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Background and aims Foreign travel for people with inflammatory bowel disease (IBD) carries an increased risk of travel-related morbidity. There is limited research looking specifically at travel-associated health risks and travel preparation in patients with IBD. The aims of this study are to explore the experience of travel, pretravel preparation undertaken by the patient with IBD and examine IBD healthcare professionals’ (HCP) confidence at providing travel advice and the content of that advice. Methods A survey of patients with IBD attending an outpatient clinic with a separate online survey sent to IBD HCPs recruited using regional and international network databases. Results A total of 132 patients with IBD, Crohn9s disease (67/132, 51%), male (60/132, 45%) and 128 HCPs (IBD nurse specialist 113, 88%; IBD physician 15, 12%) completed the questionnaires. IBD affected travel to some extent in 62% (82/132) of patients, and 64% (84/132) had experienced an IBD flare, of whom 64% still travelled overseas during this time. Only 23% (31/132) travellers sought pretravel medical advice and 40% (53/132) obtained travel insurance. Forty-eight per cent of respondents on immunomodulator therapy were unaware of the need to avoid live vaccines. Twenty-seven per cent (34/128) of IBD HCPs are not confident at providing pretravel advice; vaccination advice (54%), obtaining travel insurance (61%) and healthcare abroad (78%) are the areas of most uncertainty. Conclusions Patients do not seek adequate pretravel advice and consultations for those who do are often deficient. The majority of IBD professionals are not confident to provide comprehensive travel advice. Greater IBD-specific travel education and awareness is needed for both patients with IBD and professionals.

Background Following liver transplantation (LT), more than a third of patients with inflammatory bowel disease (IBD) will have an aggressive disease course, requiring treatment with biologics. Data on efficacy and safety of biologics in this setting are limited. We report our experience in IBD patients on biologics following LT. Methods Data were collected retrospectively from medical files of patients who underwent LT from 1989 to 2019 in a tertiary referral centre and required IBD treatment with biologics post-LT. Clinical and endoscopic responses, and concomitant corticosteroid requirement were used as a measure of efficacy. Adverse events and infections were recorded. Results We identified 10 patients who received treatment with biologics post-LT. The majority were males (n = 7), had a diagnosis of ulcerative colitis (UC) prior to LT (n = 9) and the primary liver disease leading to LT was primary sclerosing cholangitis (PSC). Median time from LT to biologic initiation was 6 years (range 2–17). All patients received tacrolimus as part of anti-rejection therapy, 8 patients were on azathioprine and 2 on mycophenolate mofetil. Two patients had a proctocolectomy prior to LT. The majority (n = 9) were biologic naïve. As a 1st line treatment 7 patients received infliximab (IFX), 1 adalimumab (ADA) and 2 vedolizumab (VDZ). Following allergic reaction to IFX, 2 patients were switched to VDZ. One patient with chronic pouchitis received ADA following IFX failure. Mean duration on IFX in patients on maintenance therapy was 23 months (range 8–33), for ADA 34 months (range 17–50) and for VDZ 12 months (range 6–24). Three patients on IFX (1 with chronic pouchitis) responded to treatment, with one achieving endoscopic remission and another improvement of pouchitis. One patient, despite initial response, treatment escalation and rescue corticosteroids, required colectomy, and so did another after failing both IFX and VDZ. The 2 patients on maintenance ADA showed clinical and endoscopic improvement. Responses to VDZ were mixed; 2 patients improved, but 3 did not respond to VDZ therapy. The infections recorded for patients on IFX (n = 4/7) were cholangitis, Clostridium difficile, TB-related erythema induratum, EBV and CMV colitis, liver and perianal abscesses and Bell’s palsy secondary to CMV/EBV. One patient (n = 1/2) on ADA had a bacterial upper respiratory tract infection, while another on VDZ (n = 1/5) developed pericarditis, corneal ulceration and viral eye infection. No cancers have been detected to date (median follow-up 107 months, range 26–253). Conclusion Anti-TNF and VDZ therapy may be effective in the post-LT IBD setting. Caution is warranted regarding infections, particularly for patients on concomitant anti-rejection therapy and IFX.

