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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.

Purpose of review Systemic diseases can afflict the small bowel (SB) but be challenging to diagnose. In this review, we aim to provide a broad overview of these conditions and to summarise their management. Recent findings Small bowel capsule endoscopy (SBCE) is an important modality to investigate pathology in the SB. SB imaging can be complementary to SBCE for mural and extramural involvement and detection of multiorgan involvement or lymphadenopathy. Device assisted enteroscopy provides a therapeutic arm, to SBCE enabling histology and therapeutics to be carried out. Summary SB endoscopy is essential in the diagnosis, management and monitoring of these multi-system conditions. Collaboration across SB centres to combine experience will help to improve the management of some of these rarer SB conditions.

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.

Item does not contain fulltext BACKGROUND: Gastrointestinal angiodysplasias are vascular malformations that often cause red blood cell transfusion-dependent anaemia. Several studies suggest that somatostatin analogues might decrease rebleeding rates, but the true effect size is unknown. We therefore aimed to investigate the efficacy of somatostatin analogues on red blood cell transfusion requirements of patients with gastrointestinal angiodysplasias and to identify subgroups that might benefit the most from somatostatin analogue therapy. METHODS: We did a systematic review and individual patient data meta-analysis. We searched MEDLINE, Embase, and Cochrane on Jan 15, 2016, with an updated search on April 25, 2021. All published randomised controlled trials and cohort studies that reported on somatostatin analogue therapy in patients with gastrointestinal angiodysplasias were eligible for screening. We excluded studies without original patient data, single case reports, small case series (ie

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.

ispartof: Endoscopy vol:52 issue:8 pages:C9- ispartof: location:Germany status: published

Purpose of review The aim of this review is to provide insight into the diagnosis and management of patients with refractory coeliac disease (RCD) and highlight recent advances in this field. Recent findings The diagnosis of RCD can be more accurately confirmed with flow cytometry in addition to immunohistochemistry. Dietary input and excretion of gluten immunogenic peptides can help rule out gluten contamination, and therefore, substantiate a diagnosis of RCD type I. Small bowel capsule endoscopy (SBCE) is important at diagnosis and follow-up in addition to duodenal histology. Apart from ruling out complications, it can give information on extent of disease in the small bowel, and therefore, help assess response to therapy. Those patients with a poor response can have earlier intensification of therapy, which may result in an improved outcome. RCD also occurs in patients with serology negative coeliac disease but with an increased mortality compared with patients with serology-positive coeliac disease. Summary Patients with RCD can present with persistent symptoms of malnutrition but can also be completely asymptomatic. Serology is not a reliable marker to detect refractory disease. Immunostaining and flow cytometry are necessary for a diagnosis of RCD. Small bowel endoscopy enables disease extent to be assessed and allows for small bowel biopsies to be taken in case of suspicious lesions. Small bowel radiology can be complementary to small bowel endoscopy.

Purpose of review The objective is to provide an overview on the cause of small bowel bleeding. We discuss the role of small bowel endoscopy in the management of small bowel bleeding and provide an outline of pharmacotherapy that can be additionally beneficial. Recent findings Small bowel capsule endoscopy (SBCE) is the initial diagnostic investigation of choice in small bowel bleeding. Computed tomography (CT) can be helpful in the context of small bowel tumours. Device-assisted enteroscopy (DAE) enables several therapeutic procedures such as argon plasma coagulation (APC) and haemoclip application. It can also guide further management with histology or by marking culprit lesions with India ink. A persistent rate of rebleeding despite APC is increasingly being reported. Pharmacotherapy has an emerging role in the management of small bowel bleeding. Somatostatin analogues are a well tolerated class of drugs that can play an additional role in the management of refractory bleeding secondary to small bowel angioectasias. Summary SBCE is useful in determining the cause of small bowel bleeding. DAE offers an endoscopic therapeutic approach to small bowel bleeding replacing surgery and intraoperative enteroscopy. Pharmacotherapy, in addition to endotherapy, can play an important role in the management of multifocal, recurring bleeding small bowel lesions.

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.

