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ObjectiveTo assess the risks and benefits of reverse mentoring of consultants by junior doctors.DesignA feasibility study divided into two phases: first a semistructured interview where performance of participating consultants was assessed by junior doctors and then a second phase allowing for feedback to be given on a one-to-one basis. Data collected through questionnaires with free text questions and Likert scores.SettingTertiary teaching hospital in the UK.ParticipantsSix junior doctors (66.6% male, age range 31–40 years) and five consultants (80% male, age range 35–65 years and consultants for 5–20 years).InterventionReverse mentoring session.Main outcome measureThe concerns and/or benefits of the process of reverse mentoring. Confidence was assessed in 7 domains: clinical practice, approach to juniors, approachability, use of technology, time management, strengths and areas for improvement using Likert scales giving a total out of 35.ResultsThe most common concerns cited were overcoming the hierarchical difference and a selection bias in both mentors and mentees. However, no participant experienced this hierarchical difference through the reverse mentoring process and no relationships were negatively affected. Mentors became more confident in feeding back to seniors (23 vs 29 out of 35, p=0.04) most evident in clinical practice and areas to improve (3 vs 4 out of 5, p=0.041 and 3 vs 5 out of 5, p=0.041, respectively).ConclusionWe present the first study of reverse mentoring in an NHS clinical setting. Initial concerns with regard to damaged relationships and hierarchical gradients were not experienced and all participants perceived that they benefited from the process. Reverse mentoring can play a role in engaging and training future leaders at junior stages and provide a means for consultants to receive valuable feedback from junior colleagues.

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The demand for small bowel (SB) capsule endoscopy (CE) is increasing in the UK. However, there remains a wide variation in the number of CE procedures performed in different centres. Across the UK there is a lack of a clear training pathway or certification process. A standardised national Joint Advisory Group (JAG) on Gastrointestinal Endoscopy approved a 1-year training and accreditation programme accessible to all professional groups that may wish to train in SB CE. Structured training is delivered using JAG-accredited CE courses and an electronic learning module. Prior to setting a knowledge-based assessment, a minimum of 50 SB CE cases are recommended to be read in tandem with a trainer at a local centre, with proficiency documented using Direct Observation of Procedural Skill (DOPS) assessments.

Capsule endoscopy has had significant development since it was introduced into the field of medicine in 2000. It is non-invasive, well tolerated, does not require sedation and is a first-line small bowel investigative modality. As it transits through the entire gastrointestinal (GI) tract, it has the potential to provide a pan-enteric examination.In this review we will discuss the new diagnostic modalities along with traditional methods which have been used for examination of the gastro intestinal (GI) tract. The main focus of this review will be on the use of capsule endoscopy for pan-enteric examination.Capsule endoscopy is an accepted first-line investigation for the small bowel. Diagnostic sensitivity of the colon capsule is comparable to colonoscopy in controlled trials and is being evaluated in high-risk patients in routine clinical practice in national programs. Preliminary data suggest that a magnetic-controlled examination of the upper GI tract could be developed to enable a complete upper GI examination.

Background Small bowel capsule endoscopy (SBCE) has an established role in the management of refractory celiac disease (RCD) for the detection of complications. The aim of this study was to define the role of SBCE in the management of patients with RCD. Method Patients with histologically confirmed RCD who underwent successive SBCEs were recruited retrospectively from 2 tertiary centers. Results Sixty patients with RCD were included. The percentage extent of the affected small bowel (SB) mucosa improved on repeating a second SBCE in 26 patients (49.1%) (median 27.6% vs. 18.1%, P=0.007). Patients with RCD type II had more extensive disease than those with RCD type I on first (41.4% vs. 19.2%, P=0.004) and second (29.8% vs. 12.0%, P=0.016) SBCE. Patients with RCD type I tended to show a greater improvement in percentage of abnormal SB involved on repeat SBCE compared to those with RCD type II (P=0.049). Nine patients (15%) had RCD-related complications. Five patients developed ulcerative jejunoileitis, 3 patients developed enteropathy-associated T-cell lymphoma, and 1 patient developed cutaneous T-cell lymphoma. Conclusions SBCE can be a useful tool for monitoring the effects of treatment, primarily following its initiation. Patients with RCD type II have more extensive SB disease, equating to a more aggressive disease pattern.

Capsule endoscopy (CE) is an established modality in the diagnostic algorithm of small bowel (SB) pathology. Its use has expanded for investigation of upper and lower gastrointestinal diseases with similar prototypes.This review covers the role and recent advances of CE, as a non-invasive investigative tool.The use of upper gastrointestinal CE is useful in patients who require surveillance for varices particularly in the current era of the COVID-19 pandemic. It has also shown high accuracy in the detection of upper gastrointestinal hemorrhage in patients presenting with a suspicion of hemorrhage. Findings on CE help to guide further management by device-assisted enteroscopy. The data on colon CE suggest comparable diagnostic accuracy to colonoscopy for polyp detection; however, more evidence is required in the high-risk group. Crohn's CE has become an integral part of the management of patients with Crohn's disease offering a comparative assessment tool post escalation of therapy. Artificial intelligence within CE has demonstrated similar if not better diagnostic yield compared to the human with a significantly shorter reading time. Artificial intelligence is likely to be in-built within CE reading platforms over the next few years minimizing reporting time and human error.

Introduction\ud \ud Patients with established coeliac disease (CD) can present with signs and symptoms requiring small bowel capsule endoscopy (SBCE) to assess for persistent disease beyond the duodenum and to rule out complications. There is paucity of data on extent of disease on SBCE in relation to histology, clinical and serological parameters. The aim of this study was to assess the relationship between symptoms, CD serology and Marsh classification of disease and extent of disease on SBCE in patients with established CD.\ud \ud \ud \ud Methods\ud \ud Hundred patients with established CD and 200 controls underwent a SBCE. SBCEs were reviewed by expert reviewers. Extent of disease on SBCE, CD findings and small bowel transit were recorded.\ud \ud \ud \ud Results\ud \ud Considering duodenal histology (D2; Marsh 3a or above) as the gold standard for diagnosing CD activity, the sensitivity of SBCE to delineate active disease was 87.2%. The specificity was 89.0%. Age at SBCE (P = 0.006), albumin (P = 0.004) and haemoglobin (P = 0.0001), Marsh score of histology from the duodenal bulb (D1) (P = 0.0001) and the second part of the duodenum (P = 0.0001), refractory CD (P = 0.007) on histology correlated with extent of affected small bowel (SB) mucosa on univariate analysis. On multiple regression analysis, albumin (P = 0.036) and Marsh score of histology (D1) (P = 0.019), vitamin B12 (P = 0.001) and folate levels (P = 0.008) were statistically significant. Extent of affected SB mucosa (11.0% vs 1.35%) was greater in patients with complications including those with refractory CD (P = 0.008).\ud \ud \ud \ud Conclusions\ud \ud This is the first study showing correlation between extent of disease and severity of duodenal histology, markers of malabsorption such as folate levels and vitamin B12 and complications of CD.