Background: We studied the management of patients with acute upper gastrointestinal (GI) bleeding (AUGIB) at the Royal Free Hospital. The aim was to compare our performance with the national standard and determine ways of improving the delivery of care in accordance with the recently published ‘Scope for improvement’ report. Methods: We randomly selected patients who presented with haematemesis, melaena, or both, and had an oesophageogastroduodenoscopy (OGD) between April and October 2009. We developed local guidelines and presented our findings in various forums. We collaborated with the British Medical Journal’s Evidence Centre and Cerner Millennium electronic patient record system to create an electronic ‘Action Set’ for the management of patients presenting with AUGIB. We re-audited using the same standard and target. Results: With the action set, documentation of pre-OGD Rockall scores increased significantly ( p ≤ 0.0001). The differences in the calculation and documentation of post-OGD full Rockall scores were also significant between the two audit loops ( p = 0.007). Patients who inappropriately received proton-pump inhibitors (PPIs) before endoscopy were reduced from 73.8% to 33% ( p = 0.02). Patients receiving PPIs after OGD were also reduced from 66% to 50% ( p = 0.01). Discharges of patients whose full Rockall score was less than or equal to two increased from 40% to 100% ( p = 0.43). Conclusion: The use of the Action Set improved calculation and documentation of risk scores and facilitated earlier hospital discharge for low-risk patients. Significant improvements were also seen in inappropriate use of PPIs. Actions sets can improve guideline adherence and can potentially promote cost-cutting and improve health economics.

Inflammatory bowel diseases (IBD) are chronic immune disorders of unclear aetiology. Dietary deficiencies may be a potential pathogenic factor in their development. Patients often take food supplements without knowledge of any evidence base. We have therefore assessed the evidence for food supplementation in the management of IBD. A PubMed search was performed for the terms Inflammatory bowel disease; nutritional deficiencies; dietary supplements; curcumin; green tea; vitamin D/other vitamins; folic acid; iron; zinc; probiotics; andrographis paniculata; and boswellia serrate. PubMed was used to search for all relevant articles published between January 1975 and September 2015. Curcumin supplementation has been reported to be effective in reducing the symptoms and the inflammatory indices in IBD patients. Similar results have been observed for green tea; however, pertinent studies are limited. Vitamin D supplementation may help to increase bone mineral density in IBD patients and to reduce disease activity. IBD patients with ileal resections higher than 20 cm may develop vitamin B12 deficiency that requires parenteral supplementation. There is no current evidence to support fat-soluble vitamin supplementation in IBD patients. Zinc and iron should be supplemented in selected cases. Probiotics (VSL#3) may reduce disease activity in IBD patients with pouchitis. Complementary and alternative medicines are used by IBD patients and some studies have shown promising results. In summary, attention to dietary factors such as curcumin, green tea and vitamins, including vitamins D and B12, appears to be beneficial and, if necessary, supplementation may be appropriate.

A previously fit and well 43-year-old male triathlete presented with severe central abdominal pain persisting for several hours. Three similar episodes in the past 18 months had spontaneously resolved. Prior investigations with abdominal ultrasound, upper and lower GI endoscopies had been unremarkable. On this presentation, the patient also had worsening malaise and fever at 40°C. He was fluid resuscitated and commenced on broad-spectrum antibiotics (intravenous piperacillin–tazobactam 4.5 g and 350 mg gentamicin). Initial biochemistry revealed absolute eosinophil count 0.56×109/L, asparate aminotransferase serum 72 IU/L and alanine aminotransferase (ALT) 78 IU/L. The alkaline phosphatase 65 IU/L, bilirubin 10 μmol/L, white cell count 7.93×109/L and C-reactive protein 5 mg/L were all normal. CT abdomen (figure 1A) did not reveal gallstones nor any small bowel pathology. As the …

