United States Department of Veterans Affairs
United States Department of Veterans Affairs

VA Puget Sound

VAMEDRES: GI Clinic Rotation

1. Introduction to GI Clinic at the Seattle VA

2. GI Clinic Schedule (Jan - June, 2002)

3. Structure of the GI Clinic

4. Hepatitis C treatment & eligibility checklist

1. Introduction to GI Clinic at the Seattle VA

A. The Players:

  1. Attendings: Sum Lee, T. Nguyen, D. Kearney, J. Dominitz, (L. Morrison, C. Ko)
  2. Fellows: Joo-Ha Hwang, Mark Mallory, Roanne Selinger, consult fellow
  3. Residents: clinic residents (1-3), consult resident
  4. Support Staff: See chart
  5. GI Unit:
  • 62285: Robin Peterson (outside records)
  • 61513: Endoscopy unit (endoscopy, manometry records)
  • 61503: Anne Croghan (Hepatology ARNP, pager 680-2171)

B. Schedule:

  1. Tuesday mornings at 8:00 am
  2. Pre-clinic conference, West Clinic Conference Room, 8:00 - 8:30 am
  3. 8:30 - noon: patient care, patients usually scheduled every 20 min
  4. Overbook (please beware of your clinic schedule; to look this up: option 12 on VISTA/DHCP)
  5. Please let Robin Peterson and Toan Nguyen know of any changes in your schedule or vacation.

C. Job Description:

  1. Attendings and clinic fellows see their own assigned patients
  2. Attending of the day on a rotating basis
  3. Consult fellows, residents, & students see GI New Patients and present to Attending of the day.
  4. Pairing: Hwang & Nguyen, Mallory & Kearney, Selinger & Dominitz

D. Computer/ GUI

  1. Endoscopy reports: See procedure section of CPRS. 
  2. Electronic notes, electronic alerts for consult if applicable. Fellows: Include "Case reviewed with [Attending of the Day], Attending." Residents & medical students: Identify [Attending of the Day] as co-signer.
  3. UW GI/Hepatology home page: http://www.uwgi.org/


E. Red Tape:

  1. Encounter forms (including phone calls)
  2. Orders
  3. X-rays: general, CT scan, MRI
  4. Endoscopy & Liver biopsy: endoscopy forms & endoscopy scheduling
  5. pH monitoring/ Manometry: Corresponding form filled out with Attending and forwarded to Robin


F. Pre-clinic conference schedule:

  • January: 8 (Croghan), 15 (Selinger), 22 (Morrison), 29 (Maleque)
  • February: 5 (Cooke), 12 (Musher), 19 (Berrington), 26 (Broussard)
  • March: 5 (Mallory), 12 (Nguyen), 19 (Dalrymple), 26 (Lee)
  • April: 2 (Dominitz), 9 (Hwang), 16 (Kearney), 23 (Gadi), 30 (Rosenthal)
  • May: 7 (Selinger), 14 (Mallory), 21 (DDW), 28 (Ochoa)
  • June: 4 (Huang), 11 (Broussard), 18 (Almaleh), 25 (Lee)

 

2. GI Clinic Schedule for January - June 2002

 

  Dominitz
 

  Kearney
 

  Nguyen
 

  Lee
 

Selinger
 

Mallory
 

  Hwang
 

Jan 8 

 1

 2

 1

 0

 1

0 

1 

 15

 1

 1

 2

 0

 1

1 

1

 22

 0

 1

 1

 2

 1

1

1

 29

 1

 2

 1

 0

 1

1

1 

Feb 5        

 0

 1

2 

0 

 1

 1

 1

 12

 2

 0

 1

 0

 1

 1

 1

 19

 0

 0

 0

 2

 1

 1

 1

 26

 1

 1

 2

 0

 1

 1

1 

March 5 

 2

 1

 1

 0

 1

 1

 1

 12

 1

 2 

 1

 0

 1

 1

 1

 19

 1

 1

 2 

0 

0 

 1

1 

 26

 2

 1

 1

 0

 0

 1

 1

Apr 2

 1

 1

 2

 0

 1

  1 

 1

9

 1

 2

 0

 0

 1

 1

 1

 16

 2

1

 1

 0

 1

 1

1 

 23

 1

1 

 2

 0

1 

1 

1 

 30

 1

2

 1

 0

 1

 1

 1

 May 7

 2

 1

 1

 0

 1

 1

 1

 14

 1

 1

 2

 0

 1

 1

 1

 21

 DIGEST.

