Barking Havering and

RedbridgeUniversity Hospitals NHS

Trust (BHRUT)

Endoscopy Induction Pack

May 2018

This document provides guidance for trainees and independent

endoscopists commencing at BHRUT.

Number: N/A Version No: 1

Approved by (name): Governance Lead for Date:16/11/2017 (Version 1)
Gastroenterology
On behalf of (Committee/Group): Combined Gastroenterology Quality &
Safety and Endoscopy User Group
Name & Title of originator/author: Dr SujonSamanta, Endoscopy Trainee
Lead
Date originally issued: November 2017 Review Date: November
2019
Contents

1) Checklist
2) Endoscopy Staff Contact Numbers
3) Welcome
4) Endoscopy Training
5) Arranging Endoscopic procedures
6) Local Clinical Guidelines
7) National Guidelines
8) Endoscopy Referral Pathways
9) Tips for Best Practice
10) Further Reading
Checklist (for all new endoscopists)

BHRUT Induction

Endoscopy Induction Pack

Endoscopy Software (Scorpio) Access

Access to local endoscopy policies

Awareness of relevant national endoscopy

policies

(additional for new trainees)

Completion of Baseline Endoscopy

Questionnaire

JETS Registration to BHRUT

Meeting endoscopy training mentor and

have baseline appraisal
Endoscopy Staff Contact Numbers
Name Position Contact Details
MANAGEMENT
Amani Specialty Manager amani.haaris@bhrhospitals.nhs.uk / 6728
Haaris
Kerry Service Manager kerry.chapman@bhrhospitals.nhs.uk / 6162
Chapman
Charlie Support Manager charlie.smith@bhrhospitals.nhs.uk / 3361
Smith
Lisa Admissions Lead lisa.o’hanlon@bhrhospitals.nhs.uk / 3361
O’Hanlon
KING GEORGE HOSPITAL
Juniper Endoscopy Reception 8300
Juniper Endoscopy Ward 8561
Jill Hayfield Admissions Officer jill.hayfield@bhrhospitals.nhs.uk / 8371
Gill Old Admissions Officer gill.old@bhrhospitals.nhs.uk / 8371
Jane Hayes Upper GI MDT jane.hayes@bhrhospitals.nhs.uk
Marjorie Lower GI MDT marjorie.robertson@bhrhospitals.nhs.uk
Robertson
QUEENS HOSPITAL
Clinical Diagnostic Unit Reception 3364
Clinical Diagnostic Unit Ward 3381 / 3374
Lynn Admissions Officer lynn.griffiths@bhrhospitals.nhs.uk / 3370
Griffiths
James Admissions Officer james.biggs@bhrhospitals.nhs.uk / 3372
Biggs
Vernessa Admissions Officer vernessa.toussaint@bhrhospitals.nhs.uk / 2394
Toussaint
Emma Admissions Officer emma.parkins@bhrhospitals.nhs.uk / 3373
Parkins
Simon Admissions Officer simon.dawes@bhrhospitals.nhs.uk / 3379
Dawes
Carolyn Upper GI MDT carolyn.fidler@bhrhospitals.nhs.uk / 3878
Fidler
Karen Upper GI MDT karen.freestone@bhrhospitals.nhs.uk 3878
Freestone
Caroline Lower GI MDT caroline.bruce@bhrhospitals.nhs.uk / 3726
Bruce
Eleanor Lower GI MDT eleanor.flack@bhrhospitals.nhs.uk / 3726
Flack
Welcome

This document is for all new GI endoscopists, whether as a trainee or

independent practitioner, so that you can get a head start in the
department.

BHRUT comprises two sites with dedicated GI endoscopy units,

Clinical Diagnostic Unit (CDU) at Queens Hospital (QH) and Juniper
Ward at King George Hospital (KGH). Both are outpatient day units
proving six endoscopy rooms with four at CDU and two on Juniper
Ward.

In addition to GI endoscopy, bronchoscopy lists are also performed.

