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ObjectiveEndoscopic resection (ER) often involves referral to tertiary centres with high volume practices. Lesions can be subject to prior manipulation and mischaracterisation of features required for accurate planning, leading to prolonged or cancelled procedures. As potential solutions, repeating diagnostic procedures is burdensome for services and patients, while even enriched written reports and still images provide insufficient information to plan ER. This project sought to determine the frequency and implications of polyp mischaracterisation and whether the use of telestration might prevent it.Design/methodA retrospective data analysis of ER referrals to four tertiary centres was conducted for the period July–December 2019. Prospective telestration with a novel digital platform was then performed between centres to achieve consensus on polyp features and ER planning.Results163 lesions (163 patients; mean age 67.9±12.2 y; F=62) referred from regional hospitals, were included. Lesion site was mismatched in 11 (6.7%). Size was not mentioned in the referral in 27/163 (16.6%) and incorrect in 81/136 (51.5%), more commonly underestimated by the referring centre (ConclusionsPolyp mischaracterisation is a frequent feature of ER referrals, but could be corrected by the use of telestration between centres. Our study involved expert-to-expert consensus, so extending to ‘real-world’ referring centres would offer additional learning for a digital pathway.

Climate change has been described as ‘the biggest global health threat of the 21st century’.1 Medical professionals have a vital role in mitigating the impact of healthcare systems on the environment and protecting vulnerable people through the development of sustainable clinical practices. We have previously written about how gastroenterologists must act now to change our endoscopy practice and make it more aligned with core principles of environmentally sustainable healthcare. But it is clear there is a significant lack of evidence to accurately define the scope of the environmental impact of gastroenterology services, or models of best practice to shape policy and move the field in a new direction. This article aims to provide a framework for us to design and implement quality improvement projects (QIPs) in gastroenterology as a strategy to deliver a more sustainable future in line with the National Health Service (NHS) Net Zero targets.2 Mortimer et al have described the key principles required,3 4 and we aim to apply these to a gastroenterology context and specifically endoscopy services. The value of a healthcare intervention relates to the outcomes delivered against its cost, and the benchmark for cost-effectiveness set by the National Institute for Health and Care Excellence is £20–30 000 per quality-adjusted life year gained.5 However, economists interested in sustainability recognise that costs also need to recognise the social and environmental impact of what is consumed: the so-called ‘triple bottom line’.6 Value can thus be presented using this schematic formula as described by Mortimer et al 3: Value=outcomes for patients and populations/environmental+social+financial impacts. Considered in this way, every healthcare intervention has not only financial implications, but also a social cost on the patient and their family/carers, and environmental implications from resource use and carbon footprint, against which the clinical benefit needs …

ObjectiveThe COVID-19 pandemic has placed increased strain on healthcare systems worldwide with enormous reorganisation undertaken to support ‘COVID-centric’ services. Non-COVID-19 admissions reduced secondary to public health measures to halt viral transmission. We aimed to understand the impact of the response to COVID-19 on the outcomes of upper gastrointestinal (UGI) bleeds.Design/methodsA retrospective observational multicentre study comparing outcomes following endoscopy for UGI bleeds from 24 March 2020 to 20 April 2020 to the corresponding dates in 2019. The primary outcome was in-hospital survival at 30 days with secondary outcomes of major rebleeding within 30 days postprocedure and intervention at the time of endoscopy.Results224 endoscopies for 203 patients with UGI bleeds were included within this study. 19 patients were diagnosed with COVID-19. There was a 44.4% reduction in the number of procedures performed between 2019 and 2020. Endoscopies performed for UGI bleeds in the COVID-19 era were associated with an adjusted reduced 30-day survival (OR 0.25, 95% CI 0.08–0.67). There was no increased risk of major rebleeding or interventions during this era. Patients with COVID-19 did not have reduced survival or increased complication rates.ConclusionEndoscopy for UGI bleeds in the COVID-19 era is associated with reduced survival. No clear cause has been identified but we suspect that this is a secondary effect of the response to the COVID-19 pandemic. Urgent work is required to encourage the public to seek medical help if required and to optimise patient pathways to ensure that the best possible care is provided.