Main RecommendationsThe European Society of Gastrointestinal Endoscopy (ESGE) has recognized the need to formalize training in small-bowel endoscopy across European centers. The following criteria and framework for training in small-bowel capsule endoscopy (SBCE) and device-assisted enteroscopy (DAE), which aim to provide uniform and high quality training to ensure that small-bowel endoscopists are competent to operate independently, are based on the current literature and experience of experts in the field. Three main areas are covered: skills required prior to commencing training in small-bowel endoscopy; structured training for trainees to become independent endoscopists; and ways of ensuring competence is achieved. 1 Centers providing training in SBCE should perform a minimum of 75 – 100 SBCEs/year. 2 Experience in bidirectional endoscopies is desirable for structured training in SBCE. 3 SBCE courses should consist of at least 50 % hands-on training and cover information on technology, indications and contraindications for SBCE, pathologies that can be encountered on SBCE, and standard terminology that should be used during reporting of SBCE. An SBCE course should be completed prior to achieving competence in SBCE reporting. 4 Competence in SBCE can be assessed by considering a minimum of 30 SBCEs. Direct Observation of Procedural Skills, short SBCE videos, and multiple-choice questions can be useful to assess improvement in the skills of trainees. 5 Centers offering training in DAE should aim to carry out at least 75 DAEs/year, should have direct links with an SBCE service, and should allow regular discussion of cases at a radiology small-bowel MDT. Training centers with lower numbers are encouraged to offer training by “buddying-up” with other centers, or using mentoring systems. 6 DAE trainees must be independent in bidirectional endoscopies and have experience in level 1 polypectomy prior to commencement of training. They should also be competent in reviewing SBCEs. 7 Training in DAE should be structured with a minimum of 75 procedures, including 35 retrograde DAEs, with therapeutic procedures undertaken in at least 50 % of the DAEs performed. Training should cover the indications, contraindications, complications including prevention, and technicalities of the DAE procedure; formal evaluation should follow. DAE trainees must acquire skills to independently manage and advise on small-bowel pathology following DAE procedures. 8 It is highly recommended that international societies develop online modules and courses on DAE, which are currently lacking across Europe.

IntroductionConventional oral upper gastrointestinal (GI) endoscopy can obe uncomfortable. By comparison, transnasal endoscopy (TNE) and magnet assisted capsule endoscopy (MACE) have superior tolerability. A cost comparison of competing upper GI endoscopic modalities have yet to be performed.MethodsWe performed a cost comparison study of oral, TNE and MACE by a combination of activity-based costing and averaging of fixed costs over 24 481 upper GI endoscopies performed for dyspepsia over a 10-year period.ResultsOn average, 9.4 procedures were performed daily. TNE was cheapest at €125.90 per procedure, costing 30% less than oral endoscopy at €184.10 and threefold cheaper than MACE at €407.10. Flexible endoscope reprocessing cost €53.80. TNE was cheaper than oral endoscopy as sedation was not required. Oral endoscopies have a further rate of infectious complications, estimated to cost €16.20 per oral procedure in inpatient admissions. Oral and TNE equipment are more expensive to purchase and maintain than MACE costing €79 330 and €81 819, respectively compared with MACE at €15 420 per annum. However, capsule endoscopes cost significantly more per procedure at €369.00 than the consumables for flexible endoscopy (per oral €12.30, TNE €5.30).ConclusionsTNE cost less to perform than conventional per oral endoscopy. The cost of capsule endoscopes will need to be reduced significantly if routine use is to be expected.

Background and study aims Oropharyngeal intubation during Esophagogastroduodenoscopy (EGD) is uncomfortable, associated with aerosol generation and transmission of airborne microbes. Less-invasive alternatives may be better tolerated. In this study, patient tolerance and acceptability of EGD and transnasal endoscopy (TNE) have been compared with magnet-controlled capsule endoscopy (MACE). Patients and methods A comparison of MACE with EGD and TNE in the investigation of dyspepsia was performed. Factors affecting patient tolerance and acceptability were examined using the Endoscopy Concerns Scale (ECS) and Universal Patient Centeredness Questionnaire (UPC-Q). Results Patients were significantly more distressed (scoring least to most distress: 1–10) by gagging (6 vs 1), choking (5 vs 1), bloating (2 vs 1), instrumentation (4 vs 1), discomfort during (5 vs 1) and after (2 vs 1) EGD compared to MACE (all P Conclusions Gagging and choking during instrumentation, the main causes of patient distress during EGD, occurred less during TNE but tolerance, acceptability and patient experience favored MACE.

Iron deficiency anaemia (IDA) is a major cause of morbidity and burden of disease worldwide. It can generally be diagnosed by blood testing and remedied by iron replacement therapy (IRT) using the oral or intravenous route. The many causes of iron deficiency include poor dietary intake and malabsorption of dietary iron, as well as a number of significant gastrointestinal (GI) pathologies. Because blood is iron-rich it can result from chronic blood loss, and this is a common mechanism underlying the development of IDA—for example, as a consequence of menstrual or GI blood loss.Approximately a third of men and postmenopausal women presenting with IDA have an underlying pathological abnormality, most commonly in the GI tract. Therefore optimal management of IDA requires IRT in combination with appropriate investigation to establish the underlying cause. Unexplained IDA in all at-risk individuals is an accepted indication for fast-track secondary care referral in the UK because GI malignancies can present in this way, often in the absence of specific symptoms. Bidirectional GI endoscopy is the standard diagnostic approach to examination of the upper and lower GI tract, though radiological scanning is an alternative in some situations for assessing the large bowel. In recurrent or refractory IDA, wireless capsule endoscopy plays an important role in assessment of the small bowel.IDA may present in primary care or across a range of specialties in secondary care, and because of this and the insidious nature of the condition it has not always been optimally managed despite the considerable burden of disease— with investigation sometimes being inappropriate, incorrectly timed or incomplete, and the role of IRT for symptom relief neglected. It is therefore important that contemporary guidelines for the management of IDA are available to all clinicians. This document is a revision of previous British Society of Gastroenterology guidelines, updated in the light of subsequent evidence and developments.

