The purpose of this case study is to critically reflect on the endoscopic journey of a patient previously diagnosed with a pre-pyloric gastric ulcer unrelated to either helicobacter pylori infection or the use of nonsteroidal anti-inflammatory drugs (NSAIDs). In order to comply with the Nursing and Midwifery Code (NMC, 2015), Data Protection Bill (2017), and to preserve the patient's anonymity (ICO, 2012), the Patient will be referred to using the pseudonym of Carol. The case study will provide a critical analysis of that episode of care from the perspective of a trainee Clinical Endoscopist (CE). Formerly called non-medical endoscopists, CEs are registered healthcare professionals, like nurses, who are trained to do diagnostic endoscopic procedures safely (HEE, 2018). The trainee was under the direct supervision of a consultant endoscopist throughout this appointment.
Gastric ulcers, also referred to as stomach ulcers, are mucosal lesions that occur on the lining of the stomach (Whittle, 2008). They can also develop in the intestine, where they are called duodenal ulcers or, albeit rarely, in the lower oesophagus where they are called oesophageal ulcers (NIDDK, 2014). Collectively, these ulcerations are called peptic ulcer disease or PUD (Najim, 2011). Traditionally, peptic ulcers were thought to be caused by increased secretion of acid due to dietary factors and stress, but the discovery of the helicobacter pylori, a gram-negative bacterium, and use of NSAIDs in the late 20th century have changed this belief (Lanas and Chan, 2017). In a clinical review by Quan and Talley (2002), h.pylori infection is widely regarded as the most common culprit of PUD and in its absence, the disease is likely caused by NSAID use. In that same review, the authors mentioned that there exists a subset of peptic ulcers that are caused by neither h.pylori infection nor NSAIDs and these are called idiopathic ulcers. The patient discussed in this case study seems to have this kind of PUD.
According to the NHS Choices (2015), one in ten people can develop stomach ulcers during the course of their lives. PUD on the whole remains to be a common condition, but its reported incidence is decreasing (Sung, Kuipers, El-Serag, 2009). A population-based cohort study done in the United Kingdom revealed that the incident rate of uncomplicated peptic ulcer as 0.75 cases per 1,000-person years, declining from 1.1 to 0.52 cases per 1,000-years from the year 1997 to 2005 (Cai et al, 2009). There are several possible explanations for this downtrend, which include the discovery of Helicobacter pylori's role in gastroduodenal pathology and the subsequent development of eradication protocols, widespread use of acid suppression medicine like Proton Pump Inhibitors or PPIs, and more conscientious use of NSAIDs (Henderson, 2015). As would be expected, with the decline in the prevalence of h.pylori infection, the proportion of patients with peptic ulcer disease unrelated to h.pylori has risen (Chow and Sung, 2007). H.pylori-negative patients tend to have longer ulcer healing time, have a higher chance of recurrence, and worse dyspeptic symptoms (Sivri, 2002). They also tend to be older and have more frequent bleeding episodes during hospital admissions (Chow and Sung, 2007).
Stomach ulcers can be very serious and potentially life-threatening if they are not detected early (Groenen, 2009). The tests used to diagnose PUD include barium radiography and endoscopy, but the latter remains to be the gold standard as it allows not only the visualisation of the ulcer, but also check for and treat active bleeding immediately (Anand, 2017). Compared to barium radiography, endoscopy also has wider availability, higher sensitivity and specificity, and the added facility for biopsy (Meyer, 2017).
The patient, a woman in her late forties, attended a non-urgent follow-up oesophago-gastroduodenoscopy (OGD) appointment to check for gastric ulcer healing. She was seen two months prior at the endoscopy unit where a pre-pyloric ulcer has been diagnosed. Her initial OGD was an urgent inpatient referral to rule out the cause of anaemia which had iron and folic acid deficiency features. She did not have melena or haematemesis during that admission, but reported fatigue and dyspepsia. As per National Institute for Health and Care Excellence (NICE) guidelines (2013), patients with iron deficiency anaemia with dyspepsia, require an urgent referral for endoscopy. The surgeon who performed the urgent OGD saw a benign-looking ulcer.
