nw gastro · metabolic disorders and provide a tertiary service for ga (general anaesthetic)...

NW GASTROTHE 13TH ANNUAL MEETING 2015

The Grand Hotel, Lytham St Annes2nd and 3rd July 2015

DILEMMAS IN SMALL BOWEL ANDNUTRITION

Meeting Booklet 2015.indd 1 22/06/2015 22:26:11

Thursday 2nd July

0915 Registration and Coffee

0950 Welcome Dr Philip Shields

1000 Feeding Dilemmas in the Elderly Dr Alistair Makin, Consultant Gastroenterologist, Manchester Royal Infirmary Dr Martin Vernon, Consultant Geriatrician, Manchester Royal Infirmary Chair: Dr Marie McMahon

1130 Coffee Exhibition Hall & Poster Viewing

1200 Clinical Research Symposium Chair: Dr Neeraj Prasad

1205 Tertiary referral centre experience of general anaesthetic assisted upper gastrointestinal endoscopy and percutaneous endoscopic gastrostomy insertion in patients with complex or inherited metabolic disorders JC Spence

1220 Outcomes of biofeedback therapy for faecal incontinence in a UK based district general hospital - how intense should the follow up regime be? DH Vasant

1235 Management of medical inpatients with anorexia nervosa: challenges, communication and confidence (or lack of it)? E Shuttleworth

1250 Success of a prospective assessment for alcoholic liver disease in high risk patients: A well liver clinic model M Roberts


1315 Lunch Poster Round Exhibition Hall

1400 Symposium Psychological Aspects of Nutrition and GI Disease Chair: Dr Richard Jones

Eating Disorders and Disordered Eating in Functional GI Disease Dr Yoram Inspector, Consultant Psychiatrist and Psychotherapist Head of Psychological Medicine Unit St Mark’s Hospital

Psychological Formulation: Theory and Practice Dr Joanne Ablett, Clinical Psychology Lead, Intestinal Failure Unit Dr Gillian Fairclough, Clinical Psychologist, Department of Clinical Health Psychology Salford Royal Hospital

1545 Coffee Exhibition Hall

1610 MARSIPAN: Is it working? Dr Sonu Sharma, Consultant Psychiatrist, Priory Eating Disorder Services Chair: Dr Alistair Makin

1710 Deanery Training Issues Dr Philip Shields

1725 Trainee Survey (trainee only section) 1800 Close

1930 Buffet Dinner


Friday 3rd July

0900 Final Year Symposium Debate: New biologics and Biosimilars Chair : Dr Salil Singh

Dr Peter Mooney, Dr Anurag Goel, Dr Tehreem Chaudhry

1000 Nutrition training in the north west and beyond Chair: Dr Philip Shields

Dr Wadi Gashau, Senior Clinical Fellow, Intestinal Failure Unit Salford Royal Hospital Dr Emma Nixon, Consultant Gastroenterologist Royal Preston Hospital 1045 Coffee Exhibition Hall

1115 Academic Research Symposium Chair: Prof Peter Whorwell

1120 Pre-endoscopy point of care testing for coeliac disease in anaemia: a cost saving economic model PD Mooney

1135 Modern pelvic chemoradiotherapy techniques continue to affect the small bowel K White 1150 The clinical and phenotypic assessment of ultra-short celiac disease PD Mooney

1205 Ampullary characteristics as a novel means of predicting ERCP complexity K McWhirter


1230 Complications of Long Term Parenteral Nutrition Dr Simon Lal, Consultant Gastroenterologist, Intestinal Failure Unit Salford Royal Hospital Chair: Dr Salil Singh

1330 Lunch Exhibition Hall

1430 Medical-Surgical Debate: Distal Ileal Crohns and Small Bowel Stricturing - cut or cure? Chair: Prof John McLaughlin

Dr R P Willert, Consultant Gastroenterologist, Manchester Royal Infirmary

Dr JA Robinson, Consultant Gastroenterologist, Salford Royal Hospital

Mr I Anderson, Consultant Colorectal Surgeon, Salford Royal Hospital

1600 Closing remarks Prof Christopher Summerton

1900 Champagne Reception

1930 Conference Dinner


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Clinical Research Symposium

Tertiary referral centre experience of general anaesthetic assisted upper gas-trointestinal endoscopy and percutane-ous endoscopic gastrostomy insertion in patients with complex or inherited metabolic disordersJC Spence1,2, K Chatten2, J Large2, C Hendriksz2, Y Ang1,2

1GI Science Centre, University of Manchester2Salford Royal NHS Foundation Trust

Introduction and Aim sWe are a tertiary referral centre for complex and metabolic disorders and provide a tertiary service for GA (general anaesthetic) endoscopy. The indi-cations, safety, complications and success rate of GA upper GI endoscopy is evaluated in this study.