DIS 

WEEK 

(DDW) 

CLINIC 

 CANCE-

LLED 

 28

 1

 2

 1

0 

1

1

1

 June 4

 2

 1

 1

 0

1

1

1

 11

 0

 1

 2

 0

 1

 1

 1

 18

 1

 2

 1

 0

 1

 1

 1

 25

 0

 1

 2

 0

 1

 1

 1

Key    0 = no appointments, out of clinic
          1 = 9 follow-up patients
          2 = no appointment, but in clinic (attending

Each GI NEW Clinic will have 12 regularly scheduled appointments and no more than 10 add-ons per clinic, personally cleared by Drs. Dominitz, Kearney, Nguyen, Sum Lee, Morrison, or Ko.

3. Structure of GI clinic

A. Endoscopy unit: Kathy Chan

  • Scheduling and education regarding endoscopy
  • Studies available: Colonoscopy, EGD, Flexible sigmoidoscopy, Liver biopsy, [manometry]
  • Processing GI consults & "GI-new no-shows"

B. Front desk: Markeata White

  • Obtain charts
  • Check in patients
  • Order tests
  • Schedule return visits
  • Process no-shows
  • Means test

C. Clinical nursing: Esther Simpson

  • Process patients after check-in at front desk
  • Hepatitis A&B vaccination (needs order)

D. GI office: Robin Peterson

  • Obtain outside records
  • Endoscopy/manometry report

E. Hepatology liaison: Anne Croghan

  • Interferon treatment
  • Liver transplant packages
  • Hepatitis C education

F. Trouble-shooter. Kathy Chan

G. Complaint Department: Toan Nguyen

 

4. Hepatitis C Treatment

A. Eligibility check-list for hepatitis C treatment

 Age 18-65
Hepatitis C (PCR & biopsy with fibrosis), no concurrent liver disease
Abnormal SGPT on 2 occasions over at least 6 months
 

No evidence for decompensated liver disease

No encephalopathy, variceal bleeding, or ascites

Bilirubin = 2 mg/dl

Albumin = 3.0 mg/dl

PT: INR < 1.5

 

*CBC within the following guidelines:

Hgb = 12 g/dl (females); = 13 g/dl for males

WBC = 3,000 / mm3

Neutrophils = 1,500 / mm3

Platelets = 70,000 / mm3

 

Abstinence from drug or alcohol abuse for at least 6 months 

No psychiatric illness or depression unless cleared by psychiatrist 

No history of organ transplantation/ current or likely treatment with immunosuppressive agent 
*Serum creatinine = 1.7 mg/dl, or creatinine clearance > 50 ml/ min
 U/S of liver negative for malignancy

Infertility or negative pregnancy test within 48 hours of entry (women) and effective contraception during treatment plus 6 months 

* No ischemia, serious arrhythmia, cardiac failure, coronary surgery, significant hypertension, angina, or MI within 12 months of entry 

*For patient with high risk for CAD, normal stress test 

No preexisting/active medical condition (CNS trauma/ seizure, poorly controlled diabetes, thyroid, or pulmonary disease, immunologically mediated disease, AIDS, steroid, malignancy, *hemoglobinopathy) 

Ophthalmologic exam with underlying diabetes or hypertension 

Documentation of attending concurrence (if applicable) & discussion of side effects, risk & benefits of therapy 
§ Guidelines only, not standard of care.

* Special consideration for ribavirin treatment

 

B. Dosing for combination therapy:

  • = 165 lbs: 1200 mg ribavirin daily & 3 MIU interferon a-2b TIW
  • < 165 lbs: 1000 mg ribavirin daily & 3 MIU interferon a-2b TIW

C. Duration:

  1. For interferon monotherapy: 48 weeks
  2. For combination therapy: 24 weeks if genotype 2 or 3, 48 weeks if genotype 1
  3. Stop treatment if HCV RNA positive after 24 weeks

D. Laboratory Tests:

Time  Date  CBC/Diff  LFT  TSH PCR  Pregnan. 
Baseline             
Week 1  Optional  Optional         
Week 2             
Week 4            
Week 8             
Week 12     Optional   Optional   
Week 16                      
Week 20             

Week 24      (Rx end)

            

E. Dose Reduction and/or Discontinuation*

Laboratory parameter
 		 Half dose reduction
 Discontinuation
 

Hgb (no cardiac history)

 

< 10 g/ dl

 

< 8.5 g/dl

 

Hgb (cardiac history)

 

decrease by > 2 g/dl

 

< 12 g/dl on reduced

WBC

 

< 1.5 x 109 / L (Interf. only)

 

< 1.0 x109 /L

 

Neutrophil

 

< 0.75 x 109 /L (Inter. only)

 

< 0.5 x 109 / L

 

Plts

 

< 50 x 109 / L (Interf. only)

 

< 25 x 109 / L

 

*Discontinuation also for psychiatric side effects, lack of response, thyroid dysfunction

 

 
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