Without a doubt, endoscopic biopsies are important for the diagnosis and treatment of ulcers and other gastrointestinal diseases (Peixoto et al, 2015). As per British Society of Gastroenterolgy (BSG) guidelines, biopsies were taken to exclude h. pylori infection as colonisation of the said bacteria causes not only to ulceration but also reduced iron uptake and increased iron loss (Goddard, 2011). According to the same guidelines, while non-invasive testing for h. pylori is preferred, rapid urease testing of biopsy specimens during initial gastroscopy can be an alternative approach, if appropriate. Although a rapid urease test is quick and cost-efficient, it is second only to histology in terms of sensitivity and specificity and can be inaccurate in patients using proton pump inhibitors or PPIs, which are acid suppressants, or antibiotics (Lee and Kim, 2015). More specifically, rapid urease tests can produce false negative results as PPIs affect the said bacteria's growth and urease activity (Siavoshi et al, 2015). As the patient was taking a PPI at the time of the test, the surgeon did a histology instead of a rapid urease test. There does not seem to be a standard as to how many biopsies to take from an ulcer (Gielisse and Kuyvenhoven, 2015), however, a prospective study done on American patients over a two-year period found that taking four samples significantly increases accurate cancer diagnosis (Graham et al, 1987). Gastric ulcers are linked with a considerable risk of malignancy at 6% and some can appear benign endoscopically, which highlights the need for taking biopsies during index endoscopy (Sellinger et al, 2016). It is widely accepted that IDA can also stem from malabsorption, so Goddard (2011) recommends screening for coeliac disease through small bowel biopsy if coeliac serology was positive or not yet carried out. No abnormalities were detected in either of Carol's gastric or duodenal biopsies. Patients who were diagnosed with gastric ulcer following an OGD need to come back in six to eight weeks for a repeat endoscopy to confirm healing and h. pylori testing, if appropriate (NICE, 2017). A repeat OGD after eight weeks has been arranged for Carol after her index gastroscopy.
The rationale behind follow-up endoscopy for patients with gastric ulceration is based on the premise that some gastric ulcers which appear benign endoscopically and histologically during index gastroscopy ultimately turn out to be malignant (Banerjee et al, 2010). However, opinion on whether it is appropriate to have repeat OGDs for patients found to have ulcers continue to be divided (Selinger et al, 2016). NICE guidelines (2014) recommend that ulcers be checked again in six to eight weeks after initiating treatment. In contrast, the American Society for Gastrointestinal Endoscopy or ASGE (2010) says that surveillance for gastric ulcers may not be necessary, and instead advices clinicians to consider patient history and demographics before arranging for a repeat test. Audits done in two large UK hospitals revealed a low yield of malignancies from follow-up gastroscopies of benign-looking ulcers (Cochrane et al, 2014; Todd et al, 2004).
OGD appointments tend to be brief as multiple patients are seen per list. To help plan lists, endoscopy units usually employ a points-based system, where a point is a unit of time (Valori, 2012). Allocating one point per fifteen-minute workload and having ten points per list are commonplace in UK hospitals, which ensures adequate time for changeovers between patients (NHS Improvement, 2012). Obtaining a patient's history aides clinicians in arriving at an accurate diagnosis and planning care, therefore it is prudent to allot sufficient time when doing this as rushing can lead to missing pertinent information and adversely affecting patient outcomes (Lloyd and Craig, 2007).
Eliciting patients' history begins with the review of their clinical record which allows the clinician to glean important background information and areas that are worth exploring prior to meeting them face to face (Bickley, Szilagyi, and Hoffman, 2017). (NEEDS TO BE DEVELOPED FURTHER)
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During consultation, Carol reported to the trainee clinical endoscopist, henceforth referred to as trainee, that she felt better overall compared to when she came in for her index gastroscopy, but that she was not symptom-free. She reported occasional right-sided abdominal discomfort, which occurred with food intake, or shortly after eating. She noted, however, that this has decreased in intensity and frequency from when she was last seen in the unit. Another persistent problem the patient reported was acid reflux that is often triggered whenever she bended over. She said this predates her first gastroscopy and has been on Omeprazole – a type of PPI, which is a medicine that suppresses acid secretion for her acid reflux. She denied having any food triggers, nocturnal symptoms, or swallowing difficulties associated with the reflux. As for bowel movements, she described them being more on the constipated side. Vakil (2010) reminds us though that symptoms are often a poor predictor of the presence of endoscopic lesions.