MethodData from 12 procedures (9 patients) with com-plex disorders or inherited metabolic syndromes who have had an upper gastrointestinal endos-copy performed under GA between 2009 and 2014 were reviewed. A successful procedure was defined as one which provided useful informa-tion relating to the ongoing care of the patient. If difficulties were experienced during percuta-neous endoscopic gastrostomy (PEG) placement or replacement, necessitating further repeat GA endoscopy, then the first procedure was classified as a successful procedure if the second procedure was completed successfully.

ResultsOf the 1100 patients under the adult metabolic service in our centre, 0.73% (9 patients with 12 pro-cedures) required an upper GI endoscopy in the past 5 years. 25% of endoscopies were performed for diagnostic purposes. 75% of endoscopies were therapeutic, with 58% of endoscopies being performed for replacement of existing PEGs and 17% being performed for insertion of new PEGs. Limited mouth opening and mandibular progna-thism were associated with difficult intubation. One (8.3%) of the procedures was an anticipated difficult intubation, and so this was performed with a Bougie and McGrath videolaryngoscope. Of the 12 procedures reviewed, the success rate was 100%. Two cases (22.2%) required a repeat GA prior to completion of their PEG replacement. One case (11.1%) scheduled for PEG plus jejunal exten-sion, required a repeat procedure due to a previ-ously unforeseen PEG-J fixation. One case (11.1%) scheduled for replacement of a buried PEG, also

had an additional procedure.

ConclusionsThis series of cases has demonstrated that per-forming upper GI endoscopy under GA is safe and clinically useful for both the diagnosis and man-agement of patients with complex or inherited metabolic disorders and severe learning difficul-ties. It is essential to recognise that these patients may be difficult to manage from an anaesthetic point of view, to ensure adequate levels of expe-rience and supervision, with a multidisciplinary team approach, in order to minimise the potential for harm. Potentially difficult intubations may re-quire an altered induction technique.

Outcomes of biofeedback therapy for fecal incontinence in a UK-based district general hospital - How intense should the follouw-up regime be?DH Vasant, K Solanki, RK Sharma, LJ Quest, R George, S Balakrishnan, N RadhakrishnanPennine Acute NHS Hospitals Trust

IntroductionBiofeedback therapy (BFT) is recommended by the American College of Gastroenterology for fe-cal incontinence (FI)1. Virtually all the data avail-able is from tertiary centres. We aimed to evaluate our commode-based BFT programme adapted from the Iowa protocol within the constraints of a District General Hospital and determine predic-tive factors for successful outcomes.

MethodsWe retrospectively reviewed 241 FI patients (me-dian 62 years, 73% female) enrolled in our Gastro-enterologist-led BFT programme between 2009-14. Where patients were lost to follow-up, data including outcomes and the reason for drop-out were obtained retrospectively from; casenotes, telephone survey and a database provided by the booking team. Patients were classified as re-sponders (complete or partial) or non-responders based on symptoms. The 2 groups were com-pared statistically for factors including; demo-graphics, symptoms, dyssynergia, QOL scores, co-morbidities, manometry data, sphincter exercise technique, duration of practice and the number and frequency of sessions.


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ResultsAll 241 patients had outcome measures despite 6% having ongoing BFT and 39% drop-out. Pa-tients attended a mean 3 (SEM ± 0.2) BFT ses-sions with an interval of 67 (±5) days between visits. Neurotrac stimulator was used in 14%. Overall, 176/241 (73%) responded (complete n=116, partial n=60) with marked reduction in FI frequency (median pre 7/week vs. post-BFT 0.25/week, P<0.0001). Whilst non-response was associated with male gender (P=0.02) and drop-out (P<0.0001), documented ‘good’ exercise technique (P=0.001), more BFT sessions (P=0.02) and longer durations of self-practice at home (P=0.003) were associated with successful out-come. The reason for drop-out was obtained for 71/93 (76%).

DiscussionDespite less intensive follow-up, we achieved comparable outcomes to FI studies reported elsewhere with bi-weekly induction followed by periodic reinforcements. Our data suggest a more intensive approach may benefit male pa-tients and those with poorer technique and com-pliance with sphincter exercises. A customized approach based on these predictive factors may improve success rates and reduce drop-out rates. Longer intervals between BFT sessions may con-tribute to high drop-out rates and systems need to be developed to counteract this. References1Wald AB et al. ACG clinical guidelines: manage-ment of benign anorectal disorders. Am J Gastro-enterol 2014; 108: 1146–57

Management of medical inpatients with anorexia nervosa: challenges, communi-cation and confidence (or lack of it)?E Shuttleworth1, S Sharma2

1University Hospital of South Manchester, 2Specialist Eating Disorder Services, The Priory Cheadle Royal

A 31 year-old woman with known Anorexia Nervosa (AN) was admitted via the Emergency Department of a University Teaching Hospital, after advice from outpatient cardiology clinic. Admission BMI was 10.8, BP was 85/62 mmHg and heart rate 62bpm. Bloods showed potas-sium of 2.6umol/l, an ALT of 5876IU/l and her

ECG a prolonged QT interval. She was admitted to a Gastroenterology ward under a nutrition Consultant. She agreed to closely monitored oral feeding, plateauing at a BMI of 12 after 2 weeks, with intravenous electrolyte replacement for the first week, then oral supplements as per MAR-SIPAN guidance (1). Her LFTs improved and QT normalised so transfer to a specialist eating dis-orders unit (SEDU) was sought. The patient cited previous breakdown of relationship with the lo-cal SEDU and was not under a Mental Health Act section. General Psychiatry advised SEDU input. Attempts to obtain alternative placement were complicated by uncertainty regarding commis-sioner funding and safety of transfer, and contra-dictory behaviour from patient and family. She eventually agreed to transfer to the local SEDU.

