The HPA Gastrenterology unit
On its way to becoming the most differentiated unit in Alentejo and Algarve

HPA Magazine 17

After the expansion that took place throughout the year 2020 and the financial investment in both human resources and equipment that necessarily took place during the whole of last year, the Gastroenterology Services of the HPA Gambelas is getting prepared to become the most differentiated service south of Lisbon, this is how the Medical Director of the HPA Gambelas – Dr Paulo Vieira de Sousa – introduced us to this renewed unit.
Indeed, the expansion that Gastroenterology as a  medical specialty, has undergone in recent years, especially in both endoscopy and medical treatment in pathologies of the digestive system, liver, bile ducts and pancreas, including preventive treatment in diseases of the digestive tract, such as cancer, justifies the investment in the modernization and development of the Gastroenterology Unit of the HPA Gambelas. The focus has been on excellent care, fundamentally based on the safety of all procedures.
These new facilities include a large examination room with fluoroscopy support, a reinforced recovery room with 6 beds and clinical re-accreditation by Joint Commission International. All the conditions have been met with the capacity to carry out advanced endoscopic techniques.  This will no doubt result, in this special examination unit becoming a reference in the southern region of the country, in the very near future, refers Dr Rita Herculano, Director of this service.
The team is fully committed to this new challenge. Improving the organization of the service, offering excellent service and projecting sustained growth, which together will allow the Gastroenterology Unit to create added value for the patient, the specialty, the HPA Group and the Algarve.

DOCTOR'S APPOINTMENTS
Gastroenterology is currently one of the most diversified medical specialties which has evolved the most in recent years. If in the past the Gastroenterologist only dealt with the diagnosis and medical treatment of digestive tract pathology, nowadays he faces the challenge of invasive diagnostic and therapeutic procedures, in some cases technically demanding.
With the development of the specialty, the need for subspecialisation of the Gastroenterologist in several areas also emerged. For this reason, we will also provide specialized consultations, promoting differentiation, organization and quality of the services provided.

General Gastroenterology Consultation
In this consultation, all benign and malignant gastroenterological pathology not treated in the more specialized consultations should be addressed. If the Gastroenterologist, after analysing the patient, finds that he has a specific pathology, he can refer him to one of the more specialized consultations.

Proctology Consultation
This specialized consultation will be available soon and will be dedicated to the diagnosis and treatment of benign and malignant diseases of the anal canal and perianal region. Benign proctologic diseases are varied, the most common being hemorrhoidal disease and anal fissure. These deserve special attention due to their significant prevalence in the younger population, says Dr Rita Herculano. However, we also treat with significant frequency, perianal fistulas, anal fibromas, rectal prolapse and anal and perianal condylomas (associated with HPV infection).
The examination most performed in a Proctology Consultation is anoscopy. This exam allows us to accurately establish the differential diagnosis and the most correct therapeutic option. For example, in the case of internal hemorrhoidal disease, according to the stage of the disease, we can perform hemorrhoidal sclerosis and hemorrhoidal elastic ligation during the consultation. In chronic fissures, we can perform minimally invasive treatment, such as botulinum toxin injection.

Hepatology Consultation
During this consultation, liver disease is addressed, from alteration of liver test results requiring   investigation, to follow-up of patients with chronic conditions, such as liver cirrhosis. In this consultation, the Gastroenterologist may perform a complementary diagnostic technique such as the hepatic Fibroscan®, a non-invasive technique (pag 18).

Pancreas and Biliary Consultation
Taking into account the high mortality rate associated with pancreatic cancer, its early diagnosis is crucial and therefore, it makes perfect sense to provide this specialized consultation.
Likewise, there are other diseases that have increased their incidence - largely due to dietary habits -, such as gallstones, cholangitis or even pancreatitis. It is therefore important to carry out a more personalized and closer follow-up, in order to avoid complex and irreversible outcomes.

Digestive Cancer Family Risk Consultation
We consider this consultation to be of added importance for a hospital like HPA Gambelas, due to its size and differentiation.
In this consultation, we will systematically follow up patients with a family history of digestive cancer, in close coordination with Oncology and General Surgery. 

Inflammatory Bowel Disease Consultation
This consultation will begin in the very near future, orientated towards the diagnosis, treatment and follow-up of Inflammatory Bowel Disease, namely Crohn's disease and ulcerative colitis.
As these diseases are chronic, with presently no cure available, it is very important that these patients feel monitored by a multidisciplinary team, which should have a Gastroenterologist at its head, but which includes other specialties such as Surgery, Imaging, Rheumatology, Dermatology, Nutrition and Psychiatry/Psychology, refers Dr Rita Herculano.