As the incidence of inflammatory bowel disease (IBD) rises and the global population ages, the number of older people living with these conditions will inevitably increase. The challenges posed by comorbid conditions, polypharmacy, the unintended consequences of long-term treatment and the real but often underestimated mismatch between chronological and biological ages underpin management. Significantly, there may be differences in disease characteristics, presentation and management of an older patient with IBD, together with other unique challenges. Importantly, clinical trials often exclude older patients, so treatment decisions are frequently pragmatic, extrapolated from a number of sources of evidence and perhaps primarily dictated by concerns around adverse effects. This review aimed to discuss the epidemiology, clinical features and considerations with management in older patients with IBD.

Background: The duodenum has become a metabolic treatment target through bariatric surgery learnings and the specific observation that bypassing, excluding or altering duodenal nutrient exposure elicits favourable metabolic changes. Duodenal mucosal resurfacing (DMR) is a novel endoscopic procedure that has been shown to improve glycaemic control in people with type 2 diabetes mellitus (T2D) irrespective of body mass index (BMI) changes. DMR involves catheter-based circumferential mucosal lifting followed by hydrothermal ablation of duodenal mucosa. This multicentre study evaluates safety and feasibility of DMR and its effect on glycaemia at 24 weeks and 12 months. Methods: International multicentre, open-label study. Patients (BMI 24-40) with T2D (HbA1c 59-86 mmol/mol (7.5%-10.0%)) on stable oral glucose-lowering medication underwent DMR. Glucose-lowering medication was kept stable for at least 24 weeks post DMR. During follow-up, HbA1c, fasting plasma glucose (FPG), weight, hepatic transaminases, Homeostatic Model Assessment for Insulin Resistance (HOMA-IR), adverse events (AEs) and treatment satisfaction were determined and analysed using repeated measures analysis of variance with Bonferroni correction. Results: Forty-six patients were included of whom 37 (80%) underwent complete DMR and 36 were finally analysed; in remaining patients, mainly technical issues were observed. Twenty-four patients had at least one AE (52%) related to DMR. Of these, 81% were mild. One SAE and no unanticipated AEs were reported. Twenty-four weeks post DMR (n=36), HbA1c (-10±2 mmol/mol (-0.9%±0.2%), p, SCOPUS: ar.j, info:eu-repo/semantics/published

The significantly increased risk of colorectal cancer (CRC) in longstanding colonic inflammatory bowel disease (IBD) justifies the need for endoscopic surveillance. Unlike sporadic CRC, IBD-related CRC does not always follow the predictable sequence of low-grade to high-grade dysplasia and finally to invasive carcinoma, probably because the genetic events shared by both diseases occur in different sequences and frequencies. Surveillance is recommended for patients who have had colonic disease for at least 8-10 years either annually, every 3 years or every 5 years with the interval dependant on the presence of additional risk factors. Currently, the recommended endoscopic strategy is high-definition chromoendoscopy with targeted biopsies, although the associated lengthier procedure time and need for experienced endoscopists has limited its uniform uptake in daily practice. There is no clear consensus on the management of dysplasia, which continues to be a challenging area particularly when endoscopically invisible. Management options include complete resection (and/or referral to a tertiary centre), close surveillance or proctocolectomy. Technical advances in endoscopic imaging such as confocal laser endomicroscopy, show exciting potential in increasing dysplasia detection rates but are still far from being routinely used in clinical practice.

We read with interest the paper by Bang et al on the equivalence of single-use duodenoscopes compared with conventional reusable duodenoscopes to prevent transmissible infections.1 We congratulate the authors for their study demonstrating the economic, technical and safety equivalence of single-use duodenoscopes to conventional reusable duodenoscopes for endoscopic retrograde cholangiopancreatography (ERCP). The drive toward single-use endoscopes was generated by the incidence of duodenoscope-related infections in the USA, prompting the Food and Drug Administration in 2019 to recommend that healthcare providers and manufacturers transition to disposable components in duodenoscopes to reduce transmissible infections. A systematic review and meta-analysis of the rate and impact of duodenoscope infection involved 15 studies with over 13 000 duodenoscope analysis and found a 15.25% rate of contamination from preprocessed patient-ready duodenoscopes.2 It must be stated that the risk …