BHRUT being one of the busiest NHS trusts in Greater London

performs over 18,000 GI endoscopy procedures per year. This makes
it ideal for providing a rich environment for trainees in GI endoscopy.

BHRUT offers advanced endoscopy training (ERCP, EUS, stenting,

balloon dilatation, PEG, capsule Endoscopy etc.). Trainees with
appropriate training objectives or competencies will be offered access
to such training.

We are a national screening centre for the Bowel Cancer Screening

Programme including Bowel Scope.

We hope that your time with us is an enjoyable and educationally

rewarding one.

Best wishes

DrSujonSamanta Training Lead for GI Endoscopy

DrYaser El Gazzar Clinical Lead for GI Endoscopy

DrPremchand Education Lead for Gastroenterology

Endoscopy Training

ON COMMENCEMENT OF THE TRAINING POST

As a trainee in GI endoscopy you will be provided with an endoscopy
training mentor. Where possible a mentor will be identified based on
your training needs as identified from completion of a baseline entry
questionnaire.

It is expected that you will meet with your mentor and record a
baseline endoscopy appraisal on JETS to formalize training
objectives around knowledge, skills, attitude and judgement.For those
of you previously signed off as competent, it is expected that your first
few procedures or lists will be supervised with DOPS completed on
JETS.

You will be categorized by level of competency for different

procedures in GI endoscopy. A list of trainees and their competencies
is listed in each endoscopy room. You should not perform an
inappropriate unsupervised procedure. In such an event it is expected
that an incident report is completed for investigation.

We expect you to undergo regular reviews with your trainer / mentor

including a mid-placement appraisal documented on JETS. This is to
allow new goals to be set and so that we can adjust to meet your
needs.

INDUCTION FOR NEW TRAINEES

The purpose of induction is to provide an overview of the layout ofthe
BHRUT endoscopy units as well as familiarization of BHRUT policy
on matters relevant to GI endoscopy.

JETS
As an endoscopytrainee at BHRUT you are expected to use JETS e-
portfolio to collect evidence of tyourraining progression.This will be
required for JAG certification in GI endoscopy.We would suggest
having the aim of completing one formative DOPS or DOPyS on
JETS per training list. Providing feedback on your learning to your
trainer via JETs is expected. The feedback is anonymous and will
allow us to be better trainers.JAG summative assessments should be
performed on completion of training for each procedure.

COURSES
Please be organized and book relevant courses within the first three
months of your endoscopy training. We willencourage you to attend
external JAG accredited courses and will support you regarding this.
All new trainees in GI endoscopy would be expected to attend a basic
skills course relevant to their procedural training in their first year.

TRAINING LIST ALLOCATION

We aim to provide trainees with 1-2 dedicated endoscopy training
lists per week. For trainees particularly in their early stages,yourlists
should be limited to 8 points.One of the weekly training lists will be
expected to be with your endoscopy training mentor.

Most other lists are service lists and, while trainees are encouraged
to attend, do not feel put out if time considerations mean handing
over to the supervising consultant when a difficult case is
encountered. Please respect the finishing time of lists. You may not
mind finishing late but the endoscopy staff might. There are some
lists where training is not permitted such as BCSP and Bowel Scope
lists unless accepted for examination.

We will provide fixed weekly training lists to aid continuity of tearning.

However, given the requirement for on-call, other service
commitments, external training and annual leave it is inevitable that
you will not be able to access all allocated training lists. We expect
you to identify such dates in advance and either offer the list to
another trainee or inform a member of the endoscopy administration
team allocated the role of co-ordinating training lists.It may be that
this will be converted to a service list.

Changes to training lists should be arranged at least six weeks in

advance.
Please contact the training lead for GI endoscopy if you are not
getting access to training lists or if there is an issue with the quality of
the training environment such as the size of the lists.