The breakthrough success of capsule endoscopy and device-assisted enteroscopy has inspired researchers to test and push the boundary of these technologies. The authors herein summarize the latest and most significant studies with clinical impact.Competing capsule endoscopy models have enriched the platform of this wireless device. The role of capsule endoscopy in Crohn's disease is expanding as we learn more of the significance of disease distribution and response to treatment. The benefit of capsule endoscopy in abdominal pain has previously been sceptical, but may have a role. Device-assisted enteroscopy demonstrates significant benefit in the management of patients with Crohn's disease and Peutz-Jeghers syndrome. On the contrary, long-term data suggest that endotherapy to small bowel angioectasia may not be as beneficial to patients as we once thought. The role of device-assisted enteroscopy in novel territory, including coeliac disease and endoscopic retrograde cholangiopancreatography, continues to be tested.The limit of capsule endoscopy and enteroscopy is yet to be reached. Accumulating long-term data alludes to the benefits of our current practice while spawning novel indications for small bowel endoscopy.

Small bowel villous atrophy can represent a diagnostic challenge for gastroenterologists and pathologists. In Western countries small bowel atrophy and mild non-atrophic alterations are frequently caused by celiac disease. However, other pathology can mimic celiac disease microscopically, widening the differential diagnosis. The several novelties on this topic and the introduction of the device-assisted enteroscopy in the diagnostic flowchart make an update of the literature necessary. Areas covered: In this review, a description of the different clinical scenarios when facing with small bowel mucosal damage, particularly small bowel atrophy, is described. The published literature on this subject has been summarized and reviewed. Expert commentary: When an intestinal mucosal alteration is histologically demonstrated, the pathology report forms part of a more complex workup including serological data, clinical presentation and clinical history. A multidisciplinary team, including pathologists and enteroscopy-devoted endoscopists, is frequently required to manage patients with small bowel alterations, especially in cases of severe malabsorption syndrome.

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 Small-bowel capsule endoscopy is advocated and repeat upper gastrointestinal (GI) endoscopy should be considered for evaluation of recurrent or refractory iron deficiency anemia (IDA). A new device that allows magnetic steering of the capsule around the stomach (magnetically assisted capsule endoscopy [MACE]), followed by passive small-bowel examination might satisfy both requirements in a single procedure. Methods In this prospective cohort study, MACE and esophagogastroduodenoscopy (EGD) were performed in patients with recurrent or refractory IDA. Comparisons of total (upper GI and small bowel) and upper GI diagnostic yields, gastric mucosal visibility, and patient comfort scores were the primary end points. Results 49 patients were recruited (median age 64 years; 39 % male). Combined upper and small-bowel examination using the new capsule yielded more pathology than EGD alone (113 vs. 52; P Conclusion Combined examination of the upper GI tract and small bowel using the MACE capsule detected more pathology than EGD alone in patients with recurrent or refractory IDA. MACE also had a higher diagnostic yield than EGD in the upper GI tract and was better tolerated by patients.

BACKGROUND Indications to double-balloon enteroscopy (DBE) are not standardized in celiac disease (CD). GOALS To evaluate the clinical usefulness of DBE in complicated CD. STUDY DBE findings in celiac patients with suspected small bowel (SB) complications were retrospectively evaluated in 2 tertiary referral centers (Milan and Sheffield). Demographic data of the studied cohort were compared with a database of 1000 noncomplicated CD patients. RESULTS Twenty-four CD cases (12 males, P=0.01 vs. controls) were reviewed. Mean age at CD diagnosis (y±SD) was 37±20 versus 27±18 and at SB evaluation 47±15 versus 38±13 (P

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.

Coeliac disease is an autoimmune mediated condition in response to gluten. A combination of innate and adaptive immune responses results in villous shortening in the small bowel (SB) that can be morphologically picked up on capsule endoscopy. It is the only imaging modality that can provide mucosal views of the entire SB, while histology is generally limited to the proximal SB. Radiological modalities are not designed to pick up changes in villous morphology. Areas covered: In this review, we provide a comprehensive analysis on the justified use of small bowel capsule endoscopy (SBCE) in the assessment of patients with coeliac disease; compare SBCE to histology, serology, and symptomatology; and provide an overview on automated quantitative analysis for the detection of coeliac disease. We also provide insight into future work on SBCE in relation to coeliac disease. Expert commentary: SBCE has opened up new avenues for the diagnosis and monitoring of patients with coeliac disease. However, larger studies with new and established coeliac disease patients and with greater emphasis on morphological features on SBCE are required to better define the role of SBCE in the setting of coeliac disease.

