PTU-111 Setting up an integrated service for PSC-IBD patients: a quality improvement project

Abstract

Introduction Primary sclerosing cholangitis(PSC) is a chronic inflammatory condition closely associated with inflammatory bowel disease (IBD), and characterised by progressive fibrosis of biliary tract leading to cirrhosis and its complications. There is an appreciable annual risk of cholangiocarcinoma(CCA), gallbladder carcinoma, colorectal cancer(CRC) and hepatocellular cancer. Annual surveillance with magnetic resonance cholangiopancreatography(MRCP), colonoscopy, ultrasound(US) (6 monthly if cirrhotic) is advised. We aimed to assess the quality of liver and bowel surveillance, and detection of complications, before and after the introduction of an integrated hepatology and IBD service. Methods Retrospective data on management of PSC/IBD patients at St Thomas’ hospital, a tertiary IBD and hepatology centre, prior the introduction of an integrated service (August 2016) and prospective data following its introduction. Results Retrospective data identified 29 patients with IBD-PSC. Annual MRCP was performed in 55.1% (16/29), colonoscopy in 55.1% (16/2, 48% having chromoendoscopy) and US in 7%. 51% (15/29) were not under joint IBD and hepatology service. This indicated significant variability in care and poor adherence to guidelines. Interventions: Reiteration to physicians at every IBD clinic to actively identify PSC–IBD patients. Prospective database maintained. PSC–IBD patients were discussed in hepatology and IBD multidisciplinary meetings(MDM) regularly and surveillance arranged. A joint PSC/IBD clinic was established for this cohort. Following these interventions, 47 PSC-IBD patients (64% male, mean age 47 years) (33 UC, 11 Crohn’s, 3 IBD-U) were identified. To date, 38 have been seen in joint PSC/IBD clinic, 45 have been reviewed in MDM and annual surveillance has improved to 91% with MRCP(p Improvement in management and surveillance led to diagnosis and appropriate treatment of 1 CCA, 2 PSC with autoimmune overlap, 3 small duct PSC, 4 patients with dysplastic polyps as well as 2 new cases of CRC and 1 case of multifocal dysplasia which resulted 3 colectomies. Four patients have been referred for consideration of liver transplantation. Conclusions Robust surveillance in this group leads to timely diagnosis of malignancy and treatment. Establishment of integrated service for PSC-IBD patients results in early detection of complications, better compliance to guidelines and appropriate management of patients.