Despite admission under a team with consider-able knowledge of MARSIPAN guidance her acute medical bed occupancy was 134 days. A survey of doctors in the Northwest Deanery, (foundation to consultants) in medical and surgical special-ties showed over half (54%) are not confident in managing patients admitted with medical com-plications of eating disorders, although 62% have managed such patients. Knowledge of criteria for inpatient admission for patients with Anorexia Nervosa was good, but services provided on SE-DUs were underestimated, potentially leading to unnecessary admission or prolongation of stay on an acute medical ward. Respondents were aware of the need for multidisciplinary nutrition and psychiatry input, but degree and frequency of psychiatry liaison was extremely variable, with multiple reports of difficulty accessing psychiatry support. Advice from local specialist services was felt to be invaluable, but bed availability and lo-cal funding disputes may delay transfer.

We aim to develop an online learning module in association with the British Association of Par-enteral and Enteral Nutrition, and a summary of MARSIPAN guidance for medical doctors. We will obtain feedback on these and opinions on how best to disseminate guidance to front line staff by recruiting a local junior doctor focus group. We will work closely with the local SEDU to de-fine clear referral and advice pathways, aiming that all patients with medical complications of AN get gold-standard multi-disciplinary care wherever they are admitted.

1Royal College of Psychiatrists and Royal College of Physicians. MARSIPAN: Management of Really


Sick Patients with Anorexia Nervosa (2nd Ed). Coll Rep CR189. 2014

Success of Prospective Assessment for Al-coholic Liver Disease in High Risk Patients: A Well Liver Clinic ModelM Roberts

IntroductionCurrently patients at high risk of developing al-coholic liver disease are given advice by health professionals, often only reach hepatology ser-vices once advanced cirrhosis or complications are seen. This out-dated system needs improvement to avoid an unprecedented increase in advanced liver disease. We aim to show that our new service of proactive assessment of at risk patients will al-low earlier recognition of liver disease in this pa-tient group.

MethodsAll eligible patients had no history of liver disease, not previously known to alcohol services and had never seen gastroenterology/hepatology. Patients were referred from Alcohol Specialist Nurses (ASN), Alcohol Assertive Outreach Team (AAOT), Specialist Drug and Alcohol Services (SDAS) or GP after screening using Alcohol Use Disorders Iden-tification Test (AUDIT), with a score ≥16 required. All patients were seen in community clinic by hepatology specialist nurse, undertaking full clini-cal assessment and Transient Elastrography (TE) using Fibroscan. Follow up: TE <8kPa – repeat in 12 months, TE 8-12kPa – repeat in 6 months, TE 12-20kPa – repeat in 3 months, TE >20kPa – refer to hepatology clinic. Any clinical concern regard-less of TE score was also referred. All patients were seen between Nov 2013 and Feb 2015.

Results527 eligible patients, 387 male and 140 female. Ages ranged from 20-82, mean age 46.1. AUDIT scores range was 16-52, with 79.1% of patients scoring 26-40. 189 patients, 141 male and 48 fe-male, were seen with the remainder failing to attend. 64 (33.8%) reported alcohol abstinence since referral, with a further 7 (3.6%) drinking <21U/week. 83 patients (43.9%) were high risk, still drinking >50U/week. TE scores were: <8kPa in 146 patients, 8-12kPa in 19, 12-20kPa in 10, >20kPa in 7,

no result in 7. Those with higher AUDIT scores (26-40) were more likely to have abnormal TE (18.8% >8kPa) and 42.8% of TE >20kPa AUDIT was 36-40. 17 patients (8.9%) were referred to hepatology, 7 with TE >20kPa and 10 on clinical grounds. The remainder had follow up arranged appropriately.

ConclusionsOur new service identified a number of patients who would benefit from specialist hepatology in-put. Those not requiring specialist input yet may benefit long term from assessment but prospec-tive data on follow up is still in its infancy. As ex-pected, those at higher risk were more likely to have evidence of liver disease. In addition, more than 1/3 of patients involved in this service signifi-cantly reduced their alcohol intake. Methods into improving attendance rates needs to be investi-gated. Overall our service for prospective assess-ment of those at high risk of alcohol related liver disease is a dynamic new approach that we hope will lead to a greater emphasis on primary preven-tion.

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Retroperitoneal duodenal perforation (Type 2) – A review of 5 years experience in a tertiary teaching hospitalA Banerjee, Y AngSalford Royal NHS Foundation Trust

AimsPerforation with Endoscopic retrograde cholan-giopancreatography is a rare complication. We aimed to detect risks for perforation and early management experience.