BackgroundThe main risk of capsule endoscopy is retention of the capsule behind a stricture. Passage of an intact Agile patency device (Medtronic, Dublin, Ireland) through the small bowel is widely used to ensure luminal patency, although capsule retention has occurred in patients who have had a reassuring patency study. The device is designed to remain intact for at least 30 hours postingestion, such that loss of signal from the radiofrequency identification tag contained within, or absence of the device on radiological imaging, implies unimpeded intestinal transit.AimTo identify the rate of premature dissolution (MethodsOutcomes of all consecutive patients having an Agile patency device were analysed.ResultsPremature dissolution of the patency device occurred in 5 of 307 patients, an incidence of 1.3%. This was recognised by the detection of a persistent radiofrequency signal after radiological imaging had failed to identify the patency device, prompting a careful search for the radiofrequency tag on the CT scout film. The tag was difficult to detect because of an oblique lie making it appear smaller than its 13×3 mm size and confusion with intra-abdominal or other metallic fragments.ConclusionsIn the absence of radiological evidence of an intact Agile patency device, premature dissolution should be suspected in patients registering a persistent radiofrequency signal and confirmed by identifying the radiofrequency identification tag. Failure to do so might result in false reassurance that capsule endoscopy could be performed without risk of retention.

Background and aimAlthough recommended, the P-score used for assessing the pertinence / relevance of findings seen in small bowel (SB) capsule endoscopy (CE) is based on a low level of knowledge. The aim of this study was to evaluate the clinical relevance of the most frequent SBCE findings through an illustrated script questionnaire.Materials and MethodsSixteen types of SBCE findings were illustrated four times each in three different settings (occult and overt obscure gastrointestinal bleeding and suspected Crohn's disease), and with a variable number (n = 1/n = 2–5/n ≥ 6), thus providing a questionnaire with 192 scenarios and 576 illustrated questions. Fifteen international experts were asked to rate the finding's relevance for each question as very unlikely (−2) / unlikely (−1) / doubtful (0) / likely (+1) / very likely (+2). The median score (≤−0.75, between -0.75 and 0.75, or ≥0.75) obtained for each scenario determined a low (P0), intermediate (P1) or high (P2) relevance, respectively.Results8064 answers were analyzed. Participation and completion rates were 93% and 100%, respectively. In overt or occult OGIB, resultant P2 findings were 'typical angiectasia', 'deep ulceration', 'stenosis', and'blood', whatever their numbers, and 'superficial ulcerations' when multiple. While in suspected CD, consensus P2 lesions were 'deep ulceration' and 'stenosis' whatever their numbers, and 'aphthoid erosions' and 'superficial ulcerations' when multiple.ConclusionThis study establishes a guide for the evaluation of relevance of SBCE findings. It represents a step forward for SB-CE interpretation and is intended to be used as a tool for teaching and academic research.

Background Endoscopically defined mucosal healing in Crohn's disease is associated with improved outcomes. Panenteric capsule endoscopy enables a single non‐invasive assessment of small and large bowel mucosal inflammation. Aims and Methods This multicentre observational study of patients with suspected and established Crohn's disease examined the feasibility, safety and impact on patient outcomes of panenteric capsule endoscopy in routine clinical practice. The potential role in assessment of disease severity and extent by a comparison with existing clinical and biochemical markers is examined. Results Panenteric capsule endoscopy was performed on 93 patients (71 with established and 22 with suspected Crohn's disease). A complete examination occurred in 85% (79/93). Two cases (2.8%) of capsule retention occurred in patients with established Crohn's disease. Panenteric capsule resulted in management change in 38.7% (36/93) patients, including 64.6% (32/48) of those with an established diagnosis whose disease was active, and all three patients with newly diagnosed Crohn's disease. Montreal classification was upstaged in 33.8% of patients with established Crohn's disease and mucosal healing was demonstrated in 15.5%. Proximal small bowel disease upstaged disease in 12.7% and predicted escalation of therapy (odds ratio 40.3, 95% confidence interval 3.6–450.2). Raised C‐reactive protein and faecal calprotectin were poorly sensitive in detecting active disease (0.48 and 0.59 respectively). Conclusions Panenteric capsule endoscopy was feasible in routine practice and the ability to detect proximal small bowel disease may allow better estimation of prognosis and guide treatment intensification. Panenteric capsule endoscopy may be a suitable non‐invasive endoscopic investigation in determining disease activity and supporting management decisions., Key Summary Summarise the established knowledge on this subject Biochemical and clinical markers poorly predict active disease and need for treatment escalation;Panenteric capsule endoscope is feasible, safe and has the potential to non‐invasively assess patients with Crohn's Disease. What are the significant and/or new findings of this study? Panenteric capsule endoscope can upstage disease in one‐third of patients with a threefold increase in the identification of proximal small bowel disease;Identification of proximal small bowel disease predicted treatment intensification.

Contains fulltext : 235679.pdf (Publisher’s version ) (Closed access) BACKGROUND: One of the aims of the European Society of Gastrointestinal Endoscopy (ESGE) is to encourage high quality endoscopic research at a European level. In 2016, the ESGE research committee published a set of research priorities. As endoscopic research is flourishing, we aimed to review the literature and determine whether endoscopic research over the last 4 years had managed to address any of our previously published priorities. METHODS: As the previously published priorities were grouped under seven different domains, a working party with at least two European experts was created for each domain to review all the priorities under that domain. A structured review form was developed to standardize the review process. The group conducted an extensive literature search relevant to each of the priorities and then graded the priorities into three categories: (1) no longer a priority (well-designed trial, incorporated in national/international guidelines or adopted in routine clinical practice); (2) remains a priority (i. e. the above criterion was not met); (3) redefine the existing priority (i. e. the priority was too vague with the research question not clearly defined). RESULTS: The previous ESGE research priorities document published in 2016 had 26 research priorities under seven domains. Our review of these priorities has resulted in seven priorities being removed from the list, one priority being partially removed, another seven being redefined to make them more precise, with eleven priorities remaining unchanged. This is a reflection of a rapid surge in endoscopic research, resulting in 27 % of research questions having already been answered and another 27 % requiring redefinition. CONCLUSIONS: Our extensive review process has led to the removal of seven research priorities from the previous (2016) list, leaving 19 research priorities that have been redefined to make them more precise and relevant for researchers and funding bodies to target.