Upon reviewing her notes, the trainee also noted that she has also been diagnosed with ankylosing spondylitis or AS, which is a kind of arthritis affecting the spine causing pain and stiffness (Arthritis Research UK, 2015). Interestingly, a considerable proportion of AS sufferers, up to ten percent of them develop subclinical gut inflammation, which can manifest as stomach pain, ulcers, diarrhoea, and indigestion (Ciccia et al, 2016; Johnson, 2017). Orlando et al (2009) says that despite the association between gut inflammation and AS, the mechanism by which this occurs remain to be confirmed by rigorous scientific study, but suggests it is an interplay among NSAID-induced injury, microbial imbalance in the gut, and alterations of the innate immune responses. Carol has been taking Sulfasalazine 500 mg and co-codamol 15/500 mg. Sulfasalazine (azulfidine) is used to treat inflammatory rheumatic conditions and it belongs to a class of drugs called disease-modifying anti-rheumatic drugs or DMARDS, which are not painkillers but instead act by slowing down the disease to bring about pain and swelling relief (NASS, 2017). Unlike with NSAIDS, like Ibuprofen and Naproxen, DMARDS have fewer side effects and are not usually associated with peptic ulcer disease (American College of Rheumatology, 2017). Co-codamol is a compound analgesic composed of codeine phosphate – an opioid, and paracetamol, and while this medicine lists stomach pain as a side effect, it is usually due to pancreatic inflammation, and not stomach ulcers (BNF, 2017).
The patient is likewise on citalopram 40 mg. This medicine belongs to a class of antidepressants called selective serotonin reuptake inhibitor or SSRI (BNF, 2017), and are preferred over other antidepressants because they are considered safer and have fewer side effects (de Abajo et al, 2016). A population-based case-control study in Denmark by Dall et al (2009) which looked at more than 3,500 cases of patients with upper gastrointestinal bleeding or UGIB from 1995 to 2006 found that SSRIs are associated with a moderately elevated risk for gastric bleeding but concedes that there are no studies yet that show they have a direct ulcerogenic effect. Dall et al (2009) further asserts that it is possible that the relationship between SSRIs and gastric bleeding may be exaggerated due to the associated increased healthcare-seeking behavior among depressed patients. Co-therapy with PPI can be used to mitigate propensity of SSRIs to cause UGIB (Targownik et al, 2009).
The patient is overweight with a body mass index (BMI) of 29.34 kg/m2 (WHO, 2017). While excess weight's role in predisposing patients to gastro-oesophageal reflux disease and gastric cancer has been well-studied, there seems to be limited data correlating it with PUD (Boylan et al, 2014). The exact mechanism of how obese individuals are more susceptible to developing PUD needs to be studied further, but Pietrzykowska (2014) suggested alteration in gut flora, reduced integrity in the gut epithelium, and increased production of inflammatory particles by fat cells as possible precipitating factors. The patient is also a smoker, with a 30 pack-year smoking history. Smoking is a widely accepted risk for gastric ulcers and may make treatment less effective (NHS, 2015). According to Meyer (2017), 23% of all peptic ulcers are associated with smoking. Maity et al (2003) believes increased gastric acid secretion and bile salt reflux, decreased production of gastro-protective prostaglandin, and impaired angiogenesis and cell renewal due to nicotine.
Upper gastrointestinal endoscopy is a widely performed procedure, but many patients dislike or are wary of it because of discomfort (Sachdeva et al, 2010). BSG (2017) recognises that some patients will require sedation or pharyngeal anaesthesia to tolerate the test. Pharyngeal anaesthesia works by reducing the gag reflux with the use of lidocaine or lignocaine, which is typically administered as an aerosol spray, or less commonly with viscous solution or lozenge (Mogensen et al, 2012). It can be administered on its own or as an adjunct to sedation where it is believed to improve the ease of endoscopy and patient tolerance of the test (Evans et al, 2006). Lidocaine is widely used but care should be taken in administering it as it can act as a respiratory depressant when given in excess (EMC, 2017). Hypotension, bradycardia, and even cardiac arrest can occur if patients receive more than 200 mg or 20 sprays prior to a procedure (BNF, 2017). Many people dislike throat sprays because of the initial irritating or burning sensation that accompanies anaesthesia, the anaesthetic feeling itself, and the unpleasant aftertaste (Shaoul, Higaze, and Lavy, 2006). Sedation in endoscopy is done to allay patient anxiety and discomfort, improve the outcome of the examination, and produce an amnesic effect (ASGE, 2018; Canard et al, 2011). Sedation practices differ in various countries depending on health system regulations and local circumstances, but in the United Kingdom, midazolam – a benzodiazepine, is the most commonly used sedative, and patients can receive up to 5 mg of the said drug as an intravenous injection (Triantafillidis et al, 2013). Cardiovascular complications like hypotension, cardiac arrhythmias, or ischemia, as well as respiratory complications such as hypoxia, airway obstruction, and aspiration of gastric contents into the lungs can occur as a result of sedation during an OGD, but these are usually transient, mild and mostly preventable (Amornyotin, 2013).