Methods1511 procedures were done in 5 years between 2007 and 2012. 5 perforations were identified and retrospectively reviewed. Data was obtained with the help of coding department and electronic pa-tient record. Individual cases were studied sepa-rately to evaluate the risk factors and management experience and then we tried to pick any common factors which will help in predicting perforations and overall outcome.

ResultsAll 5 perforations were retro-peritoneal. 3 were identified during the procedure and 2 were de-tected within 24 hours of clinical presentation. CT abdomen was the investigation of choice to detect perforation in patients presenting with clinical features suggestive of perforation. All per-forations were managed conservatively and made good recovery. Three patients needed total paren-teral nutrition and all had intravenous antibiotics and fluids.

ConclusionThrough this study we found that retro-peritoneal perforations if detected early can be managed conservatively and mortality is very much pre-ventable. Perforations can be picked up if good attention is paid to images during ERCP.

Intraprocedure quality in endoscopic retrograde cholangiopancreatography – A retrospective analysis of practice in a hepato-pancreatobiliary centre in north-west of EnglandA Banerjee, Z Al Dulaimi, T Algladi, C Gimley, Y Red-dy, M Mansoor, A Green, D LynchEast Lancashire Hospitals NHS Trust

AimsEndoscopic retrograde cholangio-pancreatogra-phy is an essential modality in management of pancrato-biliary disease. The aim was to compare our practice against the National Confidential En-quiry into Patient Outcome and Death (NCEPOD) recommendations and JAG standards.

MethodsThis was a retrospective study of 672 procedures performed by four endoscopists. ResultsThe most common indication for ERCP was cho-ledocholithiasis and the mean dose of midazolam used was 3.54 mg meeting BSG recommenda-tion. Radiological investigations were available in all patients before ERCP and clotting profile was checked in 87.5% of cases (589/672) in less than a week pre-procedure. The selective bile duct can-nulation rate was 87.8% and the total completion rate was 83.6%. The overall complication rate was 6%.

ConclusionsThe practice of ERCP adhered to the key recom-mendations by NCEPOD and standards set by JAG in most areas but there is improvement needed in pre-ERCP investigations. Recommendations are being implemented following this study

Little Bleeders: a quality improvement projectL Morris, B Miller, P IsaacsBlackpool Victoria Hospital

IntroductionBlackpool Victoria Hospital covers a large area and cares for patients from all socioeconomic classes. Upper gastrointestinal bleeding is a common problem in Blackpool, especially given the high levels of alcoholic liver disease. To cope with the high numbers of these patients, Blackpool has a dedicated out of hours endoscopy service staffed by consultants and endoscopy nurses. In order to improve the service, regular measurement of out-comes is required.

MethodsWe performed a prospective audit of patients pre-senting with ‘red haematemesis’ or ‘frank melaena’ between 21/09/14 and 10/11/14. 35 patients were 9

Poster Round


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Poster Round

included. We audited against NICE guidelines and JAG auditable outcomes framework for acute up-per GI bleed. We calculated Glasgow Blatchford and Rockall scores for all patients and noted times taken from admission to referral and from refer-ral to endoscopy. We recorded pre-endoscopy management, endoscopic findings and therapy, as well as outcomes at 30 days and length of in-patient stay.

ResultsIn our data set, recording of Glasgow Blatchford Score was poor. The use of blood products and correction of clotting was not adherent to the cur-rent guidelines in many patients. Three patients were over-transfused red cells. Of the five patients with elevated INRs on warfarin, only one was given prothrombin complex concentrate prior to gastroenterologist intervention. Patients with suspected variceal bleed were treated appropri-ately with antibiotics and/or terlipressin in 66% of cases.

Interestingly, unstable patients waited longer than stable patients before being referred to a gastroenterologist with a median time to referral of 10.6 hours, compared to 7.2 hours for stable pa-tients. Once referred, unstable patients had a gas-troscopy in a median time of 2.3 hours (5.5 hours for stable patients).Endoscopic management of these patients adhered to national guidelines, with a 100% primary haemostasis rate.

Post-endoscopy omeprazole infusion was pre-scribed appropriately, but aspirin was not restart-ed in the majority of patients despite good indi-cations. 6% of patients developed pneumonia post-endoscopy. 30 day mortality was 11.4%.

DiscussionPre-endoscopy management was varied, but gen-erally there is room for improvement. Worryingly, NICE guidelines for correction of anticoagulation were not followed. This led to delays in endos-copy which could have led to adverse events in these patients. For reasons that remain unclear, the patients who were unstable on presentation were referred later than patients who were stable at presentation. After being referred, the gas-troenterology consultants arranged endoscopy promptly.