ACCESS TO EMERGENCY AND URGENT ENDOSCOPY

We hope and expect you to get access to numerous urgent and
emergency therapeutic endoscopies. By definition, such events are
unplanned and are often slotted into the beginning / end of lists
including those allocated to training. However, please be proactive
and liaise with senior endoscopy nursing staff who will often know of
referrals in advance.
I
If you are a gastroenterology trainee at Queens Hospital youmay
carry the referrals DECT phone (6267 or 6367) during normal working
hours. Similarly, a trainee at King George Hospital will carry a pager
for referrals. This will allow you the opportunity to know of unplanned
therapeutic endoscopies in advance and become involved.

SIMULATOR TRAINING
We are pleased to have possession of an endoscopy training box
simulator for lower GI endoscopy. This is based on Juniper Ward
(KGH) with access potentially on Tuesday mornings although this can
only be granted under supervision. Please contact Dr Samanta or
Israel Omojola if you are interested.

SCOPE GUIDE
All endoscopy rooms on CDU (QH) have scope guides which will be
helpful for colonoscopy training particularly with regards to loop
recognition and formation. Trainees will still be expected to learn
without a scope guide when unavailable. KGH currently does not
have scope guides although this is expected to change in the near
future.

Arranging Endoscopic procedures

From the outpatient clinic, endoscopic procedures are arranged by

completing a paper request form and handing it to the patient to take
to endoscopy reception. Alternatively, forms can be collection by an
outpatient nurse usually at the end of clinic to take to endoscopy. We
are currently able to organize for most routine investigations to occur
within 4-6 weeks. Please note that patientsare notroutinely given an
appointment date and time there and then.

It is important to indicate prioritization. Please do not mark forms as

‘urgent’ or ‘2 week wait’ unless this is true. If there is some other
indication for expediting a case please indicate this. It is important to
indicate on the referral if the patient has any special requirements eg:
 Frail elderly who may need inpatient bowel preparation prior
tocolonoscopy
 Unstable diabetics who may need admission prior to procedure
 Anticoagulated patients needing therapeutic procedures
 Ileoscopy referrals who may not need preparation.

For colonoscopy, there is a legal requirement to prescribe bowel

preparation. There is a second sheet attached to the colonoscopy
request form for prescribing which provides relevant
contraindications.

For inpatients, an inpatient endoscopy request form must be

completed and delivered to the endoscopy unit at Queens and to
endoscopy admissions office at KGH. If urgent, then the doctor
bringing the form to the unit must speak and agree it with the
endoscopist on whose list the patient is added. Please note that there
is a dedicated form for GI bleeds which includes a Blatchford Score
calculation to allow for effective prioritization.

We provide a 24 hour, 7 day a week emergency GI endoscopy

service. There should be an on-call endoscopist available from 5pm
to 8am weekdays and throughout the weekend contactable via
switchboard.
Local Clinical Guidelines

There are a number of clinical guidelines available on the intranet and

in paper form in the endoscopy suites. These include:

1. Safety in sedation
2. Antibiotic prophylaxis in endoscopy
3. Anticoagulants and antiplatelet therapies in endoscopy
4. The diabetic patient
5. Cardiac disease in endoscopy
6. Respiratory disease in endoscopy
7. Gastrointestinal haemorrhage and endoscopy
8. Withdrawal of consent

Consent
Consent must be obtained before the patients reach the endoscopy
procedure room. In line with trust policies, the following statements
need to be considered when obtaining consent:

 All adults are presumed to have capacity unless proved otherwise.

Consequently informed consent is essential before examination or
treatment.

 There is a legal right to refuse treatment and no reason need be

given

 The only exception to this is treatment for a mental disorder where

the patient is detained under the Mental Health Act 1983.