Background There are currently 12 centres offering device assisted endoscopy (DAE) in the UK and between 30–35 offering video capsule endoscopy (VCE). There is a paucity of data on those offering training. We therefore quantify the training provided in small bowel endoscopy (SBE) across the UK to assess future training requirements. Methods Online surveys and targeted calls to SBE centres were conducted of all British Society of Gastroenterology members in the UK to establish whether they were in SBE training and what level of training was offered to them. Results From 17 centres there were 22 responses from gastroenterology fellows, trainees and consultants (36.4%, 18.2%, 45.5% respectively). Of all responders, 95.4% were independent in gastroscopies and 90.9% colonoscopies. Training centres: In total, 86.4% of centres offered VCE with 3 (IQR: 2–4) endoscopists per site interpreting videos. DAE was available in 72.7% of centres performed by 2 endoscopists (IQR: 2–3) per centre. Single and double balloon endoscopy was performed in 64.7% and 35.3% respectively under conscious sedation, deep sedation and both (35.3%, 29.4%, 35.3% respectively). Training in video capsule endoscopy: VCE was interpreted by 63.6% of responders of which 78.6% were independent. 31.8% of responders were undergoing training in both VCE and DAE, 36.3% in VCE and 9.1% in DAE. Of those who did not regularly review VCE, 75% were interested in becoming proficient. Physicians required 50 (IQR: 20–50 videos) VCEs to gain competency. All physicians were confident in identifying pathology. To become independent, 50 videos (IQR 25–70) were reviewed. Responders who had attended VCE courses felt more confident in identifying pathology (100% vs 33.3% p= 0.002). Training in device assisted endoscopy: Only 36.4% of individuals undertook DAE of which 75% were independent. However 42.9% were interested in becoming proficient. On average, participants completed 55 (IQR: 19–85) procedures prior to being independent taking 12 months (IQR: 6–27 months). The target lesion was reached in 50–100% of cases. All DAE trainees performed therapeutic procedures. Moderate to severe pain was reported in 10% of patients under conscious sedation and no sedation related complications reported. The learning curve for antegrade DAE was easier than retrograde DAE. The terminal ileal intubation rate during retrograde DAE varied from less than 50% to greater than 90%. Conclusion Training offered in SBE is heterogenous with individuals having different levels of prior experience. There is a need to offer and formalise VCE and DAE training to ensure uniform competence. However, centres must have set requirements to achieve prior to being able to offer training to ensure the training offered is up to standard.

Background The BSG offers a mentorship programme aimed at those in transitional phases of their career and less at experienced consultants. Reverse mentoring, the act of junior persons mentoring seniors, has gained traction in non-healthcare settings as a means of closing the gap between Boomers and Millennials. There is no data on applying this to a medical workforce. We present the first data of real clinical experience. Methods A mixed-methods feasibility study on the practicalities of reverse mentoring complete in two phases. Phase 1: all clinical fellows in a teaching hospital were invited to provide feedback in a group semi structured interview on their supervisors in 7 domains: use of technology, clinical practice, approach to juniors, time management, approachability, strengths and areas for improvement. Phase 2: information was fed back to consultants on a 1-2-1 basis with the opportunity to discuss the points raised. Pre and post mentoring questionnaires were collected. Likert scales were used to assess several aspects on a scale from 0 to 35 and thematic analysis to record participants thoughts. Results A total of 6 clinical fellows participated in the phase 1 feedback session (66.6% male, age range 31–40 years) and agreed to be mentors. All supervising consultants invited agreed to being mentees (80% male, age range 35–65 years) and have been consultants for 5–20 years. Mentoring sessions lasted 45 minutes (range 28–180 minutes) and all felt the time devoted was about right. Both mentors and mentees reported a good or excellent experience. Juniors became more confident in feeding back to seniors after the session (21vs 31, p=0.008) and had a greater understanding of their role as reverse mentors (2.5/5 vs 4/5, p=0.024). Seniors became more aware of how they were viewed after mentoring (25vs 32, p=0.04). All seniors felt this was a useful experience that will change their clinical practice and 80% reported less concern about reverse mentoring afterwards. All participants believed that feedback was important both prior to and after the study (31 vs 33, p=0.196) Common themes highlighted included the benefit of a different perspective to the norm and new ideas which can be implemented. There were concerns raised of the power gradient preventing effective mentoring and risks to relationships, however these were expressed as potential concerns and not experienced. Conclusion The experience of all participants in this feasibility study were positive supporting the benefits of reverse mentoring in a healthcare setting. Junior doctors became better equipped to be future mentors. Consultants were given a new perspective which inspired them to improve their clinical practice and work environment.

Introduction Capsule endoscopy (CE) is well established the investigation of small-bowel (SB) pathology. We compared the use of double-headed (DH) capsules, to conventional single-headed (SH), in a real-world patient cohort in the first multicentre British study. Methods Over 9 months, patients referred for routine SBCE at 4 tertiary referral centres in the UK underwent DH CE instead of conventional SH using MiroCamⓇ MC2000 as per local protocols. One head (L/R) was chosen at random and reported by an expert reviewer. The DH recordings, anonymised and randomised, reported by another expert or re-read after a 4-week interval. For each CE, numbers and types of findings and overall conclusion/diagnosis were compared between SH and DH examinations. Results 211 CEs were performed. 7 failed to reach the SB; 204 analysed. Indications were: SB bleeding (n = 94); ?SB inflammation or reassessment of known inflammatory bowel disease (IBD) (n = 84); ?SB neoplasia including suspicious radiological imaging (n = 15); and, others e.g. ?celiac disease (n = 11). For SB bleeding: 27/94 (28.7%) examinations reported differences between SH and DH readings. In 17 (18.1%) the findings were clinically significant. SH CE missed angiectasias (5 pts), SB inflammation (7 pts), oesophagitis (2 pts) and SB masses (2 pts). In 1 patient, the extent of angiectasias seen was greater on the DH reading. For IBD: findings differed in 30/84 (35.7%) of CEs; 11 (13.1%) were clinically significant. In 5, signs of active inflammation were missed by the SH reading. In 6, assessment of extent/severity differed. For?SB neoplasia findings differed in 2/15 (13.3%) of examinations. Both were clinically significant. For others: 1/11 (9.1%) examinations differed; however, not deemed clinically significant. Overall, use of DH CE impacted the diagnosis in 30/204 (14.7%). Conclusions The use of DH CE provides more information with the potential to change clinical diagnosis and therefore management. Therefore, the routine adoption of DH CE in SB assessment should be considered.

Small bowel capsule endoscopy (SBCE) can be complementary to histological assessment of celiac disease (CD) and serology negative villous atrophy (SNVA). Determining the severity of disease on SBCE using statistical machine learning methods can be useful in the follow up of patients. SBCE can play an additional role in differentiating between CD and SNVA. De-identified SBCEs of patients with CD and SNVA were included. Probabilistic analysis of features on SBCE were used to predict severity of duodenal histology and to distinguish between CD and SNVA. Patients with higher Marsh scores were more likely to have a positive SBCE and a continuous distribution of macroscopic features of disease than those with lower Marsh scores. The same pattern was also true for patients with CD when compared to patients with SNVA. The validation accuracy when predicting the severity of Marsh scores and when distinguishing between CD and SNVA was 69.1% in both cases. When the proportions of each SBCE class group within the dataset were included in the classification model, to distinguish between the two pathologies, the validation accuracy increased to 75.3%. The findings of this work suggest that by using features of CD and SNVA on SBCE, predictions can be made of the type of pathology and the severity of disease.