NURSING CARE
For Nurse Catarina Bentes, Head Nurse of the Special Examinations Unit, the emphasis is on functionality and safety. With this new unit, we effectively gained more functional circuits, improved structural conditions and increased the level of safety throughout the patient's stay. Storage, disinfection and reprocessing of highly differentiated equipment requires specific care, which has significantly improved.  
The recovery area has also undergone a significant improvement. The new layout and expansion offer additional safety and comfort. For example, after waking up from sedation, the patient remains monitored, in a fully equipped unit, in privacy and comfort until all clinical criteria have been met for a safe hospital discharge. On discharge, the patient is offered a snack and safety conditions for getting back home are confirmed (especially with people who live on their own or have undergone more complex invasive procedures).
The fact that we are accredited by Joint Commission International since 2018, has facilitated this integration, with which we work today; our norms follows the best international standards and practices at all levels/areas when providing nursing care in Gastroenterology. 
The nursing teleconsultation was also initiated. In the near future we intend to cover and support more specialized areas.
Recently, we were once again subjected to a strict audit by Joint Commission International. 
We are very proud that our Unit received a very positive assessment for the structure implemented and the care we provide. The entire team of Nurses and Medical Assistants remain committed to our patients, to daily provide more and better care.

TECHNOLOGY AND INOVATION
Hepatic Elastography
Hepatic elastography, also known as FibroScan®, is used in the diagnosis of liver function, namely for the evaluation and quantification of fibrosis and hepatic steatosis (fat) (alcoholic and non-alcoholic), but also with a differentiation in the diagnosis and follow-up of hepatitis B and C, biliary diseases, metabolic or autoimmune diseases, among other conditions.
Taking into account the prevalence and incidence of obesity, FibroScan® has also been used to massively screen risk groups - obese, cirrhotic patients, diabetics - in order to anticipate problematic diagnoses and reduce fatal outcomes, says Dr Rita Herculano.
Presently, the HPA is the only hospital in the Algarve to have this equipment, with a high level of accuracy in terms of early diagnosis, a crucial aspect in the field of liver diseases. In addition, FibroScan® is a non-invasive, completely painless and quick exam, does not use radiation, (can take approximately 10 minutes), does not require any specific preparation (fasting for 3-4 hours is recommended) with results available immediately after the exam.

Video Capsule Endoscopy 
It is a simple, safe and non-invasive diagnostic test that permits visibility of all segments of the small intestine.
This video capsule is about 0.5 cm x 2.5 cm and has a light source and camera that captures the images and records them through sensors placed on the patient's body and a receiver that is attached to his waist.
As a rule, it is indicated in obscure gastrointestinal bleeding (when upper endoscopy and colonoscopy results are normal); in iron deficient anaemia; in the diagnosis and classification of Crohn's disease; in diet-refractory/complicated celiac disease; in the diagnosis of tumours of the small intestine; in hereditary polyposis syndrome or to clarify other exams.
After intestine preparation, the capsule is swallowed with water and advances along the digestive tract, propelled by one’s normal digestive movements. Over fourteen hours, the capsule will record the images as it passes along the intestine, allowing the patient to carry out his normal activities. The images are then processed and viewed on a monitor by the Gastroenterologist and after 24-72 hours, the video capsule is naturally eliminated with the faeces.
It is important to mention that the Management of the HPA Gambelas is currently renegotiating agreements with the subsystems and insurance companies, so that this examination can be accessible to a greater number of people.

In addition to Hepatic Elastography and Video Capsule Endoscopy, the Gastroenterology Service of the HPA Gambelas also performs:
• Anoscopy
• Endoscopic Retrograde Cholangiopancreatography – ERCP
• Placement of Intragastric Balloon
• Colonoscopies
• Dilation of Gastrointestinal Stenoses with placement of endoscopic prostheses
• Upper Digestive Endoscopies
• Percutaneous Endoscopic Gastrostomies and associated techniques
• Elastic ligation of oesophageal varices
• Mucosectomies (Endoscopic Mucosal Resection)
• Flexible Rectosigmoidoscopy
Other techniques will also soon become available in the coming months, namely high-resolution oesophageal manometry and oesophageal impedance pH-metry. These techniques will support benign oesophageal-gastric surgeries, such as the treatment of gastroesophageal reflux and other oesophageal diseases the cause of motility.
High resolution anorectal manometry will also be acquired for HPA-Gambelas, to improve for example, the study of chronic constipation or pelvic floor abnormalities, such as faecal incontinence. In fact, this equipment will be extremely important in supporting the proctology consultation.