Action planThe results of the initial audit have been present-ed to a number of groups and committees within

the Trust. After feedback from these meetings, we developed and implemented a streamlined “Up-per GI bleed pathway” to standardise the man-agement of these patients pre-endoscopy. This guideline specifies which patients need emergen-cy endoscopy and under which circumstances the on call gastroenterologist should be contacted. Being able to follow the guideline should encour-age medical staff to contact the endoscopist early and appropriately to reduce the waiting times of these patients.

Real life outcomes of biofeedback thera-py for chronic constipation in a UK-based district general hospital - is there a case for less intensive follow-up?DH Vasant, K Solanki, RK Sharma, LJ Quest, R George, S Balakrishnan, N Radhakrishnan The Pennine Acute NHS Hospitals Trust

IntroductionBiofeedback therapy (BFT) is effective for chronic constipation, particularly in dyssynergic defeca-tion (DD). Whilst bi-weekly induction followed by periodic re-enforcements is advocated, evidence for this approach is unclear. We retrospectively evaluated outcomes in our less-intensive com-mode-based BFT programme adapted from the Iowa protocol.

MethodsChronic constipation patients satisfying Rome III criteria (n=100, median 42 years, 88% female) enrolled in our Gastroenterologist-led BFT pro-gramme between 2009-14 were reviewed. Where patients were lost to follow-up, data including outcomes and the reason for drop-out were ob-tained retrospectively from; casenotes, telephone survey and a database provided by the book-ing team. Patients were classified as responders (complete or partial) or non-responders based on symptoms. The 2 groups were compared statisti-cally for factors including; demographics, symp-toms, DD, QOL scores, comorbidities, anorectal manometry (ARM) data, anorectal co-ordination (ARC) technique/practice and the number and frequency of sessions.

ResultsPatients attended a mean 3 (SEM ±0.2) BFT ses-sions with 59 (±3) days between visits. Despite 90% having anismus on ARM, only 64% met strict criteria for DD, 21% had normal transit, 2% slow transit and 13% unspecified constipation. All had


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Poster Round

outcome measures despite 11% having ongoing BFT and 46% drop-outs. Sub-analysis of com-pleted cases (n=43) revealed 35/43 (81%) were responders, with improved stool frequency (me-dian pre 1.5/week to 7/week post-BFT, P<0.0001). Of interest, 32/43 completed patients had DD with 78% response vs. only 27% response in non-DD (P=0.002). By contrast, only 23/57 pa-tients that had not completed BFT responded, giving an overall response rate of 58% (complete n=30, partial n=20). Responders were younger (P<0.0001), had lower incidences of rectal digita-tion (P=0.004) and co-existing fecal incontinence (FI) (P=0.02), lower baseline stool frequency (P=0.002), better ARC technique (P=0.008) and fewer drop-outs (P<0.0001). The reason for drop-out was obtained for 32/46 (70%).

DiscussionDespite 2-monthly BFT without bi-weekly in-duction we achieved outcomes comparable to intensive BFT in completed cases. Our data suggest a more intensive approach may benefit older patients, those rectally digitating, those with co-existing FI and poorer ARC technique. A customized regime based on these predictive factors may improve outcomes and reduce drop-out rates.

Day case oesophageal self explanding metallic stent (SEMS) placemenent is safe and saves bed daysV Balachandrakumar , A Goel , E Darling , M Hen-drickse, V MaheshBlackpool Victoria Hospital

IntroductionSEMS is an accepted endoluminal palliative treatment for symptom control in patients with oesophageal cancer.Current practice of SEMS placement including techniques, pre and post procedure care varies widely across the UK; with many hospitals admitting patients both pre and post procedure.

AimsTo evaluate the safety and effectiveness of day case SEMS placement for oesophagogastric can-cer.

MethodsRetrospective case note review of all patients undergoing SEMS placement from Jan 2012 to Dec 2014 was performed. Day case patients were

admitted to the endoscopy unit in the morn-ing, standard consent and sedation procedures was followed. SEMS inserted under radiological and endoscopic or endoscopic guidance alone. Patients were monitored for 1.5-2hrs post pro-cedure, nurse led discharge with a prescription for oral liquid opiates, anti-emetics and Proton pump inhibitors . All had telephonic access to a dedicated cancer specialist nurse during working hours and on call team out of hours. Inpatients needing stenting followed similar protocol for post-procedure care. Relevant outcomes data was collected and statistical analyses were per-formed on GraphPad Prism Version 6 and Epi Info 7.

Results

Complications Day Case(79)

In Patients(59)

Pain 12 2

Migration 8 2

Reflux 7 1

Bleeding 1 2

30 day mortality 1 2

138 procedures were carried out on 127 patients (41 women, 86 men) with a median age 78.2 (IQR 69 – 83.25), Range (52- 96). 93 patients had ade-nocarcinoma, 26 squamous cell carcinoma, 6 ex-trinsic compression and 2 benign diseases. SEMS deployment was successfully achieved in all 138 procedures, 79 as day case (DC) and the rest 59 as inpatients (IP). Median stent length used was comparable in the groups DC 11cm (IQR 10-12), IP 11cm (IQR 10-12.5). Good dysphagia alleviation was obtained in both groups (dysphagia scores: IP cohort pre-stent 2.7 ± 0.16, post-stent 0.57 ±0.66 P < 0.001; DC cohort pre-stent 2.63 ± 0.11, post-stent 0.48 ± 0.17 P < 0.001). Median survival was 136 days (IQR43–171) in IP group and 125 days (IQR 29.65–183.5) in DC group. DC cohort reported more post procedure pain requiring analgesia and reflux symptoms as compared to IP. Bleeding (minor), stent migration and 30 day mortality was comparable in the two groups. No major procedure related complications reported.

