Introduction Patients with alarm symptoms for upper gastrointestinal (GI) cancer or those over 55 years with persistent, recent onset dyspepsia are referred for a specialist opinion under the two week rule (TWR) referral pathway. Referrals are vetted by two consultants, and in the majority of cases patients are sent directly for upper GI endoscopy (OGD). The incidence of gastric cancer in patients undergoing TWR endoscopy is around 4%.¹ Alarm symptoms have very variable specificity and sensitivity for upper GI cancer.² This study aimed to analyse outcomes for both patients triaged direct to OGD and direct to clinic.

Methods A prospective analysis of patients referred to a single centre in South London (St George’s Hospital) under the TWR pathway for upper gastrointestinal cancer was performed. Patients referred during two random four week periods in 2012 were identified. The referral form, endoscopy records, clinic letters, radiology reports and histology results were reviewed.

Results Data were analysed for 114 patients. Mean age was 63 years, with 23% of referrals aged under 55 years.

96 (84%) patients went direct to OGD, of which 3 (3%) had upper GI cancer and 4(4%) had significant non-malignant pathology. In the 27 (28%) patients under 55, no significant pathology was identified at OGD. Dyspepsia, dysphagia and weight loss were the commonest indications for the referrals.

47 (49%) patients had further imaging after endoscopy of which 18 (38%) had significant pathology leading to a change in management.

18 (16%) were seen directly in clinic following referral of which 11 (61%) went on to have further imaging. Of these patients, 45% had malignancy and 35% had significant abnormalities leading to a change in management.

Conclusion The yield of pathology at OGD undertaken as a first line investigation in patients referred via the TWR pathway is low, regardless of the referral criteria. However, imaging modalities appear to have a reasonably high yield of pathology in this group of patients. This suggests that General Practitioners are identifying the correct group of patients for referral, but that perhaps OGD is not the most appropriate first line test. Clinical review, as a first point of contact of patients referred via the TWR pathway, is likely to facilitate a more guided investigation process, while reducing the number of endoscopies being undertaken, and has potential cost-saving implications.

References

1. Gut 2005;54(1):40–5

2. Gastroenterology 2006;131(2):390–401

Disclosure of Interest None Declared.