Background ESO-2 video capsule endoscopy provides images of the oesophageal mucosa and continues to transmit gastric, and often small bowel images, for up to 30 min. This study compares ESO capsule endoscopy capsule oesophago-gastro-duodenoscopy (Cap-OGD) with conventional endoscopy (OGD). Methods 50 outpatients with uncomplicated dyspepsia underwent Cap-OGD followed by OGD which was recorded on DVD. Cap-OGD and OGD were each reported independently by two gastroenterologists. A benchmark report was also produced by two gastroenterologists viewing both Cap-OGD and OGD on side-by-side monitors. Major findings included large hiatus hernia, Barrett9s oesophagus, oesophagitis, erosive gastritis, tumour and ulceration. Minor findings included histologically-proven superficial gastritis, pouting gastric folds and fundic gland polyps. A questionnaire assessed the patient experience. Results 49 patients completed the study. In 61%, Cap-OGD transmitted in the duodenum. In the benchmark study, all the major OGD findings were observed on Cap-OGD. Cap-OGD revealed fewer minor findings. When reported independently, Cap-OGD and OGD reports indicated differences in interpretation most marked between the capsule readers with or without previous ESO-2 experience. Patients expressed a clear preference for Cap-OGD. Conclusions When compared side-by-side, all the major findings on OGD are seen on Cap-OGD while there is under-reporting of minor findings. Previous experience of ESO-2 capsule reporting improves reading accuracy and indicates the need for training. This pilot study provides a backdrop to explore the possible role of Cap-OGD, especially where patients are reluctant to undergo conventional OGD or where there is risk of prion contamination of the endoscope.

BACKGROUND AND AIMS: Ulcerative colitis (UC) associated with primary sclerosing cholangitis (PSC) is usually clinically mild. The aim of the study was to assess whether there is an association between severity of PSC and activity of UC, comparing the course of UC in patients with PSC not needing liver transplantation (LT) and those eventually transplanted. METHODS: Between 1990 and 2009, 96 consecutive patients with PSC/UC were seen in the authors' institution. Data were evaluated from a database regarding UC activity (median follow-up 144 months). Follow-up was censored at time of LT or last clinical review. RESULTS: Patients with PSC/UC were divided into two groups: 46 did not need LT (no-LT) and 50 were transplanted (LT). There were no significant differences concerning duration of UC or PSC and extent of UC. The LT group had significantly (p=0.002) more clinically quiescent UC compared with the no-LT group. The LT group had fewer UC flare-ups (p=0.04) and required fewer steroid courses (p=0.025) with shorter duration (p=0.022) and less use of azathioprine (p=0.003). There was an increased need for surgery in the no-LT group (p=0.006). Colon carcinoma and high grade dysplasia were more frequent in the no-LT group (p=0.004). The no-LT group had increased inflammation in the colonic mucosa at histology (p=0.011), but without visual difference at colonoscopy. CONCLUSIONS: Clinically progressive PSC requiring LT is associated with a milder course of UC (reduced disease activity and less use of steroids, azathioprine and surgery). This is paralleled by less histological activity and reduced incidence of dysplasia and colon carcinoma. Gut