ConclusionSEMS placement as day case is safe and compli-cation rates and mortality is equivalent to inpa-tients. In our hospital, the basic cost of a gen-eral medical hospital bed day is £330, thereby equating to a £26000 in total cost saving per day


of admission in bed cost. Day case SEMS produced a reduction in hospital admissions and hospital bed day occupancy with major cost savings.

An unusual life-threatening complication of routine diagnostic upper GI endoscopy – a case for being less random with duodenal biopsies?DH Vasant, M Sapundzieski, N Radhakrishnan, R GeorgePennine Acute NHS Hospitals Trust

IntroductionDiagnostic upper gastrointestinal endoscopy is a re-markably safe procedure. One of the commonest indications for this procedure is to obtain duodenal biopsies to diagnose or exclude coeliac disease. Re-cent British Society of Gastroenterology and American College of Gastroenterology guidelines have recom-mended changes to biopsy practice to improve diag-nostic yield.

Case PresentationHere we present the case of a previously well female referred with iron deficiency anaemia who developed acute upper abdominal pain within two hours follow-ing a ‘straight-to-test’ diagnostic upper gastrointes-tinal endoscopy. During the procedure she had duo-denal biopsies taken to exclude coeliac disease. She underwent a series of laboratory and imaging inves-tigations and endured a lengthy hospital admission for severe acute necrotising pancreatitis and related septicaemia which required multiple necrossectomy procedures. She developed long-term complications such as a pancreatic pseudoscyst which required a cyst gastrostomy and both endocrine and exocrine pancre-atic dysfunction. This patient did not have any of the usual risk-factors for acute pancreatitis and given the close temporal relationship it was felt the procedure was implicated.

DiscussionThis case is topical in light of recent changes to duode-nal biopsy recommendations and has important learn-ing points. Inadvertent trauma to the ampulla from the biopsy forceps during distal duodenal biopsies was felt to be the most likely mechanism of acute pancreati-tis. Whilst an extremely rare occurrence review of the literature reveals six other similar reported cases. We have considered ways in which similar occurrence may be avoided in the future during random duodenal bi-opsies1.

Reference1Vasant et al. Gastrointestinal Endoscopy (in press

2015) Diagnosing adult celiac disease – a case for be-ing less random with duodenal biopsies?

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Poster Round


Ampullary characteristics as a novel means of predicting ERCP complexityK McWhirter, A MakinCentral Manchester Foundation Trust

IntroductionEndoscopic Retrograde CholangioPancreatography (ERCP) is a technically demanding procedure, with significant risk of complications. Cannulation success is widely regarded as a key performance indicator of high- quality ERCP practice1, 2. Multiple factors affect-ing the complexity of a complete ERCP procedure have been suggested as a way of adding meaning and rele-vance to success rates and incidence of complications. We propose that a concept where complexity stratifi-cation is used to predict outcome based on ampullary characteristics.

MethodsNative ampullae were classified into three distinct groups, non-prominent, prominent and distorted based on endoscopic appearance. The method of can-nulation was recorded, as was the number of ampul-lary contacts. The success rate of cannulation and inci-dence of complications was compared.

ResultsOne hundred and five ERCP cases were recorded pro-spectively (54 men; mean age 64 years). The most common indication was bililary duct stones (61 cases). Ampullae were classified as non-prominent in 44 cas-es, prominent in 19 and distorted in 42. Within the dis-torted group 20 were obscured by a covering mucosal fold, 12 were peri-diverticulum and 10 had tumour involvement. Overall deep cannulation was success-ful in 98 cases (93.3%). Fewer contacts were made with the ampulla prior to successful cannulation in the non-prominent ampulla group (p=0.01), with less use of needleknife fistulotomy to gain access (p=0.005). Complications occurred in 9 patients (8.6%), compris-ing pancreatitis (6), readmission (2) and perforation (1). Complication rate was not affected by cannulation outcome, number of ampullary contacts or trainee in-volvement. Most complications were seen in the non-prominent ampulla cohort, with 5 episodes of pancre-atitis, one readmission with pain and one perforation.

DiscussionThe assessment of ampullary characteristics may prove to be a novel means of predicting cannulation difficulty and anticipating risk of complication. Non-prominent ampullae appear to be easier to cannulate, with fewer ampullary contacts and less use of needle-knife fistulotomy. However, complication rates ap-

pear highest in this group, requiring further study. In prominent and distorted ampullae there is more tissue around the papilla, allowing leeway when attempt-ing cannulation and safe margins when performing sphincterotomy. A non-prominent ampulla, perceived to be simple, may result in a less careful technique, but we suggest the concept of “ampullary safe space” and therefore more consideration given to anatomy when performing therapy. These findings have implication for case selection in ERCP training, and may add valid-ity to key outcome quality indicators in practice.