As with any procedure, patients should provide informed consent for the test to be performed through a process which includes a discussion of benefits, risks, limitations, as well as possible alternatives (NICE, 2012; NHS Constitution, 2015). Everett et al (2016) highlighted that owing to the invasive nature and inherent risks of endoscopic procedures of the gastrointestinal tract, consent should be obtained, and in written form, except in emergencies. Beg et al (2017) emphasises that although consent taking for high-volume, low risk procedures like OGD is sometimes delegated to appropriately trained non-endoscopists, it is still the endoscopist performing the test who is ultimately accountable for ascertaining the appropriateness and completeness of the consent. In this case, the trainee obtained permission from the patient while being supervised by a senior endoscopist. To obtain Carol's consent, the trainee used the aide-memoire EMBRACE, which stands for Explanation of the proposed procedure, Motive for doing the procedure, Benefits of the procedure to the patient, Risks, Alternatives, Complications, and Effects of the Procedure (Bell, 2004). As this is a repeat OGD for Carol, rather than give an explanation of the test and its motive, the trainee opted to check her understanding what the test is and why it needs to be done (Hall et al, 2010). The patient confirmed that she will have an OGD to check for ulcer healing. Despite being a follow-up test, it is advisable for clinicians to inform patients of any material or significant complications or unavoidable risks, even if minor, as well as the risks of not having the test (DOH, 2009). The trainee informed Carol that although having an x-ray test is an available alternative, OGD has the benefit of being more accurate and useful as tissue samples can be taken for analysis (NIDDK, 2014). The patient was reminded that overall, an OGD is a safe test, and the risks of serious complications are small, especially when it is just used to diagnose a condition where it has less than 1 in 1,000 chances of causing complications (NHS Choices, 2015). Some of the iatrogenic complications associated with OGDs include bleeding, perforation, and cardiovascular and respiratory effects brought about by sedation (Cotton, 2008). Pre-assessment to check for significant co-morbidities that increase likelihood of sedation-related adverse events must be done prior to scoping (AOMRC, 2013). The American Society of Anaesthesiologist (ASA) physical status classification system is a useful risk stratification tool in endoscopy, with patients who have higher ASA class, 3 or greater, being at higher risk for complications (Enestvedt et al, 2013). As Carol is a smoker, overweight and has mild systemic disease which does not substantially limit her activities, she is given the score of ASA 2 (ASA, 2014). Assessment for fitness to undergo a diagnostic OGD should also include checking for antiplatelet or anticoagulation therapy status (Beg et al, 2017). Carol was not on any blood thinning medications.
The patient opted to have both pharyngeal anaesthesia and sedation for this test as she found her index gastroscopy difficult with just the throat spray. In a joint statement of the BSG and the Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland (2017) regarding using pharyngeal anaesthesia with intravenous sedation, they highlighted that there is currently insufficient evidence on the heightened risk of aspiration pneumonia and other complications post-gastroscopy with this combination, so endoscopists are advised to use this combination prudently especially in at-risk groups, like the elderly. Due to risks of aspiration with the dampened airway-protective reflexes, patients who opt to have sedation should have fasted for a specific period of time, six hours for meals and 2 hours for liquids, to allow for gastric emptying prior to the test (ASGE Standards of Practice Committee, 2018; Callaghan et al, 2016). The patient confirmed that she has fasted from the night before. As the sedative will need time to wear off, patients cannot drive for twenty-four hours and will need someone to look after them overnight (NIDDK, 2017; Chiu et al, 2009). The trainee confirmed that escort arrangements have been in place for Carol. In view of Carol's continued dyspeptic symptoms and current NICE guidelines (2014) on peptic ulcer management, the trainee, senior endoscopist and the patient mutually agreed to proceed with the planned follow-up investigation.