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 Gastroscopy (OGD) is invasive and not always well tolerated. The NaviCam® (Ankon Technologies Co. Ltd., Shanghai, China) combines capsule endoscopy technology with external robot magnetic control. Operator joysticks command the robot to steer the capsule within the stomach. Real-time visualisation is displayed on two workstation monitors. When compared to OGD, the NaviCam® has already demonstrated high sensitivity and specificity for identifying focal gastric lesions.1 The focus of this study was to grade imaging quality and patient tolerance of the NaviCam®. Method Patients with dyspepsia were recruited. Patients swallowed 100 mls of water (containing 10 mls simethicone) 15 min prior to 1L of water followed by the NaviCam®. Clarity of views and adequacy of gastric distension were assessed (1, poor; 2, reasonable; 3, good), as was completeness of views of the oesophagogastric mucosa (1,>75% obscured; 2,>50% obscured; 3, Results Eighteen participants were included (mean age 53±16.1 years, 27.8% male). The NaviCam could be held stationary within the stomach (resisting peristaltic waves) and could cartwheel over rugal folds to a chosen proximal location using a preset programme activated by a ‘shoot’ button on the joystick. Mean examination duration was 25±3.4 mins. Mean clarity (2.3±0.7) and distension scores (2.9±0.3) were good. Complete views (5±0) for all areas of the gastric body (greater and lesser curvature, anterior and posterior wall) and distal stomach (antrum and pylorus) were achieved. Views of the oesophagus (4.3±1.3) and proximal stomach (cardia, 4.9±0.2; fundus 4.8±0.3) were also good. Duodenal images were not assessed real-time (but are provided after the capsule traverses the pylorus). Tolerance scores for anxiety, discomfort and pain were all lower with MACE compared to OGD (2.2±1.4 vs 5.8±3, 1.3±1 vs 4.9±3, 2.4±2.4 vs 3.4±2.5, respectively; p Conclusion The NaviCam® demonstrates excellent oesophagogastric views. The NaviCam® is extremely well tolerated compared to OGD and patients experience significantly fewer undesirable symptoms associated with upper GI endoscopy. Reference . Liao Z, et al. Clin Gastroenterol Hepatol2016;14(9):1266–73.e1.

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.

Introduction The interpretation of Small Bowel Capsule Endoscopy (SBCE) requires a high level of concentration. An abnormality may be present on just a few of the many thousands of images presented for interpretation. It is unknown whether fatigue affects the accuracy of SBCE reporting or how many SBCE can be read in one session. Methods 32 participants (16 Experienced readers and 16 Novices) were invited to participate in this study. Each was asked to read 6 consecutive pre-selected SBCE cases, these were presented in a random order. All readings took place using the single view mode, with readers able to choose the frames per second viewed from a pre-defined range. Fatigue was measured subjectively using a Likert scale and objectively using a computer based Psychomotor Vigilance Test (PVT). These measures were performed at prior to commencing the study and after every second capsule read. Accuracy in lesion detection was determined by comparison with a gold standard reading, derived from the non-consecutive readings of two experienced readers. Accuracy was plotted against reading order. Results In keeping with published data, high intra-observer variability amongst the participants was observed. Experienced readers demonstrated a mean correct detection rate of 48.3% (SD:16.1), compared to 21.3% (SD:15.1) amongst Novices. The accuracy of Experienced readers declined after interpreting just a single SBCE case (p=0.01) and plateaued thereafter. Novice readers demonstrated no significant change across time points, with a trend towards improvement, perhaps indicating skill acquisition during the study. The mean reading time to read a single SBCE case was 32 mins. When analysed with respect to reading order a statistically significant reduction in reading time was observed (p=0.05). Reading times were on average 25% faster when reading Case 6 compared to Case 1, representing a mean reduction of 9 mins and 36 secs (range 9–11 mins). Reading at higher frame rates was associated with a reduction in accuracy, which was most pronounced amongst Novice readers. No significant relationship between subjective fatigue or PVT and correct lesion detection was demonstrated. Conclusions This is the first study to demonstrate that accuracy in SBCE declines after reading a single capsule study. This phenomenon should be considered when reading high risk cases or when a SBCE case has been reported as normal, despite high clinical suspicion.