References1ASGE. Quality Indicators for ERCP. 2015.2British Society of Gastroenterology. ERCP - The Way Forward. A Standards Framework. 2013.

The clinical and phenotypic assessment of Ultra-Short Coeliac DiseasePD Mooney, M Kurien, KE Evans, M Hadjivassiliou, P Vergani, SS Cross, JA Murray, DS Sanders Royal Hallamshire Hospital, Sheffield IntroductionData suggests that an additional duodenal bulb (D1) biopsy may increase the diagnostic yield for coeliac disease (CD) by up to 10%. However no consensus exists on necessity of D1 biopsy. One reason may be that it is not clear if these patients with Ultra-Short Co-eliac Disease (USCD) have the same phenotype or are at risk of the same consequences as conventional CD. We aimed to assess the clinical phenotypes of patients with USCD compared to those with conventional dis-ease.

MethodsAll patients attending a specialist CD endoscopy list were invited to take part. All patients had duodenal biopsy taken as routine. Patients had standard qua-drantic biopsies taken from the second part of the duodenum (D2) and at least one biopsy taken from D1. Biopsies were analysed separately according to the Marsh classification system. Marsh 3 disease was required to diagnose CD. Patients had concurrent tis-sue tranglutaminase (tTG) and endomysial antibodies (EMA) and total IgA. All patients with VA were followed up in the CD specialist clinic where routine hematol-ogy, biochemistry, HLA typing and DXA scans were re-quested. Presenting symptoms and immunology were compared for all presentations. Hematology and bio-chemistry results were compared to a control group of patients that had CD excluded with normal serology and histology.

Academic Research Symposium

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Results1378 new presentations (62% female; mean age 50.3) underwent duodenal biopsy. 268 (19.4%) new diag-noses of CD were made (66% female; mean age 41.6). CD patients were significantly younger than controls (p<0.0001). 25/268 (9.3%) of new CD patients had USCD. Univariate analysis showed fewer USCD patients had diarrhoea than conventional CD (3.8 vs 24.0%, P<0.0001). Decision tree analysis to identify USCD showed the absence of diarrhoea was the single dis-criminating factor (Adj P=0.018). Rates of osteoporo-sis (p=0.78) and anaemia (p=0.14) were equal. Ferritin deficiency (P=0.007) and folate deficiency (P=0.003) rates were higher in conventional CD than USCD and controls. On multivariate analysis, patients with USCD were younger than those with conventional CD 36.6 vs. 42.1 (AOR 0.97 (0.94 – 0.998) P=0.03), had lower tTG titres (AOR 0.89 (0.81 – 0.98) P=0.02) and were less likely to have folate deficiency (AOR 1.17 (1.01 – 1.36) P=0.03) compared to conventional disease. ConclusionsUSCD appears to represent early disease with younger age and lower tTG titres and may represent a milder form of CD with lower rates of diarrhoea and folate de-ficiency. Long term follow up of patients with USCD is required to fully assess the clinical impact of diagnosis.

Modern pelvic chemoradiotherapy tech-niques continue to affect the small bowelKL White1, CC Henson2, S Burden3, S Lal4, SE Davidson1, J McLaughlin3

1Christie NHS Foundation Trust, 2Royal Liverpool Uni-versity Hospital, 3University of Manchester, 4Salford Royal Foundation Trust

IntroductionAcute diarrhoea is common during pelvic chemora-diotherapy and is multifactorial in origin. Previous studies show a prevalence of 44-57% bile acid mal-absorption (BAM), 26% small intestinal bacterial over-growth (SIBO) and 15-44% lactose intolerance during the acute toxicity phase. However radiotherapy tech-niques have evolved since these earlier studies from 2D to 3D techniques and with recently introduced Volumetric Modulated Arc Therapy the radiotherapy beam can be shaped more closely around the tumour to spare organs at risk such as the small bowel. We aimed to determine the prevalence of these diagnoses in symptomatic patients receiving newer techniques at our centre.

MethodsThis nested study was part of a trial evaluating the use of a gastrointestinal intervention for patients with cer-vical and bladder cancer receiving pelvic chemoradio-therapy. When patients developed lower gastrointesti-nal symptoms, SeHCAT and hydrogen-methane breath tests were performed using the Quintron Breathtrack-er to detect BAM, SIBO and lactose intolerance.

ResultsOf 21 patients, 20 had hydrogen methane breath test-ing for SIBO and 17 for lactose intolerance. Twenty patients underwent SeHCAT. Of the 11 patients with bladder cancer, 10 were male. All received 20 fractions of radiotherapy over 4 weeks with weekly chemother-apy. See table for full demographics.