A 70-year-oldwomanwith a longstanding history of ileocolonic Crohn’s disease was reviewed in our inflammatory bowel disease clinic. Although her Crohn’s diseaserelated symptomswerewell controlled on azathioprine and 5-aminosalicylic acid therapy, computed tomography enterography (CTE) demonstrated active disease affecting the distal ileum and right colon with an ileal polyp that had increased in size from 14mm to 30mm over a 2-year follow-up period (●" Fig.1). Histopathology of biopsies taken from the distal ileal polyp were consistent with an inflammatory etiology but, because of its increasing size and the risk of intussusception, the lesion was deemed to merit endoscopic excision. Retrograde double-balloon enteroscopy (DBE) identified the ulcerated polypoid lesion located within a segment of severely active Crohn’s disease that was affecting the last 40cm of the terminal ileum (●" Fig.2). Theheadof thepolypwas injected with a 1:10000 epinephrine solution to reduce its size and bleeding risk [1]. The lesionwas then removed by en bloc endoscopic mucosal resection (●" Fig.3). Histopathological examination confirmed complete excision of a submucosal lesion composed of sparsely cellular proliferating spindle cells, set within an edematous stroma containing small and large vessels and inflammatory cell infiltrate rich in eosinophils (●" Fig.4), consistent with an inflammatory fibroid polyp (IFP). IFPs are rare benign submucosal lesions which, although they may arise anywhere within the gastrointestinal tract, affect the small bowel in only 18% of cases [2]. Intussusception, obstruction, and bleeding are recognized complications of small-bowel IFPs [3]. Simultaneous occurrence of active Crohn’s disease with such lesions has rarely been described, and it has been proposed that disease activity may be the local stimulus for the formation of this apparently reactive lesion [4]. To the best of our knowledge, this is the largest small-bowel IFP (and only the third such case) to be resected by balloon-assisted enteroscopy [2,5].

This study assessed the duration of action of single doses of ranitidine (75 mg), cimetidine (200 mg), or placebo on intragastric acidity in healthy subjects. When dosed with placebo, mean daytime intragastric acidity (0-10 hr after dose) was 37.62 mmol/liter, decreasing to 17.21 mmol/liter (mean decrease 59%; P < 0.001 vs placebo) and 25.06 mmol/liter (mean decrease 35%; P < 0.001 vs placebo) when treated with ranitidine and cimetidine, respectively. Ranitidine inhibited intragastric acidity to a greater degree than cimetidine (P < 0.001). Mean nighttime (10-20 hr after-dose) intragastric acidity when dosed with placebo was 34.37 mmol/liter, decreasing to 29.06 mmol/liter (mean decrease 18%; P = 0.027 vs placebo) when dosed with ranitidine and remaining virtually unchanged at 33.85 mmol/liter (mean decrease 2%; NS vs. placebo) when dosed with cimetidine. Ranitidine inhibited acidity to a greater degree than cimetidine (P = 0.043). The inhibitory effect of ranitidine, 75 mg, on intragastric acidity can be detected from 0-15 hr after an oral dose. Cimetidine 200 mg has little inhibitory effect beyond 10 hr.

Background & Aims: α4 integrins are important mediators of leukocyte migration across vascular endothelium.This pilot placebo-controlled study aimed to assess the safety and efficacy of natalizumab, a recombinant humanized monoclonal antibody to α4 integrin, in patients with mild to moderately active Crohn's disease. Methods: Thirty patients with active Crohn's disease (Crohn's Disease Activity Index [CDAI] ≥151 and ≤450) received a 3-mg/kg infusion of natalizumab (n = 18) or placebo (n = 12) by double-blind randomization.The study's primary endpoint was change in CDAI at week 2. Results: At week 2, the CDAI decreased significantly from baseline after infusion of natalizumab (mean 45 points) but not placebo (mean 11 points).Seven (39%) natalizumab-treated patients achieved remission at week 2, compared with 1 (8%) treated with placebo.In contrast, 4 (33%) of the placebo-treated patients required rescue medication by week 2, compared with 2 (11%) natalizumab-treated patients.Significant increases in circulating B and T lymphocytes were detected only after natalizumab administration.The frequency of commonly reported adverse events did not differ significantly between groups. Conclusions: A single 3-mg/kg natalizumab infusion was well tolerated by Crohn's disease patients, although the dose used may have been suboptimal.Elevated circulating lymphocyte levels after natalizumab suggest interrupted lymphocyte trafficking.Natalizumab therapy in active Crohn's disease merits further investigation. GASTROENTEROLOGY 2001;121:268-274