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Background & Aims: Patients with small bowel angioectasias (SBAs) can be difficult to manage as they are generally elderly with multiple co-morbidities. Angioectasias are multiple and tend to recur. Argon plasma coagulation (APC), despite being a commonly used method to treat these patients has an associated persistent rate of re-bleeding necessitating additional treatment to manage these patients.Methods: All patients with refractory iron deficiency anaemia secondary to SBAs were retrospectively subdivided into two groups. Patients in group 1 were managed with double balloon enteroscopy (DBE) and APC alone and those in group 2 received Lanreotide in addition to DBE and APC.Results: A total of 49 patients were included in this study: group 1: 37 patients (75.5%), group 2: 12 patients (24.5%). All had significant comorbidities and the mean duration of anaemia was 114.3, SD 307.0 months. Significant improvements in haemoglobin (Hb) (11g/L vs 3.2g/L p=0.043), transfusion requirements per month (0.8 vs 4.7 p=0.052) and mean bleeding episodes (1.08 vs 2.6 p=0.032) were demonstrated in group 2 when compared to group 1. One patient developed symptomatic gallstone disease and one patient stopped Lanreotide due to a lack of response.Conclusions: This is the first study comparing endotherapy to a combination of endotherapy and pharmacotherapy. It shows a significantly better outcome in patients receiving a combination of endotherapy and Lanreotide. Lanreotide can be a safe additional treatment in patients not responding to APC alone.Abbreviations: APC: argon plasma coagulation; CE: capsule endoscopy; DBE double balloon enteroscopy; Hb: hemoglobin; OGIB: over gastrointestinal bleeding; SBAs: small bowel angioectasias.

ObjectiveTo evaluate the diagnostic yield of investigating dyspepsia with oesophagogastroduodenoscopy (OGD) with or without mucosal biopsy.DesignRetrospective service evaluation study.SettingTwo teaching hospitals: The Royal Hallamshire Hospital and Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, UK.Patients500 patients, 55 years of age and over, who underwent OGD to investigate dyspepsia were included. The study period included a 3-month window. All OGDs were performed on an outpatient basis.InterventionsData were extracted from electronic OGD records within the study period.Main outcome measuresDiagnostic yield provided by endoscopic examination and histological assessment.Results378 patients (75.6%) were reported to have some form of endoscopic abnormality, and 417 patients (83.4%) had biopsies taken. The most common findings at OGD were gastritis (47.2%) and oesophagitis (24.4%). Oesophagogastric malignancy was seen in 1%. Diagnoses made endoscopically or histologically that would not have been appropriately managed by empirical therapies were seen in 16.2%.ConclusionOGD in dyspepsia influences patient management in approximately one-sixth of cases. However, the majority of patients are sufficiently managed withHelicobacter pyloritesting and eradication and/or a trial of proton pump inhibitor therapy. Further non-invasive approaches are needed to identify patients who need endoscopy for biopsy or therapy.

Introduction Bowel purgatives are common practice prior to small bowel capsule endoscopy (SBCE). The use of Polyethylene glycol (PEG) laxatives is suggested to improve SB visualisation quality and diagnostic yield [Kotwal, Eur J Gastro Hep 2014]. However, this finding is not completely consistent, with other studies suggesting no clear benefit of PEG preparation over clear fluids only [Hookey, GIE 2017]. Therefore, unlike colonoscopy where the routine use of split dose bowel preparation to improve right colon cleansing has become a standard of care [Flemming, GIE 2012], the benefit and timing of purgatives prior to SBCE is unknown. We report the interim results from a clinical trial comparing the use of split dose PEG and single dose PEG against clear fluids only. Methods Adult patients referred for SBCE were invited to participate and subject to exclusion criteria, were randomised to control (clear fluids only), single dose PEG (2L PEG at 6am on the day of the exam) and split dose PEG (1L PEG at 7pm the day before and 6am on the day of the exam). Briefly, the mean red to green colour intensity from SBCE procedure colour bars were used to calculate a computed assessment of cleansing (CAC) scores described elsewhere [Van Weyenberg, Endoscopy 2011]. The CAC is a validated 10 point scoring system (0–10; least - most clean) used to assess small bowel visualisation quality. CAC scores are reported as mean ± SEM and student t-tests performed to compare the means. Results A total of 78 patients (35% male, mean age 48±2.0) were included (split n=28, single n=24 and control n=26). Intention to treat analysis show that split dose PEG preparation results in significantly greater mean CAC score in the distal quartile (5.58±0.16) of the small bowel compared to control (4.78±0.30; p=0.02). No differences in the overall, first, second and third quartile CAC score of the small bowel was found between control and PEG groups. Complete ingestion of PEG preparation occurred in 88% and 77% of single vs split dose (p=0.33). Subgroup analysis showed that amongst patients that completed preparation successfully, those randomised to both split dose (5.52±0.20; p=0.01) and single dose (5.64±0.18, p=0.003) PEG had a significantly greater mean CAC score in the distal quartile of the small bowel compared to control (4.58±0.28). Conclusions The use of split dose laxatives improves the visualisation quality of the distal small bowel. Initial results may suggest that the PEG dose in the morning of the procedure improves distal quartile visualisation.

Introduction Up to 64% of patients with obscure gastrointestinal bleeding (OGIB) have lesions that can be reached with a standard gastroscope [1]. Positive findings outside the small bowel (SB) have been detected on axial small bowel capsule endoscopy (SBCE) (PillCam system, (Given Imaging) in patients with OGIB in up to 22% of patients in the stomach and 6% in the colon [2]. Our aim was to assess the diagnostic yield (DY) of panoramic SBCE (Capsocam) for the upper gastrointestinal tract, SB and colon in patients with OGIB. Methods Patients at a tertiary centre who underwent Capsocam as part of the examination of OGIB following negative gastroduodenoscopy and colonoscopy or CT colonography were included. This study was carried out over a 6 year period. Findings on SBCE were recorded. Results Forty-eight patients (37, 77.1% overt, 11, 22.9% occult OGIB) were included in this study. Thirty (62.5%) were males. Mean age was 67.5±16.5 years. OGIB was present for a mean of 19.9 SD±92 months. Only one SBCE (9.1%) was incomplete within the occult OGIB group (p=0.229). The panoramic SBCE had a diagnostic yield of 37.5% (18 patients) in the SB. It also picked up additional findings in the stomach (n=5, 10.4%) and in the colon (n=3, 6.3%). Some patients had more than one pathology (table 1). Conclusions Panoramic SBCE can be useful in the detection of lesions in the stomach and colon missed during upper and lower gastrointestinal examinations. It can also be better in the detection of pathologies in overt OGIB than in occult OGIB. References Zaman A, Katon RM: Push enteroscopy for obscure gastrointestinal bleeding yields a high incidence of proximal lesions within reach of a standard endoscope. Gastrointest Endosc 1998, 47:37–76. Riccioni ME, Urgesi R, Cianci R, Marmo C, Galasso D, Costamagna G: Obscure recurrent gastrointestinal bleeding: a revealed mystery? Scand J Gastroenterol 2014, 49:102–026.