Cervical cancer (n=10) Bladder cancer (n=11)

Median age 48 (27-62) Median age 69 (53-75)

Chemoradiotherapy regime:

3D conformal 6VMAT 4Median dose 4000 Gy

Cisplatin 10

Chemoradiotherapy regime:

3D conformal 11Median dose 5250 Gy

Gemcitabine 11VMAT - Volumetric Modulated Arc Therapy

From the start of radiotherapy SeHCAT was completed after a median 25 days, glucose hydrogen methane breath testing after a median of 19 days and lactose hydrogen methane breath testing after a median of 27 days. Overall the prevalence of BAM was 65% (13/20). SeHCAT was positive in 90% of the patients with cervi-cal cancer and 40% of the patients with bladder can-cer. Of the 13 patients who had BAM the prevalence of mild, moderate and severe BAM were 23%, 31% and 46% respectively. SIBO was diagnosed in 21% (4/19) by a rise in hydrogen in all cases. Of patients with cervical cancer 38% (3/8) had SIBO compared with 9% (1/11) patients with bladder cancer. Lactose intolerance was diagnosed in 29% (5/17) patients by a rise in hydrogen in all cases. Of the patients with bladder cancer 30% (3/10) had lactose intolerance while 29% (2/7) of the patients with cervical cancer tested positive. Of the VMAT treated patients, 3/4 tested positive for BAM, 0/3 for SIBO and 1/2 for lactose intolerance.

ConclusionsDespite recent advances in radiotherapy treatment with techniques sparing the small intestine from direct irradiation, the prevalence of BAM, SIBO and lactose in-tolerance in symptomatic patients in this study is simi-lar to that previously described. This suggests that the

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new radiotherapy techniques do not reduce the risk of small bowel bystander effects. The mechanistic basis for this is currently unclear.

Pre-endoscopy point of care testing for co-eliac disease in anaemia: a cost saving eco-nomic model1PD Mooney, 2L Svabe, 2K Andrews, 2S Moreea, 3I Hay-them, 3S Hoque, 4J Elias, 4K Bundhoo, 4G Corbett, 5M Lau, 5L Wong, 5H Tsai, 1DS Sanders1Royal Hallamshire Hospital, Sheffield2Bradford Royal Infirmary, Bradford3Whipps Cross University Hospital, London4Addenbrookes Hospital, Cambridge5Hull Royal Infirmary, Hull

IntroductionCurrent British iron deficiency anaemia guidelines recommend pre-endoscopy serological testing for coeliac disease (CD) and duodenal biopsy only for patients with a positive test. However many patients who attend endoscopy for investigation of anaemia do not have serology available. Thus the clinician is then committed to perform a duodenal biopsy. This gap in clinical practice could be bridged by a rapid point of care test (POCT). We aimed, to assess the role of a novel POCT (Simtomax which detects IgA and IgG de-ami-dated gliadin peptide antibodies) in anaemic patients in a pre-endoscopy setting.

MethodsGroup 1, a multicentre retrospective analysis of pa-tients attending endoscopy for duodenal biopsy was undertaken in 4 UK hospitals (Whipps Cross, Hull, Brad-ford, Addenbrookes). The presenting characteristics and availability of serology prior to endoscopy was re-corded. Group 2, patients presenting to endoscopy for investigation of anaemia were prospectively recruited. All patients received the POCT prior to their OGD and duodenal biopsy. Results were compared to the gold standard of villous atrophy.

ResultsGroup 1, 2339 patients (58% female, mean age 75.3) underwent duodenal biopsy. Serology was available prior to endoscopy in 912 patients (39%). Anaemia was the most common indication (934 patients, 39.9%). In anaemia, serology was available prior to OGD in 32%. On multivariate analysis of presenting characteristics patients with anaemia were less likely to have serol-ogy available than other groups (AOR 0.55 (0.44 – 0.70) p<0.0001). CD was more likely if patients had serology done prior to their OGD (8.1% vs. 1.1%, p<0.0001).

Group 2, 129 patients (64% female; mean age 56.6) being investigated for anaemia underwent POCT and duodenal biopsy. 23 patients (17.8%) were diagnosed with CD. Sensitivity, specificity, positive and negative predictive values of the POCT were 100% (82 – 100), 76% (67 – 84), 48% (34 – 63) and 100% (94 -100). In this cohort 81 (63%) duodenal biopsies could have been avoided. Based on a cost of £86 for duodenal biopsy this could result in a saving of £5,399 per 100 endos-copies. In a recent 3 month audit in Sheffield 479/2719 (18%) OGDs were performed for anaemia. Using the POCT in Sheffield could save £103,445 per year.

ConclusionsAvailability of coeliac serology prior to endoscopy is poor. Diagnostic yield of duodenal biopsy is signifi-cantly higher in patients who have had serology prior to their endoscopy (p<0.0001). An accurate POCT prior to endoscopy could significantly reduce the numbers of unnecessary duodenal biopsies resulting in signifi-cant cost savings. In this pilot cohort, Simtomax had 100% sensitivity. Further large studies are required.


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