Background—The course of inflammatory bowel disease after liver transplantation has been reported as variable with usually no change or improvement, but there may be an increased risk of early colorectal neoplasms. In many centres steroids are often withdrawn early after transplantation and this may affect inflammatory bowel disease activity.Aims—To evaluate the course of inflammatory bowel disease in primary sclerosing cholangitis transplant patients who were treated without long term steroids.Methods—Between 1989 and 1996, there were 30 patients transplanted for primary sclerosing cholangitis who survived more than 12 months. Ulcerative colitis was diagnosed in 18 (60%) patients before transplantation; two had previous colectomy. All patients underwent colonoscopy before and after transplantation and were followed for 38 (12–92) months. All received cyclosporin or tacrolimus with or without azathioprine as maintenance immunosuppression.Results—Ulcerative colitis course after transplantation compared with that up to five years before transplantation was the same in eight (50%) and worse in eight (50%) patients. It remained quiescent in eight and worsened in four of the 12 patients with pretransplant quiescent course, whereas it worsened in all four patients with pretransplant active course (p=0.08). New onset ulcerative colitis developed in three (25%) of the 12 patients without inflammatory bowel disease before transplantation. No colorectal cancer has been diagnosed to date.Conclusions—Preexisting ulcerative colitis often has an aggressive course, while de novo ulcerative colitis may develop in patients transplanted for primary sclerosing cholangitis and treated without long term steroids.

I bowel disease (IBD) is a chronic relapsing inflammatory process limited to the large bowel [ulcerative colitis (UC)] or occurring anywhere along the gastrointestinal tract [Crohn’s disease (CD)], but is also associated with many extraintestinal complications. The liver and bile ducts are often affected, but only a few patients have overt disease (1,2). The most common clinically important liver disease and possibly the most common extraintestinal complication in IBD patients is primary sclerosing cholangitis (PSC) (2,3). PSC occurs more often in patients with UC (2.5%– 7.5%) than in those with CD (1.2%) (1–6). In particular in patients with CD, PSC has been associated almost exclusively with disease of the colon (1,7,8). On the other hand, the prevalence of IBD in PSC patients is as high as 55–75% (6,8). Since the prevalence of UC is higher than that of CD and PSC is generally more common in UC patients, most of our knowledge of the natural history of IBD and PSC is based on UC and PSC cases. Whether the type, extent and activity of one disease have any effect on the course of the other remains undefined. The extent, duration or severity of IBD correlates poorly with the natural course of established PSC (2– 6). On the other hand, patients with PSC usually have mild or asymptomatic but extensive colitis (3,9,10). No specific therapy has been identified that can arrest the progression of liver disease in PSC patients, and hepatic failure and complications of portal hypertension develop in many cases (2,3). Orthotopic liver transplantation (OLT) is the only life-saving and potentially curable therapy for advanced cases (11,12). The impact of OLT and the subsequent immunosuppression on the natural history of IBD has been the subject of a few recent studies, but the results are quite contradictory.

