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Why a nurse-led ‘sponge on a string’ test offers a fast alternative to endoscopy

Non-invasive alternative to endoscopy can boost early detection of oesophageal adenocarcinoma

Non-invasive alternative to endoscopy can boost early detection of oesophageal adenocarcinoma

A new nurse-led outpatient service at University College London Hospital , where I am a clinical nurse specialist in the upper gastrointestinal team, offers people with Barretts oesophagus an alternative to endoscopy. All they have to do is swallow a capsule attached to a string.

When the capsule dissolves in the stomach it releases a small sponge, and as the string is pulled up it collects samples from the lining of the oesophagus.

Barretts oesophagus causes the cells in the lining of the oesophagus to be replaced by intestine and stomach cells. The condition develops over time and is associated with the presence

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Non-invasive alternative to endoscopy can boost early detection of oesophageal adenocarcinoma

Sally Thorpe carrying out the non-invasive and quick test Picture: UCLH
Sally Thorpe carrying out the non-invasive and quick test Picture: UCLH

A new nurse-led outpatient service at University College London Hospital, where I am a clinical nurse specialist in the upper gastrointestinal team, offers people with Barrett’s oesophagus an alternative to endoscopy. All they have to do is swallow a capsule attached to a string.

When the capsule dissolves in the stomach it releases a small sponge, and as the string is pulled up it collects samples from the lining of the oesophagus.

Barrett’s oesophagus causes the cells in the lining of the oesophagus to be replaced by intestine and stomach cells. The condition develops over time and is associated with the presence of gastro-oesophageal reflux disease (GORD), where acid from the stomach spills up into the oesophagus and causes changes to the lining of the oesophagus.

Left untreated, the condition can develop into cancer

The risk of developing GORD is greater if you are overweight, have a hiatus hernia, smoke, consume too much alcohol and eat spicy foods.

Capsule containing the ‘sponge on a string’ Picture: UCLH
Capsule containing the ‘sponge on a string’ Picture: UCLH

University College London Hospitals NHS Foundation Trust (UCLH) is the largest Barrett’s oesophagus centre in the UK, so we have some of the highest numbers of patients in the country. It is estimated that there are between 375,000 and one million people in the UK with the condition, which contains the potential for the cells to change and become precancerous – known as high-grade dysplasia.

Left untreated, the condition can develop into cancer, specifically oesophageal adenocarcinoma (OAC). Progression to OAC occurs in less than 1% of people with Barrett’s oesophagus but their five-year survival rate can be lower than 20%. Early detection of OAC is extremely important for patient outcomes, because when monitored and detected at stage one, survival rates can be greater than 90%.

Vital to find alternative to endoscopy, as earlier referrals and monitoring could save lives

The standard method to diagnose and monitor patients is through an endoscopy. However, the COVID-19 pandemic has created a significant increase in the number of people on waiting lists for such surveillance, as well as in the length of time they have to wait.

In England alone, by the end of August 2020 the proportion of patients waiting six weeks or more for an endoscopy had increased by 48 percentage points from a year earlier.

The test can be carried out by nurses
Picture: UCLH

The impact of this delay may have been detrimental for some people, as their condition may have progressed without them knowing. This meant it was vital to find an alternative solution to endoscopy, given that earlier referrals and ongoing monitoring could potentially save lives.

The solution came in the form of a ‘sponge on a string’ test that we had been piloting at UCLH. Thanks to the success of this we have now made it an established procedure.

What is exciting about the procedure is the ability to triage patients

The Cytosponge device is a small sponge inside a capsule the size of a multivitamin pill that is attached to a string, which the patient swallows with a glass of water. After seven and a half minutes the capsule dissolves in the stomach and releases the sponge. The string is then gently pulled back up through the oesophagus by the nurse. As the sponge is pulled it collects cells from the lining of the oesophagus during its journey back into the patient’s mouth.

The method is non-invasive for the patient and fast, as well as a fraction of the cost of a regular endoscopy. Unlike endoscopy, patients can attend appointments unaccompanied, there is no need for sedation, and they are free to eat and drink normally as soon as the procedure is finished.

What is exciting about a procedure such as this is the ability to triage patients and its potential use in other healthcare settings, such as GP surgeries. In addition, the test can be conducted by nurses and there is no need for an endoscopist or specialist endoscopy suite.

The encouraging results we have seen so far have made the procedure a fixture at UCLH. Six staff are now trained to carry out the procedure, four of whom are nurses. We have already used it to identify one patient whose Barrett’s oesophagus had progressed to a pre-cancerous stage, and two cases of cancer. These are the high-risk people who could have otherwise been missed and are now receiving the treatment they need.


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