ObjectiveThe aims of this study were to describe community antibiotic prescribing patterns in individuals hospitalised with COVID-19, and to determine the association between experiencing diarrhoea, stratified by preadmission exposure to antibiotics, and mortality risk in this cohort.Design/methodsRetrospective study of the index presentations of 1153 adult patients with COVID-19, admitted between 1 March 2020 and 29 June 2020 in a South London NHS Trust. Data on patients’ medical history (presence of diarrhoea, antibiotic use in the previous 14 days, comorbidities); demographics (age, ethnicity, and body mass index); and blood test results were extracted. Time to event modelling was used to determine the risk of mortality for patients with diarrhoea and/or exposure to antibiotics.Results19.2% of the cohort reported diarrhoea on presentation; these patients tended to be younger, and were less likely to have recent exposure to antibiotics (unadjusted OR 0.64, 95% CI 0.42 to 0.97). 19.1% of the cohort had a course of antibiotics in the 2 weeks preceding admission; this was associated with dementia (unadjusted OR 2.92, 95% CI 1.14 to 7.49). After adjusting for confounders, neither diarrhoea nor recent antibiotic exposure was associated with increased mortality risk. However, the absence of diarrhoea in the presence of recent antibiotic exposure was associated with a 30% increased risk of mortality.ConclusionCommunity antibiotic use in patients with COVID-19, prior to hospitalisation, is relatively common, and absence of diarrhoea in antibiotic-exposed patients may be associated with increased risk of mortality. However, it is unclear whether this represents a causal physiological relationship or residual confounding.

Symptomatic diverticular disease (DD) is a major worldwide healthcare burden, and diverticular bleeding is one of its most common manifestations. Endoscopic clipping of selected diverticula in the acute or early posthaemorrhage period has been reported as a haemostatic intervention, but the effect of elective clipping is not known. We present the prospective series of elective endoscopic clipping with the aim of treating all visible diverticula in patients with previous bleeding, resulting in near-complete disappearance of DD. This may have significant implications for the management of DD worldwide and warrants further prospective research. This was a prospective, single-centre study enrolling consecutive patients attending a specialist DD clinic at our institution, who had been previously hospitalised for lower GI bleeding due to DD (table 1). The procedures and follow-up colonoscopies were carried out from April 2015 to April 2017 at King’s College Hospital, London, UK. Patients with other GI pathologies were excluded from the study. View this table: Table 1 Episodes of confirmed diverticular bleeding requiring transfusion and hospitalisation before the procedure and in 1 year of follow-up Patients were enrolled only if the diagnosis had been confirmed by abdominopelvic CT scan and full colonoscopy during an episode of PR bleeding. The results and management plan were discussed in a multidisciplinary team meeting with informed consent from the patients. Any patients requiring previous admissions and transfusion for confirmed severe diverticular bleeding were included in the study. Patients underwent colonoscopy after full oral bowel preparation (Moviprep, Norgine Pharmaceuticals) under conscious sedation with midazolam and fentanyl. On withdrawal of the colonoscope (Olympus CF-H260DL or CF-H260AZL), all visible diverticula were carefully cleaned of residual stool using water delivered through the working channel …

> “It is more important to know what sort of person has a disease than to know what sort of disease a person has.” Hippocrates The medical management of patients with irritable bowel syndrome is often unsatisfactory. Doctors are still taught that irritable bowel syndrome is a diagnosis of exclusion, and patients readily sense that they are being told that nothing is really wrong with them. Many people soon come to appreciate that the range of medical treatments available is limited in both scope and efficacy. The mood of negativity, once established, is difficult to dispel. #### Summary points Current medical treatment includes drugs that alter intestinal motility—such as antispasmodics, 5-hydroxytryptamine antagonists, antidiarrhoeals, and laxatives—and dietary changes, including fibre supplementation and identification of food intolerances.1 Response may vary, but the failure rate of these “physical” treatments is high, which may lead to the conclusion that irritable bowel syndrome has a strong psychological component. A diagnosis of exclusion has been made—again with negative, rather than positive therapeutic, connotations. Although many doctors are aware that antidepressants have been used in irritable bowel syndrome, they seem reluctant to prescribe such agents, not least because suggesting this as a valid option to patients who are clearly not depressed …