Introduction The relationship between symptomatology, serology and findings on small bowel capsule endoscopy (SBCE) in patients with coeliac disease (CD) remains unclear. Clarifying such associations will help determine if symptoms and serology can predict severity and extent of disease on SBCE. Methods Patients with newly diagnosed CD (villous atrophy on duodenal histology and positive CD serology) were recruited. Patients underwent a SBCE at the time of diagnosis. Information on SBCE was recorded. Signs and symptoms at presentation, serological markers, histological classification of disease in the duodenum were noted. Results Sixty patients with newly diagnosed CD (mean age 44.9 years SD±17.4, 17 - 76) were included in this study. Older patients (p=0.025) and patients presenting with iron deficiency anaemia had more extensive small bowel (SB) involvement (p=0.026). Patients presenting with weight loss were more likely to have SB involvement beyond the duodenum (p=0.027). Patients presenting with iron deficiency anaemia (p=0.038) and weight loss (p=0.009) were significantly older at diagnosis. Serum albumin was lower in those patients diagnosed later on in life (p=0.007). There was no significant association between anti-tissue transglutaminase antibody (p=0.396) and extent of affected SB mucosa. Patients with more severe Marsh classification of disease on histology from the duodenal bulb had more extensive SB involvement (p=0.017). Conclusions This is the largest study on newly diagnosed CD and SBCE. Older patients are likely to have more extensive disease on SBCE at diagnosis. Symptoms and serology had no impact on the findings on SBCE apart from weight loss and iron deficiency anaemia. Reference Lau M, Mooney P, White W, et al. PWE-058 The Role of A Point of Care Test, Simtomax, in Predicting Histological Remission in Coeliac Disease on A Gluten Free Diet. Gut 2016;65:A166–A167.

Introduction Flexible spectral imaging colour enhancement (FICE) is a form of virtual chromoendoscopy that is incorporated in the capsule reading software and that can be used by reviewers to enhance the delineation of lesions in the small bowel. This has been shown to be useful in the detection of pigmented (ulcers, angioectasias) lesions. However, its application to coeliac disease (CD) images from small bowel capsule endoscopies (SBCEs) has rarely been studied. Methods This was a European, multicentre study that included 5 expert capsule reviewers who were asked to evaluate a number of normal and abnormal deidentified images from SBCEs of patients with CD to determine whether the use of FICE and blue light can improve the detection of CD related changes. Results Sensitivity and specificity of conventional white light in the delineation of CD related changes were 100%. The next best image modification was FICE 1 with a sensitivity of 88% and a specificity of 96%. There was no difference between conventional white light, FICE and blue light for the identification of CD related changes. There was a low agreement (Fleiss Kappa 0.107; p=0.147) between expert reviewers in selecting the best image modification that detected CD related changes. Conclusions FICE and blue light were not found to be superior to conventional white light in the delineation of macroscopic changes related to CD on SBCEs.

Introduction Capsule endoscopy (CE) is a well-established mode of investigation for small bowel (SB) pathology. This study examines the potential benefits of using double-headed capsules compared to conventional single-headed ones in a real-world cohort of patients referred for CE. We present initial results from the first multicentre British study. Methods Over a 9-month period, patients referred for routine SBCE at 4 tertiary referral centres in the UK underwent double-headed CE in lieu of conventional single-headed CE using MiroCam MC2000 capsules. CE was carried out as per routine protocols at each centre. Clinical data were anonymised. One head (L/R) was chosen at random and reported by an expert reviewer. The double-headed recordings, also anonymised and randomised, were reported by another expert reviewer. In centres with only one expert reviewer, double-headed CEs were read after a 4-week interval to minimise recall bias. For each CE, numbers and types of findings and overall conclusion/diagnosis were compared between single and double-headed examinations. Results 211 CE examinations were performed. 7 failed to reach the SB; 204 cases were analysed. Indications were (a) SB bleeding; (b) ?SB inflammation or reassessment of known inflammatory bowel disease (IBD); (c) ?SB neoplasia including suspicious radiological imaging and (d) others e.g. ?coeliac disease. Results are presented in table 1. Conclusions The use of double-headed CE provides more information which has the potential to change clinical diagnosis and therefore management. Therefore, the routine adoption of double-headed CE in SB assessment should be considered.

Introduction: Flexible spectral imaging colour enhancement (FICE) is a form of virtual chromoendoscopy that is incorporated in the capsule reading software and that can be used by reviewers to enhance the delineation of lesions in the small bowel. This has been shown to be useful in the detection of pigmented (ulcers, angioectasias) lesions. However, its application to coeliac disease (CD) images from small bowel capsule endoscopies (SBCEs) has rarely been studied. Methods: This was a European, multicentre study that included 5 expert capsule reviewers who were asked to evaluate a number of normal and abnormal de-identified images from SBCEs of patients with CD to determine whether the use of FICE and blue light can improve the detection of CD-related changes. Results: Sensitivity and specificity of conventional white light in the delineation of CD-related changes were 100%. The next best image modification was FICE 1 with a sensitivity of 80% and a specificity of 100%. There was no difference between conventional white light, FICE and blue light for the identification of CD-related changes. There was a low agreement (Fleiss kappa 0.107; p = 0.147) between expert reviewers in selecting the best image modification that detected CD-related changes. Conclusions: FICE and blue light were not found to be superior to conventional white light in the delineation of macroscopic changes related to CD on SBCEs.

Background & Aims: There is no literature on the role of repeat small bowel capsule endoscopy (SBCE) in patients with refractory coeliac disease (RCD) following treatment with steroids +/- immunosuppressants.Methods: The findings on SBCEs from a group of patients with histologically proven RCD (n=23) were compared to the findings from patients with uncomplicated coeliac disease (n=48). All patients had concurrent duodenal histology and serology taken at the time of SBCE.Results: Patients with RCD had a greater extent of mucosal involvement on SBCE than patients with uncomplicated CD (42.4±34.1% vs 9.7±21.7%, p=0.0001). Following treatment with steroids and / or immunosuppressants, patients with RCD had an improvement in the extent of affected small bowel mucosa (42.4±34.1% vs 26.4±28.9% p=0.012). There was no statistical difference in histology and serology taken at the time of the first and second SBCE in patients with RCD.Conclusions: Our study suggests that SBCE is valuable in documenting the extent of mucosal involvement in patients with RCD. This is the first study that delineates the value of a second look SBCE to assess improvement in the extent of disease in the small bowel following treatment.