Introduction Repeat upper gastrointestinal (GI) examination and small bowel capsule endoscopy should be considered in iron deficiency anaemia (IDA) when recurrent/refractory. Magnetically assisted capsule endoscopy (MACE) using a handheld magnet to steer the MiroCam Navi (Intromedic Ltd., Korea) capsule around the stomach followed by passive small bowel transit might satisfy both requirements as a single procedure. Methods MACE was performed in patients with recurrent/refractory IDA who were due gastroscopy (OGD). Total (upper GI and small bowel) and upper GI diagnostic yields and patient tolerance of the two modalities were compared. Assuming a diagnostic yield of 25% and 55% for OGD and small bowel capsule endoscopy (SBCE) respectively in recurrent/refractory IDA, 41 patients were needed to achieve 80% power and 5% two-sided significance. McNemar’s test was used to measure differences in paired proportions. To allow for withdrawal, 50 patients were recruited. MACE mucosal visualisation was also assessed. Results OGD was performed within 2 days (IQR=13) of MACE in 49 patients (one failed to attend for OGD; median age 64 years (IQR=13), 39% male). Combined upper and mid-gut examination using MACE and passive SBCE yielded pathology in more patients than OGD alone (32 vs 6 (CI, 0.37 to 0.69); p Conclusions Combined upper GI and small bowel examination with the MiroCam Navi yields more pathology than OGD alone in patients with recurrent/refractory IDA. MACE also has better diagnostic yield than OGD in the upper GI tract and was better tolerated.

AIM To test the feasibility and performance of a novel upper gastrointestinal (GI) capsule endoscope using a nurse-led protocol. METHODS We conducted a prospective cohort analysis of patients who declined gastroscopy (oesophagogastroduodenoscopy, OGD) but who consented to upper GI capsule endoscopy. Patients swallowed the upper GI capsule following ingestion of 1 liter of water (containing simethicone). A series of positional changes were used to exploit the effects of water flow and move the upper GI capsule from one gravity-dependent area to another using a nurse-led protocol. Capsule transit time, video reading time, mucosal visualisation, pathology detection and patient tolerance was evaluated. RESULTS Fifty patients were included in the study. The mean capsule transit times in the oesophagus and stomach were 28 s and 68 min respectively. Visualisation of the following major anatomical landmarks was achieved (graded 1-5: Poor to excellent): Oesophagus, 4.8 (± 0.5); gastro-oesophageal junction (GOJ), 4.8 (± 0.8); cardia, 4.8 (± 0.8); fundus, 3.8 (± 1.2); body, 4.5 (± 1); antrum, 4.5 (± 1); pylorus, 4.7 (± 0.8); duodenal bulb, 4.7 (± 0.7); second part of the duodenum (D2), 4.7 (± 1). The upper GI capsule reached D2 in 64% of patients. The mean video reading time was 48 min with standard playback mode and 20 min using Quickview (P = 0.0001). No pathology was missed using Quickview. Procedural tolerance was excellent. No complications were seen with the upper GI capsule. CONCLUSION The upper GI capsule achieved excellent views of the upper GI tract. Future studies should compare the diagnostic accuracy between upper GI capsule and OGD.