Introduction Inadequate bowel preparation reduces the diagnostic accuracy of colonoscopy. This has a significant impact on patients’ safety and the endoscopy units waiting lists. 90% adequate bowel preparation is a quality and safety indicator for endoscopy according to the Joint Advisory Group (JAG). The aim of this study is to determine the effect of patient pre-assessment on the quality of bowel preparation. The role of the cleansing agent was also assessed. Methods This is a retrospective observational study on consecutive patients undergoing elective colonoscopy in our centre from October 2014 until September 2015. Adults undergoing routine diagnostic colonoscopy, bowel cancer screening colonoscopy and chromoendoscopy were included. Sodium picosulphate (PIC) was used as cleansing agent in the first two groups whereas pegylated ethylene glycol with senna (PEG) was used in the latter. According to duration pre-assessment was either limited (LIM, 15 mins) or prolonged (PRO, 45 mins). Quality of bowel preparation was rated as inadequate, adequate and excellent. Results 2900 procedures were evaluated. 60% of the patients were male and the mean age was 58.8 +/- 15.68 years. 1670 (57.58%) were pre-assessed, of which 1329 received LIM/PIC, 280 PRO/PIC and 65 LIM/PEG. 1230 (42, 42%) were not preassessed and had PIC (NO/PIC). Inadequate bowel preparation was reported in 13.31% (n = 386) of the whole cohort. The rate of inadequate bowel preparation in each group was: NO/PIC (17.8%), LIM/PIC (11.51%), LIM/PEG (10.77%), PRO/PIC (2.53%). Pre-assessment showed significant association with bowel preparation outcome (p Further multiple regression analysis showed that patients who had no pre-assessment were more likely to present with inadequate bowel preparation (OR 15.46, CI [7.15–33.4]) compared to patients who underwent prolonged preassessment. Patients undergoing limited preassessment were more likely to present with inadequate bowel preparation (OR 8.16, CI [3.76–17.70]) compared to patients who underwent prolonged pre-assessment. Conclusion This study identifies a prognostic role of preassessment in bowel preparation for colonoscopy. The cleansing agent seems to have no effect but only a small number of patients receiving preparation with PEG were included in this study. Further analysis of more categorical independent variables is required to formulate a predictive model for inadequate bowel preparation. Reference 1 R. Valori. BSG Quality and Safety Indicators for Endoscopy, March 2007 Joint Advisory Group. Disclosure of Interest None Declared

Introduction The clearance of Escherichia coli (EC) from the tissues in Crohn9s disease (CD) is grossly impaired,1 particularly at high inoculating doses of bacteria. It has not been determined whether this is specific to Gram-negative bacteria. These studies were conducted to determine whether the inflammatory response to the Gram-positive bacterium S. aureus (SA) in vivo and clearance of these bacteria is abnormal in CD. Macrophage cytokine secretion, which in CD is markedly deficient in response to stimulation with EC1, was also studied in response to SA. Methods The acute inflammatory response to SA, and clearance of 32 P-labelled, UV-killed SA (NCTC 6571) from a forearm injection site1 was compared over 72 h in five healthy controls (HC) and 5 patients with CD. Results were compared with historical data for EC (in the same subjects). TNF-α secretion by peripheral blood monocyte (PBMC)-derived macrophages after stimulation with SA and EC were compared in all participants, and up to n=50 for HCs and CD (using Bioassay and ELISA techniques). Results Local blood flow after inoculation of 3×10 7 SA was significantly lower than that observed after inoculation of 3×10 7 EC (p Conclusion EC is a more potent activator of acute inflammation than SA. Macrophage cytokine secretion and subsequent clearance of SA was normal in CD – a significantly different response to that seen with EC. This is likely to reflect the different composition of these organisms (particularly the presence of LPS in Gram-negative species) and could explain the restriction of CD predominantly to areas of the gastrointestinal tract containing high concentrations of Gram-negative bacteria.

Autologous haematopoietic stem cell transplantation (HSCT) for Crohn’s disease has been described by Oyama and co-workers as producing remission in 11 of 12 patients with refractory Crohn’s disease after a median follow up of 18.5 months.1 They postulated that autologous HSCT was useful for refractory Crohn’s disease. We report the case of a 32 year old woman with biopsy proven Crohn’s disease diagnosed when she was 16 years old. Her mother also suffered from Crohn’s disease. She developed a KI1 positive anaplastic non-Hodgkin’s lymphoma (NHL) three years later, treated successfully with ablative CHOP chemotherapy and autologous HSCT, inducing remission for …