Background and Aims Seronegative villous atrophy (SNVA), raised intraepithelial lymphocytes (IELs), and crypt hyperplasia on duodenal histology can be secondary to celiac disease (CD) or other causes such as medications or infections. Our aims were to assess the role of small-bowel capsule endoscopy (SBCE) in these patients and to ascertain whether findings on SBCE at diagnosis can predict disease outcome. Methods Patients (n = 177) with SNVA, IELs, ± crypt hyperplasia on duodenal histology were studied. These patients all had an equivocal diagnosis of CD. Results Overall, 56 patients (31.6%) had a positive SBCE. Thirty-three patients (58.9%) had disease affecting the proximal third of the small bowel (SB). The diagnostic yield of SBCE was 40.0% (22 patients), 51.4% (18 patients), 27.0% (10 patients), and 14.0% (7 patients) in patients with an unknown cause for SNVA (SNVA-UO), patients with SNVA who responded to a gluten-free diet (SNVA-CD), patients with a known cause for SNVA, and patients with railed IELs ± crypt hyperplasia, respectively. In SNVA-UO, SBCE at diagnosis was more likely to be positive in patients with persistent SNVA (10, 90.9%) and persistent SNVA with lymphoproliferative features (4, 80.4%) than patients with spontaneous resolution of SNVA (8, 20.5%) (P = .0001). All patients in the SNVA-CD group who eventually developed adverse events had a positive SBCE (P = .022). They also had more extensive SB disease than those without adverse events (50% vs 1% P = .002). More extensive SB disease on SBCE correlated with a higher SNVA-related mortality in patients with SNVA-UO and SNVA-CD (P = .019). Severity of histology did not correlate with mortality (P = .793). Conclusions A positive SBCE at diagnosis predicts a worse outcome. More importantly, more extensive disease in these patients is associated with poor survival. Targeting patients with extensive disease at diagnosis with more aggressive therapy can help to improve prognosis.

The wireless nature of capsule endoscopy offers patients the least invasive option for small bowel investigation. It is now the first-line test for suspected small bowel bleeding. Furthermore meta-analyses suggest that capsule endoscopy outperforms small bowel imaging for small bowel tumours and is equivalent to CT enterography and magnetic resonance enterography for small bowel Crohn’s disease. A positive capsule endoscopy lends a higher diagnostic yield with device-assisted enteroscopy. Device-assisted enteroscopy allows for the application of therapeutics to bleeding points, obtain histology of lesions seen, tattoo lesions for surgical resection or undertake polypectomy. It is however mainly reserved for therapeutics due to its invasive nature. Device-assisted enteroscopy has largely replaced intraoperative enteroscopy. The use of both modalities is discussed in detail for each indication. Current available guidelines are compared to provide a concise review.

Introduction Small bowel capsule endoscopy (SBCE) is used in refractory coeliac disease (RCD) to assess the extent of disease and ensure there are no complications (lymphoma or ulcerative jejunitis). However there are no published reports on SBCE in RCD following immunosuppressive therapy. Methods Patients with histologically confirmed refractory coeliac disease (RCD) who underwent a SBCE at baseline and after treatment were enrolled in this study. These were compared to a group of control CD patients with no underlying RCD. Results 19 patients (median 53 years) with RCD (12 patients; 63.2% – type 1) were compared to 28 patients with control CD (median 48 years). There was no statistically significant difference in duration of disease, gender, age at SBCE and serology between the 2 groups. Patients with RCD were more likely to have worse histology (Marsh 3a-c) than SBCE. control CD who had a higher percentage of normal histology at the time of SBCE. (p=0.002) Those with RCD had a longer abnormal small bowel (SB) mucosa (185 SD ±167.6 vs 29.5 SD ±73 min p=0.0001) and longer percentage of abnormal SB (53.9 SD ±38.0 vs 6.9 SD ±15.2 min p=0.0001) when compared to those with control CD. A repeat SBCE was carried out after a mean of 9.63 SD ±6.6 months in patients with RCD following treatment. There was no statistical significant difference in histology and serology at the time of the first and second SBCE. Patients received the following treatment: 36.8% steroids, 26.3% immunosuppressants, 36.1% combination of mycophenolate azathioprine and steroids. However, there was an improvement in the length of abnormal SB mucosa (185 vs 116 min; p=0.035) and the percentage of abnormal SB (50.8 vs 32.9%; p=0.027). 7 patients (36.8%) had diffuse mucosal involvement on the first SBCE but only 4 (21.1%) had diffuse disease on repeat SBCE. (p=0.007) There was no statistical correlation between coeliac serology and small bowel passage time, length of mucosal abnormality and percentage of affected SB at first and second SBCE. The same findings were also true for histology. Conclusions More severe SB involvement on SBCE can be found in patients with RCD. This is the first study that shows an improvement in SB abnormality on SBCE following treatment of RCD patients. Histology is useful in distinguishing RCD from non-RCD but not for assessing improvement in patients with RCD following treatment. SBCE might potentially be regarded as a less invasive, more accurate way of following up these patients.

Introduction Capsule endoscopy may have a role in triaging patients with suspected acute upper gastrointestinal (GI) bleeding who need further invasive investigation. Method The Mirocam Navi (Intromedic Ltd., Korea) is a single camera capsule endoscope steerable by a handheld magnet. Magnetically assisted capsule endoscopy (MACE) was performed in stable patients with suspected acute upper GI bleeding and a decision made as to whether same day discharge was appropriate, prior to gastroscopy (OGD) performed by a different, blinded endoscopist followed by standard care by the admitting team during which small bowel capsule endoscopy was completed. Diagnostic yield and comfort were compared. Potential impact on hospital stay was examined and MACE mucosal visualisation quality was assessed. Results A total of 90 upper GI lesions were detected in 30 patients (80% male, median age 57 years (IQR=26)): 21 (23%) concomitantly identified by MACE and OGD, 49 (54%) by MACE alone and 20 (22%) by OGD alone (CI 0.05–0.58; p=0.0007). MACE and OGD concomitantly detected 50% of major pathologies (gastric and duodenal ulcers and oesophageal and gastric varices (n=2 each)). MACE alone identified 31% (D1 ulcers (n=4) and varices (n=1)) whereas OGD alone identified three D1 ulcers (19%; p=0.7). Ulcers (all classified as Forest class III at OGD) missed by MACE were due to rapid D1 transit and insufficient imaging. Review of small bowel images identified additional causes for GI bleeding distal to D2 in five cases: small bowel lymphoma (n=1), angioectasia (n=2), fresh bleeding in the proximal and distal small bowel with no culprit lesion seen (n=1 for each). MACE correctly suggested safe discharge for 21/21 patients. The median hospital stay of uncomplicated admissions where MACE suggested discharge was 53 (range 14–103) hours. Pain, discomfort and distress scores were lower with MACE than OGD (p 2 =133 (p Conclusions MACE has better diagnostic yield than OGD in suspected upper GI bleeding (with both modalities missing lesions), is better tolerated and used ‘at the front door’ might allow immediate discharge for two thirds of patients saving a median hospital stay for each of over two days. In addition, it suggests that about 10% of suspected upper GI bleeding may have a small bowel source.