BACKGROUND: Bactericidal/permeability-increasing protein (BPI), a constituent of primary neutrophil granules, is a potent natural antibiotic and an antineutrophil cytoplasm antibody (ANCA) antigen in cases of vasculitis in which the target antigen is neither myeloperoxidase (MPO) nor proteinase-3 (PR3). AIM: To investigate BPI as a possible target antigen for ANCAs in inflammatory bowel disease. METHODS: ANCAs were detected by routine immunofluorescence (IIF) and solid phase enzyme linked immunosorbent assay (ELISA) performed for antibodies to the purified neutrophil granule proteins; MPO, PR3, cathepsin-G, lactoferrin, and BPI in serum samples from 88 patients with inflammatory bowel disease (36 with Crohn's disease, 52 with ulcerative colitis). Thirty patients with bacterial enteritis acted as controls. RESULTS: Significantly more patients with ulcerative colitis were ANCA positive by IIF (60%) than patients with Crohn's disease (28%) or infectious enteritis (23%) (p < 0.001). IgG anti-BPI antibodies were present in 29% of patients with ulcerative colitis, 14% of patients with Crohn's disease, and 23% of patients with infectious enteritis, occurring in 44% of those patients with inflammatory bowel disease who were ANCA positive by IIF. Antibodies to other ANCA antigens were rare. The presence of ANCAs was not related to either disease activity or extent; presence of anti-BPI antibodies was significantly related to both a lower serum albumin concentration (p = 0.001) and a higher erythrocyte sedimentation rate (p = 0.02) in patients with ulcerative colitis, and to colonic involvement in patients with Crohn's disease (p = 0.01). CONCLUSION: BPI is a significant minority target antigen for ANCAs in inflammatory bowel disease that seems related to colonic Crohn's disease and disease activity in ulcerative colitis. Anti-BPI antibodies occur in infectious enteritis.

A common reason for referring patients to hepatologists is persistently abnormal serum transaminase levels with vague constitutional symptoms. In the United Kingdom, these abnormalities are most often caused by a fatty liver either related to obesity or alcohol abuse; they are less commonly caused by chronic liver disease, particularly chronic viral hepatitis, autoimmune hepatitis, or chronic biliary disease. Endocrine disease is rarely a cause of these abnormalities, although hypothyroidism and hyperthyroidism are well-recognized causes. Addison's disease has been only reported once in the literature by R. G. Olsson as a cause of increased transaminase levels associated with constitutional symptoms; it is not mentioned in textbooks on hepatology. Three patients with Addison's disease are reported here, all of whom had increased serum transaminase levels for more than 6 months before the recognition of the hypoadrenalism with resolution to normal after steroid replacement. Hepatologists should consider subclinical Addison's disease as a cause of persistently increased transaminase levels with constitutional symptoms in the absence of evidence for fatty liver as well as viral and autoimmune markers.

Background and aims Testing for LTBI is recommended prior to anti-TNFα agents. This includes an assessment of TB risk factors, chest radiograph, and interferon-gamma release assay alone or with concurrent Tuberculin skin testing. Here we review our experience and cost-effectiveness of using T-SPOT.TB IGRA to detect mycobacterial infection in patients with IBD suitable for anti-TNFα therapy. Methods This was a single-centre, retrospective review and economic evaluation (compared to British Thoracic Society guidance) of 125 adult IBD patients (90 anti-TNFα naive, 35 established on anti-TNFα) tested for LTBI using T-SPOT.TB IGRA. Results All subjects had normal chest radiographs and no clinical evidence for TB. 109 (87%) were BCG vaccinated. 27 (22%) of all patients tested were not using immunomodulation at the time of testing. 66 (53%) were taking thiopurines, 22 (18%)corticosteroids, and 35 (28%) anti-TNFα agents. One hundred twenty two (98%) had a negative IGRA result, two (2%) had positive results, and one (1%) had an indeterminate IGRA. A strategy using IGRA to guide TB preventative treatment produced cost savings of £10.79 per person compared to the BTS guidance. Eighty eight percent of the anti-TNFα naive group have subsequently received treatment with either infliximab or adalimumab (median follow-up of 24 months, IQR 18–30) with no cases of TB disease occurring. Conclusions The use of a simple screening protocol for LTBI incorporating T-SPOT.TB IGRA in place of TST in a largely BCG vaccinated population, many using immunomodulatory agents, appears to work well and is a cost-effective strategy in our IBD service.

Screening for, and treatment of, latent tuberculosis infection (LTBI) before anti- tumour necrosis factor α therapy has been shown to decrease the incidence of active tuberculosis by more than 80% and is recommended before initiation of treatment. In the absence of a 'gold standard' test for LTBI, current screening involves taking a clinical history of risk factors, chest radiograph and tuberculin skin test. Alternative cellular immune-based screening tests have been developed to detect Mycobacterium tuberculosis infection. This paper summarises the current position and advances in the use of newer screening strategies for LTBI.