 Mental Capacity Act 2005. This Act applies to any adult who lacks
capacity. The principals include the need for the attending doctor
to:

1. Assess capacity at the time a particular decision needs to be

made. If any doubt about capacity remains, seek advice from
nursing staff, relatives who know the patient well or other
colleagues with relevant specialist expertise e.g.
Psychiatrists. Under the Act, a person is regarded as being
 unable to make a decision if, at the time the decision needs
to be made, he or she fails one or more parts of this test:
 To understand the information relevant to the decision
 To retain the information relevant to the decision
 To use or weigh the information, or
 To communicate the decision (by any means)

2. Treatment is then provided according to the best interest of

the patient. The following principles should be borne in mind
when deciding the best interest of the patient:

 The doctor must ensure that the decision is the least

restrictive of that individual’s fundamental rights or
freedoms.
 The person’s past and present wishes and feelings,
including any relevant written statement made when she
or he had capacity are taken into account – this would
include general statements of wishes or ‘living wills’ His or
her beliefs or values where they would have an impact on
the decision.
 A crucial part of any best interests judgment will involve a
discussion with those close to the individual, including
family, friends or carers, where it is practical or
appropriate to do so.
 If a patient does not have any next of kin or close friends
with whom the best interest decision can be discussed,
then an Independent Mental Capacity Advocate is
required. To make a referral for an IMCA please contact
the external agency charged with this – HUBB Tel 0208
590 2666.
http://aglovale/assets/pdfs/further_cats/policymentalhealth
.pdf
Standard consent document should be used:

Form 1 - Competent adults 18 years and above

Form 2 - Parental consent for a child or young person under 18;

patient consent by a young person aged 16 or 17 years or by a child
under 16.
Form 3 - Where the patient is expected to be fully conscious
throughout the procedure and knowingly general anaesthetic is
anticipated.

Form 4 - Adults who are unable to consent to investigation or

treatment. This must be completed by the medical team looking after
the patient and before arriving in the Unit. It will be further
countersigned by the endoscopist.

Form 5 - Adult patients to include Jehovah Witnesses (refusing the

use of blood transfusion or blood products)

National Guidelines
Please be aware that there are a number of important national
guidelines relevant to safe and best practice in GI endoscopy. Many
have been developed by the British Society of Gastroenterology
(BSG).

Sedation
The BSG have produced guidelines for the safe use of sedation for
endoscopy. The key safety points are:
1. In young fit patients
a. 5mgs midazolam should usually be the maximum dose given
b. Doses in excess of 50mgs pethidine or 100mcg fentanyl are rarely
required

2. In elderly patients
a. less sedation is required
b. doses of 1-2mgs midazolam should be given initially with a
sensible pause to observe effect. In general, elderly patients should
not be receiving doses of midazolam in excess of 2.5mgs
c. doses in excess of 25mgs pethidine or 50mcgs fentanyl are rarely
required

In all patients, the opioid should be given first and the effect observed
before giving midazolam.
Antibiotic Prophylaxis in Endoscopy
BSG last produced guidelines in 2009 with the recommendation that
routine antibiotic prophylaxis is only indicated in the following
circumstances:
 Percutaneous endoscopic gastrostomy (and equivalent
procedures)
 ERCP (if pancreatic pseudocyst, or if unlikely/unable to achieve
complete biliary decompression)
 Endoscopic ultrasound-guided drainage of pancreatic
pseudocyst

If a patient requires prophylaxis, the following antibiotic regimes

should be used:

Penicillin NON-allergic (adults)

1g amoxicillin/ampicillin iv
1.5mg/kg (80-120mgs) gentamicin iv (over 2-3mins)

Penicillin ALLERGIC (adults)

400mgs teicoplanin iv
1.5mg/kg (80-120mgs) gentamicin iv (over 2-3mins)

NICE has also considered this issue and has come out against the
use of antibiotic prophylaxis to prevent endocarditis during
gastrointestinal endoscopy.

Endoscopy Referral Pathways

Please note that there are a variety of endoscopy referral pathways

which include:

1) 2WW Suspected Cancer Referral

2) Direct Access Gastroscopy (via GP)
3) Straight To Test Colonoscopy (via GP)
Tips for Best Practice

Barrett’s Oesophagus
Please use Prague Criteria to define Barrett’s. If using the non-
targetted approach to sampling the oesophageal mucosa, quadrantic
biopsies should be taken every 2cms ABOVE the gastro-
oesophageal junction, only in those areas of the oesophagus where
there are changes consistent with Barrett’s oesophagus/columnar
lined oesophagus (CLO). This method is known as the Seattle
Protocol.