Background: Recent data imply young patients (age ≤50 years) undergoing small-bowel (SB) capsule endoscopy (CE) for iron deficiency anaemia (IDA) show higher diagnostic yield (DY) for sinister pathology. We aimed to investigate DY of CE in a large cohort of young IDA patients, and evaluate factors predicting significant SB pathology. Materials and methods: This was a retrospective, multicentre study (2010–2015) in consecutive, young patients (≤50 years) from 18 centres/12 countries, with negative bidirectional gastrointestinal (GI) endoscopy undergoing SBCE for IDA. Exclusion criteria: previous/ongoing obscure-overt GI bleeding; age 50 years; comorbidities associated with IDA. Data retrieved: SBCE indications; prior investigations; medications; SBCE findings; final diagnosis. Clinical and laboratory data were analysed by multivariate logistic regression. Results: Data on 389 young IDA patients were retrieved. In total, 169 (43.4%) were excluded due to incomplete clinical data; data from 220 (122F/98M; mean age 40.5 ± 8.6 years) patients were analysed. Some 71 patients had at least one clinically significant SBCE finding (DY: 32.3%). They were divided into two groups: neoplastic pathology (10/220; 4.5%), and non-neoplastic but clinically significant pathology (61/220; 27.7%). The most common significant but non-neoplastic pathologies were angioectasias (22/61) and Crohn’s disease (15/61). On multivariate analysis, weight loss and lower mean corpuscular volume(MCV) were associated with significant SB pathology (OR: 3.87; 95%CI: 1.3–11.3; p = 0.01; and OR: 0.96; 95%CI: 0.92–0.99; p = 0.03; respectively). Our model also demonstrates association between use of antiplatelets and significant SB pathology, although due to the small number of patients, definitive conclusions cannot be drawn. Conclusion: In IDA patients ≤50 years with negative bidirectional GI endoscopy, overall DY of SBCE for clinically significant findings was 32.3%. Some 5% of our cohort was diagnosed with SB neoplasia; lower MCV or weight loss were associated with higher DY for SB pathology.

Elderly patients with multiple co-morbidities are at an increased risk of developing small bowel angioectasias. Treating these lesions can be both challenging and costly with patients requiring extensive investigations and recurrent admissions for iron infusions and blood transfusions as well as invasive procedures. This review presents treatment options and describes in detail drugs that should be considered whilst taking into account their effectiveness and their safety profile. Areas covered: A PubMed search was carried out using the following keywords: small bowel angiodysplasias, small bowel angioectasias, small bowel bleeding and obscure gastrointestinal bleeding to assess existing evidence. The pathophysiology and risk factors are covered in this review together with appropriate methods of investigation and management. Treatment options discussed are endoscopic measures, surgical options and pharmacotherapy. The role of serum biomarkers is also discussed. Expert commentary: Future work should be directed at alternative drugs with a good safety profile that target biomarkers. Novel pharmacotherapy directed at biomarkers could potentially provide a non-invasive treatment option for angioectasias particularly in the elderly where management can be challenging.

Background and Aim Excretion of the patency capsule (PC) within a certain time frame may be used to demonstrate luminal patency prior to capsule endoscopy (CE). We aimed to determine how often further radiological imaging is needed to confirm luminal patency after PC, assess radiologists' ability to locate the PC on plain abdominal films, and evaluate the outcomes of a novel computed tomography (CT) protocol for PC localization. Methods A study of the ability of radiologists to localize PC using plain abdominal films was performed. A novel protocol targeting a limited CT at the level of the PC identified on the “scout” film if retained 30 h post-ingestion was prospectively evaluated in 400 consecutive patients undergoing PC. Results In a study of the confidence with which radiologists could localize the PC on plain films, radiologists preferred abdominal CT to localize PCs identified on plain films in 74% of cases. In a protocol based on the use of a PC and targeted, limited CT scan to confirm small bowel patency in those failing to excrete the PC 30 h post-ingestion, the sensitivity, specificity, positive, and negative predictive value were 99.4%, 90.0%, 99.7%, and 81.0%, respectively. Crohn's disease was the only statistically significant predictor associated with higher risk of luminal stricture (P = 0.001) in post-hoc analysis. Conclusions Excretion of the PC 30 h post-ingestion reliably predicts safe CE passage. Plain abdominal radiology is unreliable and a scout film targeted, limited CT scan offers an accurate minimal radiation method of determining small bowel patency.

Out of programme (OOP) opportunities are to be encouraged. This article gives an insightful view of the Sheffield Clinical Research Fellowship Programme. Unique trainee feedback is provided. The take home message is clear - trainees should grab OOP experiences with both hands! For consultants the logistics described are potentially transferrable to their own regions.