A 27-year-old man developed extensive hepatic portal venous gas (HPVG) shortly after staging colonoscopy for active, ulcerating, terminal ileal Crohn's disease. Non-operative management was instigated with broad-spectrum antibiotics and thromboprophylaxis. Radiology at 72 h demonstrated resolution of HPVG but revealed fresh non-occlusive left portal vein thrombus. Anticoagulation with warfarin was continued for 1 year, during which the thrombus initially progressed and then organised with recanalisation of the portal vein. There were no long-term clinical consequences. HPVG has previously been documented as a rare complication of inflammatory bowel disease and endoscopic intervention. We hypothesise that the barotrauma sustained during endoscopy, in association with active ulceration and mucosal friability, predisposes to the influx of gas and bacteria into the portal system. We describe successful non-operative management of HPVG in this setting and draw attention to an additional complication of portal venous thrombosis, highlighting the importance of thromboprophylaxis and serial radiological examination.

Introduction The internet offers a wealth of information for patients with chronic disease, facilitating education and shared decision making; however, this can often be unregulated and inaccurate. 1 Inflammatory bowel disease (IBD) patients use of the internet has been investigated 2 but no studies have examined whether internet use alters with disease activity or influences patients decisions regarding health. We evaluated patients internet use for health-related information (HRI), including factors influencing website choice and whether this information influences decisions regarding healthcare or changes with disease severity. Methods A prospective, pilot survey of 170 consecutive patients attending the IBD clinic over a one month period in November 2013. The anonymous questionnaire included demographic information on age, gender, education level, diagnosis and disease activity. There were also questions regarding use of the internet for HRI, determinants of website quality and influences of information found on the internet on decisions affecting their health. Results A total of 136 IBD patients completed the questionnaire (80% response rate), 60 [44%] male, age 18–85 years [median age 37 years] 67 [49%] had CD; 84 [62%] reported a flare of symptoms in the preceding 6 months. 126 (93%) use the internet, 110 (81%) of which access HRI information via the internet. 94% of patients were educated to completion of high school or above and level of education did not affect internet use. Using NHS direct (46%), Crohn’s and colitis UK (40%) and IBD forums (29%), patients searched for general health (77; 57%); IBD specific (63; 46%) and medication (47; 35%) information. 45 (33%) stated that information found on the internet would influence their choice of medication, irrespective of a flare within the last 6 months. 71% (96) felt confident that they could obtain factual information on the internet, although when determining website quality, overall appearance and position in search engines and whether the site was non-commercial were ranked least important and IBD-specific sites from a reputable source most important. Conclusion In our study, internet use is shown to be a major source of disease –specific information and can affect patients’ decision making. Internet usage and type of information sought do not alter with disease activity, suggesting that information is equally useful to all patients with IBD. References 1 Fortinsky et al . Innflam Bow. Dis 2012; 18(6):1156–63 2 Cima et al . Inflamm Bowel Dis 2012; 13 (10)1266–1270 Disclosure of Interest None Declared.