Dysphagia
All patients in whom no endoscopic cause for dysphagia is found
should have at least FOURRANDOM OESOPHAGEAL BIOPSIES
taken, in addition to appropriate sampling of other abnormalities if
present. The endoscopist must include the differential diagnosis of
EOSINOPHILIC OESOPHAGITIS on the histology request form.

Peptic ulcer disease – GU

1. If the ulcer is NOT pre-pyloric (low cancer risk), biopsies should
be taken from the edge of the ulcer (+/- brushings).
2. 2 biopsies should be taken for Helicobacter pylori from the
gastric antrum (1 biopsy) and body (1 biopsy) and sent to
microbiology if a CLO test is not performed

NB – the patient should have a repeat gastroscopy after 6 weeks of

treatment to ensure healing of ALL non-pre-pyloric gastric ulcers.

Peptic ulcer disease – DU

1. 2 biopsies should be taken for Helicobacter pylori from the
gastric antrum (1 biopsy) and body (1 biopsy) and sent to
microbiology if a CLO test is not performed

Fe defanaemia/positive TTG
In all patients in whom coeliac disease is suspected, 4 duodenal
biopsies should be taken including one from the duodenal bulb.

Suspected GI malignancy
Any lesion that has a malignant appearance should be sampled with
6-8 biopsies. Consider the use of jumbo biopsy forceps. Write
“URGENT” on the histology form or “2WW” if the patient has been
referred via the 2 week wait system. Also see “tattooing” below.
Surveillance for CRC in patients with colonic IBD
Please consider the use of chromoendoscopy to enhance
dysplasia detection. I recommend the use of 0.2% indigocarmine
on withdrawal with the colon divided into five segments with re-
inspection of each segment after spraying dye. Take biopsies of
abnormal mucosal areas identified using chromoendoscopy.

Alternatively take four biopsies should be taken every 10cms

during withdrawal.

Unexplained diarrhoea
Even in the presence of normal looking colonic mucosa, biopsies
should be taken from the right colon, left colon and rectum to rule
out microscopic colitis.

Tattooing
Tattooing is recommended for the following situations:
1. Any high risk polyp or suspected malignant polyp
2. Any large (generally > 10mm), flat polyps that are removed via
endoscopic mucosal resection (NB use Indigo carmine to raise the
polyp)
3. Any smaller lesions that are not removed at the index
colonoscopy (rare as all lesions should be dealt with at the index
colonoscopy)

At least 2 sites should be tattooed.

Please use the “saline test injection” technique to define the

submucosal plane to prevent dye infiltration of the
muscularispropria or spillage into the peritoneum. One method is
to first inject saline solution into the submucosa to ensure
formation of a submucosal bleb.The syringe with saline solution is
then replaced by a syringe containing India ink / SPOT while the
needle is still in the submucosal plane.
Further Reading
Antibiotic prophylaxis in gastrointestinal endoscopy (2009)
Allison MC, Sandoe JAT, Tighe R, Simpson IA, Hall RJ, Elliott
TSJ,

BSG position statement on serrated polyps in the colon and

rectum

BSG-ACPGBI guidelines for the management of large non-

pedunculated colorectal polyps

Endoscopy in patients on antiplatelet or anticoagulant therapy,

including direct oral anticoagulants

ESGE Guidelines on Small-Bowel Capsule Endoscopy (BSG

Endorsed)

Guideline for obtaining valid consent for gastrointestinal

endoscopy procedures

Prescription and administration of oral bowel-cleansing agents

Quality standards in upper gastrointestinal endoscopy: a position

statement of the BSG and AUGIS

The Management of Gastric Polyps

Updated guideline on the management of common bile duct

stones (CBDS)