran Ratnasingam Surgeon Hospital Tuanku Jaafar Seremban Negeri Sembilan Dr. Azrina Abu Bakar Surgeon Hospital Tuanku Jaafar Seremban Negeri Sembilan Dr. Chik Ian Hospital Tuanku Jaafar Seremban Negeri Sembilan Dr Shirley Tang Hospital Tuanku Jaafar Seremban Negeri Sembilan

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Mr. Chu Teck Hoe Hospital Tuanku Jaafar Seremban Negeri Sembilan

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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 service does 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 o o o . Elevated (IIa) Flat (IIb) Depressed (IIc) Excavated (type III)

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Description of a lesion in the stomach

1. 2. 3. 4. 5.

Site size shape margin floor

Classification of macroscopic subtype of early gastric cancers [Adapted from Japanese Classification of Gastric Carcinoma - 2nd English Edition

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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]

*Taken from ESGE recommendation for quality control in gastrointestinal endoscopy

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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 Endoscope Service in Malaysia - A move towards specialized 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 by Department 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 and disorders 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 for symptoms called gastritis. The time delay from the first appearance of symptoms to the time of endoscope was estimated to about 8 months Using this system we are hoping to filter and shorten the referral process of endoscopy and 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. QUADRANT A: AGE Score < 40 yrs 40 49 yrs 50 yrs Sector Total QUADRANT C: MODIFIED ALARM SYMPTOMS Score Anaemia 3 Epigastric Mass / 3 Fullness Persistent vomiting 3 Significant LOW Dysphagia Early satiety / eating less over a period of time Sector Total 3 5 3 2 3 5 QUADRANT B: RECENT UGIB (including melena) Score Occurred more than 1 year ago Occurred less than 1 year 1 5

Sector Total QUADRANT D: DYSPEPSIA Score 1 3 5

Intermittent, more than 1 year Intermittent, less than 1 year Persistent for MORE than 2 weeks

Sector Total

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

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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 flow 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 follow-up guide)

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 Parkin DM. Global cancer statistics in the year 2000. Lancet Oncol 2001; 2:533543. BC Cancer Agency, Oncology Nutrition November, 2004 Revised September 2005 National cancer registry 2003-2006. 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. 1. 2. 3. 4.

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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 the upper 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 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 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 ubatubatan 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 SPRAY INTRAVENOUS SEDATION


24 BIOPSY 2-3

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Detect STOMACH CANCERS early.

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MARKs Quadrant
QUADRANT A: DYSPEPSIA Score Intermittent, more than 1 year Intermittent, less than 1 year Persistent for 2 weeks 1 Occurred more than 1 year ago QUADRANT B:UGIB(including melena) Score 1

3 5

Occurred less than 1 year

QUADRANT C: Modified ALARM Symptoms Score Anaemia Epigastric Mass / Fullness Persistent vomiting [>2wks] Significant LOW Dysphagia Early satiety
Definitions

QUADRANT D: AGE Score Less than 40 yrs 40 49 yrs 50 yrs Total score: [a score of 10 and above will warrant an urgent ODGS] 2 3 5

3 3 3 3 5 3

1. Dyspepsia - is defined as pain or discomfort centered in the upper abdomen (i.e. in or around the 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.
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2. Melena The 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

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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Hospital _______________
OPEN ACCESS Endoscope service referral form
To 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

OPEN ACCESS Endoscope service


AFFIX NAME LABEL HERE
(if none, enter patient name, address, insurer)

Name: NRIC: Tel:

Age: Race:

endoscope service, Department , hospital *For referring doctors only Please circle the appropriate scores below and refer to us

Appointment date:
Important notice Open Access endoscopic service is fast track endoscope referral 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 be hazardous 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 for patients and family memebers to read after they are given this form.

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


QUADRANT A: DYSPEPSIA Intermittent, more than 1 year Intermittent, less than 1 year Persistent for 2 weeks Score 1 3 5 QUADRANT D: AGE Score < 40 yrs 2 40 49 yrs 3 50 yrs 5 Total score: QUADRANT B: RECENT UGIB (including melena) Occurred more than 1 year ago Occurred less than 1 year Score 1 5

QUADRANT C: Modified ALARM Symptoms Score Anaemia 3 Epigastric Mass / Fullness 3 Persistent vomiting 3 [>2wks] Significant LOW 3 Dysphagia 5 Early satiety / eating less 3 over a period of time

*Patients with score of 10 and above will be scoped within __ weeks Referring doctor: . Name:__________________________ Phone: Fax:

Medical history Medical illness:.. Drug allergies: NO YES Is the patient on clopidogel NO YES Is the patient on warfarin? NO YES Is the patient on heparin? NO YES Has patient been instructed to stop warfarin 3-5 days prior to the procedure: NO YES NA Current medications: . * If the patient has any medical illness or condition that may complicate the endoscope procedure; kindly inform the endoscope centre.

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 membantu doktor 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 ubatubatan 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 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 ubat sedatif atau komplikasi jantung atau jangkitan paru-paru. Walaupun komplikasi selepas atas endoskopi adalah sangat jarang berlaku, ia adalah penting untuk mengenal pasti tandatanda 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 doctors find out the cause of bleeding from the upper gastrointestinal tract. 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. 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 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 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 ?

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blood thinner ---lidocane spray Intravenous sedation 24 biopsy

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