Introduction Confirmed (visual) passage of an intact Agile (Medtronic Ltd) patency device (which contains a radiofrequency (RF) tag), absence of an RF signal or failure to identify the patency device on radiological imaging 30 hours post-ingestion predicts safe capsule endoscopy. [Hererrias et al., Gastrointest Endosc 2008] Premature dissolution of the device would give false reassurance that capsule endoscopy could be performed safely. Methods Retrospective review of 2017 patency capsule database. Results RF scan was performed on 490 patients 30 hours after swallowing an Agile patency device and, if an RF signal was present, patients went for a scout film and, where indicated, limited CT scan. Premature dissolution occurred in four cases (0.8%). All had normal colonoscopies and symptoms of Crohn’s disease (two of whom had abnormal, one normal and one no prior small bowel imaging). In two, the scout films were reported normal, but a persistent RF signal prompted re-examination of the films and the identification of the RF tags. In the two later cases, the RF tag alone or with adjacent high density material (consistent with barium) was recognised as demonstrating premature dissolution. Conclusions This is the first report of premature dissolution of the Agile patency device which occurred in about 1:100 cases. If the RF signal remains 30 hours post ingestion, care should be taken to look for the RF device on radiological imaging when the intact patency device (see figure 1) is not evident. The tags may be confused with surgical clips, IUCDs, metallic items of clothing and jewellery.

Introduction Guidelines support endoscopic assessment of mucosal healing in Crohn’s disease before a change in therapy. [Gomollon, J Crohn’s Colitis 2016] A recent study has shown that the PillCam Crohn’s (PCC, Medtronic, Dublin, Ireland) has a better diagnostic yield than ileocolonoscopy [Leighton, Gastrointest Endosc 2017] and that colon capsule (for which the same bowel preparation is used) is better tolerated [Ojidu, European J Gastroenterol Hepatol, in press]. We report the first experience of PCC in routine clinical practice. Methods Data was collected prospectively in Sheffield and South Tyneside hospitals. Montreal classification was used (ileal:L1; colonic: L2; ileocolonic: L3; upper GI: L4; B1: non-stricturing/penetrating; B2: stricturing; B3: penetrating). All patients passed an Agile patency capsule (Medtronic). Results Eighteen patients (median age 35 years, 38.9% male, known Crohn’s in 83%) had PCC. Indications were: symptom assessment (77.8%), assess response to treatment (11.1%), consideration of stepping down therapy (16.7%). Patients with established Crohn’s had L1 (53.3%), L2 (13.3%), and L3 disease (33.3%) which was uncomplicated (40%), stricturing (46.7%) and penetrating (13.3%). Patients were on medical treatment in 73.3%. PCC changed staging of disease in 33% of cases (L1 to L3 n=1, B2 to B1 n=3 and B1 to B2 n=1). One of three patients with suspected Crohn’s disease subsequently had endoscopic confirmation (L3 B1). PCC was normal (5/18), revealed L1 disease alone (8/18), L2 disease alone (1/18) and L3 disease (5/18). There were three incomplete procedures, all with an otherwise normal visualised colon. No capsule retentions occurred. Follow up data was available in 11 patients. Of eight patients with symptoms, five had active disease and three no or minimal activity. Of the five, three had a step-up in treatment, one had adalimumab temporarily suspended due to a perianal abscess and management continues to be discussed in one patient on maximal medical therapy. Other causes of symptoms were sought in the patients with inactive disease. Three patients had no symptoms, one had active disease and a step up in treatment, two had no or minimal activity of whom one continued therapy due to poor prognostic factors and one was already on no treatment (PCC being performed to provide supportive evidence of a diagnosis made in childhood). No patient known to have Crohn’s has been referred for further small bowel imaging or colonoscopy. Conclusion PCC provides a single visit assessment of both small and large bowel which was useful in guiding patient management without complications.

Introduction High amylase does not always signify acute pancreatitis and it can occur due to focal areas of ischaemia in the pancreas due to mechanical stress during double balloon enteroscopy (DBE). The use of rectal NSAIDs to prevent post DBE pancreatitis has never been explored unlike in ERCP where patients receiving rectal NSAIDs have a lower incidence of pancreatitis. Methods Patients who received rectal indomethacin (100 mg) 30 min prior to antegrade DBE were compared to a control group who did not receive indomethacin before the above protocol was implemented. Serum amylase and CRP 3 hours before and after DBE were compared. Results 240 patients (56 indomethacin, 184 controls; 50% males; mean age 58.5±SD14.0) were included. Indications included IDA (37.5%), obscure overt gastrointestinal bleeding (17.1%), suspected crohn’s disease and strictures (17.9%), complication of coeliac disease (1.3%), small bowel (SB) tumours/polyps (17.9%), others (8.3%). Patients had a median of 13.0±SD13.0 passes, 65.0±SD25.0 min, 170±SD52.0 cm of SB examined. 36.3% underwent a therapeutic procedure during DBE: APC/adrenaline/clips (27.5%), foreign body removal (0.4%), polypectomy (8.3%). Only 4 (1.67%; 2 females) patients developed pancreatitis, all prior to implementation of indomethacin into the local protocol. They had a median age of 47.0±SD3.20 years, 11±SD29.4 passes, 90±SD52.0 min, 150 cm ±SD64.2 cm of SB examined and median hospital stay of 14±SD3.70 days. 3 had polypectomies. 2 episodes occurred in the same patient. All had evidence of pancreatitis on CT scan. None of the patients received indomethacin before DBE. Mean amylase (51.6±SD22.7 vs 143.0±SD143.9 IU/L p=0.0001) and CRP (13.0±SD46.1 vs 17.3±SD81.7 mg/L p=0.0001) after the procedure were significantly higher than before the procedure. Females had a significantly higher amylase than males post procedure (155.2 vs 130.7 IU/L p=0.017). Mean amylase 3 hours after DBE was significantly lower in patients who received indomethacin (114 vs 152) (p=0.044). 83.9% had a rise in amylase in the indomethacin group compared to 92.2% controls.(p=0.064). Whilst there was no correlation between post-procedure amylase (p=0.552), CRP (p=0.058) and duration of the procedure, there was a significant association between amylase post procedure and length of SB examined.(Spearman’s rho 0.186; p=0.005) Conclusions This study identifies a role for rectal indomethacin in patients undergoing antegrade DBE. We have demonstrated that rectal indomethacin reduces amylase post DBE and no patients given indomethacin experienced pancreatitis. Larger studies are required to assess if this also transforms into lowering risk or severity of pancreatitis.