Matharoo et al (2015) states that mistakes in endoscopy can happen, but because these are usually inconsequential, they often are left unrectified. Nonetheless, they assert that a succession of minor mistakes can ultimately prove fatal and steps should be taken to improve patient safety. Team briefing and debriefing, and a surgical safety checklist which are done pre- and post-procedure can help improve patient safety (WHO, 2008; NPSA, 2010). Checklists have been implemented in other areas of medicine and surgery, and the body of evidence that confirms their usefulness in reducing errors, morbidity, and mortality continues to expand (Haynes et al, 2009). While professional medical and surgical societies in the UK and Ireland advocate for the adoption of this tool in the endoscopy setting, they also acknowledge that there is no single endoscopy checklist used nationally (Beg et al, 2017). Team briefing and debriefing, apart from improving patient safety, are helpful in ensuring that lists run smoothly without delays (NPSA, 2010). During the team brief for this OGD session, list and case details were shared with the team which included relevant clinical information about the patient, equipment requirements, anticipated difficulties, and staff responsibilities (NHS England, 2015). A local safety checklist developed according to WHO recommendations (2008) was used before and after the procedure. Immediately before the procedure started, a phase commonly referred to as Time Out, the patient was introduced to the team and requested to confirm her identity by asking her to say her name and date of birth while the trainee and a nurse checked these against the reporting system screen and patient's notes, respectively (Matharoo et al, 2014). Following the World Alliance for Patient Safety guidelines (2008) on checklist implementation, confirmation of consent, patient preference for sedation, relevant comorbidities, anticoagulation status, and readiness of equipment and accessories, specifically biopsy forceps, were also checked at time out. Carol was not on any anticoagulation, and the team were in agreement that it was safe to proceed.
Carol was given four sprays of xylocaine 10 mg to the pharyngeal area and midazolam 3.0 mgs. When patients require a sedative, endoscopists titrate the drug to achieve a safe target state called conscious sedation where the patient's ventilation is adequate, the cardiovascular function is stable, and the patient maintains verbal responsiveness (AOMRC, 2013). As per local Patient Group Directions (PGD), practitioners can give 1.0-2.0 mgs two minutes pre-procedure and can add aliquots of 0.5-1.0 mg every two minutes if required. Following AOMRC guidelines (2013) and local sedation protocols, the patient was hooked to pulse oximetry and blood pressure monitor and received nasal administration of oxygen of 2 litres per minute. ECG monitoring is not required for patients who are young and have no history of cardiovascular problems (NCEPOD, 2014). It is also nonessential during sedated OGD as long as verbal contact is maintained (AOMRC, 2013).
Gastroscopies are now performed using high-definition video endoscopy systems, which enable the capturing of images and review at a later date (Canard et al, 2011). One can surmise that having a record of these images can be useful in patients like Carol, as it allows clinicians to check if the ulcers have healed, stayed the same, or worsened since they were last seen. The European Society of Gastrointestinal Endoscopy or ESGE (2001), advocates taking images of detected lesions and anatomical stations, namely the upper oesophagus, gastro-oesophageal junction, the fundus in retroflexion, the gastric body, the incisura in retroflexion, the antral region, duodenal bulb, and the second part of the duodenum. To accurately identify lesions like ulcers during endoscopy, it is important to have mucosal visualisation which can be achieved through proactive lens cleaning, sufficient air insufflation, suctioning gastric residuals, and flushing the mucosa (Beg et al, 2017). The trainee's view was initially obscured by intraluminal foam which was dissipated using a mixture of sterile water and defoaming agent, specifically simethicone, flushed through the accessory channel of the endoscope (BSG and AUGIS, 2017).
No active ulceration was seen during the follow-up gastroscopy, but a white scar measuring less than 3 mm was seen which is consistent with ulcer healing (Si, Cao, and Wu, 2005). Features suggestive of malignancy like elevated irregular borders around the ulcer and abnormal adjacent mucosal folds were absent as well (ASGE, 2010). According to a clinical audit done by Selinger et al (2016) on more than 400 patients over a 20-month period, there is a low cancer yield in follow-up OGDs when biopsies from the index gastroscopy were benign. As the ulcer during Carol's subsequent test appeared to be healing, no repeat biopsies were taken.
As part of the safety checklist, the trainee checked the histological samples with a nurse to make sure that they were labelled correctly, and that the report was complete and accurate before the patient left the room (Matharoo et al, 2014). No further investigations were arranged for Carol, but she will be seen in clinic depending on her biopsy results and to check how she is.
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Gastric ulcer is traditionally linked to h. pylori infection or recent exposure to NSAIDs (Lanas and Chan, 2017), so it is interesting to find a patient whose stomach ulcerations are not related to either. However, in view of the patient's risk factors, it is likely that her ulcers are brought about by a combination of lifestyle and drug-related factors. Surreptitious NSAID use is also a possibility (Gisbert and Calvet, 2009), although in hindsight, this was not sufficiently explored by the trainee. Most gastric ulcers will go away with treatment and time (Si, Cao and Wu, 2005). The appropriateness of surveillance OGDs for benign-looking ulcers will continue to be debated because of their low cancer yield, but clinicians can use risk stratification to identify which patients to rescope (Selinger et al, 2016).