Introduction Travellers’ with Inflammatory bowel disease (IBD) are at greater risk of travel-related morbidity with European guidelines recommending expert consultation prior to travel. 1 Previous research into travel and IBD found travel consultations and patient travel preparation and knowledge to be deficient. 2,3 As a result we developed a dedicated, evidence-based non-profit IBD travel advice website (www.ibdpassport.com) to enhance informed, safe travel. Here we present formal evaluation of this website. Method A link to the website, along with a structured web-based survey was sent to a sample of 15 UK IBD patients, clinical nurse specialists and Gastroenterologists respectively. The survey contained demographic questions and asked respondents to rate the content, functionality and credibility of the website using a series of parameters including a 5-point Global Quality Score and Integrity Score. 4 Readability statistics were graded on a 100 word sample of text from each page on the website using the Flesch Reading Ease and Flesch-Kincaid Grade level scores. Results A total of 33 individuals responded (73% response rate; 11, 33% Patient; 10, 30% Nurse; 12, 36% Gastroenterologist. The mean Global Quality score was 4.5 out of a possible 5 (Range 3–5). The Flesch-Kincaid Grade level score was US school grade 10.9 (range 7.2–17.1) and median Flesch Reading Ease score 50.5 out of a possible 100 (Range 22.4–65.1). The integrity score was 4.0 out of 6. The majority of respondents strongly agreed the website was an accurate source of travel information for IBD (60%), used appropriate citations (67%), and was easy to navigate (70%). 26/33 (79%) felt the website improved their knowledge of travel-related issues in IBD. All respondents would recommend the site to peers. Conclusion IBD Passport is the first internet-based travel resource created for both patients and professionals to provide IBD-specific travel information. Our findings demonstrate that patients and healthcare professionals consider IBD Passport to be an excellent quality, evidence-based resource. The readability statistics are favourable when compared to results from other studies examining website quality. Disclosure of interest None Declared. References Rahier JF, et al . J Crohns Colitis 2014;8:443–468 Soonawala D, et al . Inflamm Bowel Dis. 2012;18(11):2079–85 Greveson, et alet al. A recent flare of disease does not prohibit travel: early results of a single centre study in inflammatory bowel disease and travel digestive diseases week, 2014, abstract ID:Su1095 Bernard A, Langille M, Hughes S, et al . A systematic review of patient inflammatory bowel disease information resources on the world Wide Web. Am J Gastroenterol. 2007;102:2070–2077

This study assessed the duration of action of single doses of ranitidine (75 mg), cimetidine (200 mg), or placebo on intragastric acidity in healthy subjects. When dosed with placebo, mean daytime intragastric acidity (0-10 hr after dose) was 37.62 mmol/liter, decreasing to 17.21 mmol/liter (mean decrease 59%; P0.001 vs placebo) and 25.06 mmol/liter (mean decrease 35%; P0.001 vs placebo) when treated with ranitidine and cimetidine, respectively. Ranitidine inhibited intragastric acidity to a greater degree than cimetidine (P0.001). Mean nighttime (10-20 hr after-dose) intragastric acidity when dosed with placebo was 34.37 mmol/liter, decreasing to 29.06 mmol/liter (mean decrease 18%; P = 0.027 vs placebo) when dosed with ranitidine and remaining virtually unchanged at 33.85 mmol/liter (mean decrease 2%; NS vs. placebo) when dosed with cimetidine. Ranitidine inhibited acidity to a greater degree than cimetidine (P = 0.043). The inhibitory effect of ranitidine, 75 mg, on intragastric acidity can be detected from 0-15 hr after an oral dose. Cimetidine 200 mg has little inhibitory effect beyond 10 hr.

Introduction Acute upper GI bleeding (AUGIB) has 7% new-admission mortality.1 The authors studied the management of patients with AUGIB at the Royal Free Hospital (RFH), London. The aim was to compare our performance to the standard practice as set by SIGN guidelines,2 and determine ways of improving delivery of care. Methods The authors randomly selected 15% of patients3 who presented with haematemesis, melaena, or both, and had an oesophagogastroduodenoscopy (OGD) in April to October 2009. Acute assessment and management were matched to the SIGN guidelines (audit standard). The authors developed local guidelines, and presented their findings in various forums including the Grand Round and clinical governance meetings. The authors collaborated with the British Medical Journal (BMJ) and Cerner Millennium electronic patient record system to create an electronic Action Set for the assessment and emergency management of adult patients presenting with AUGIB. The Action Set went live in April 2010 and the authors reaudited using the same standard and target. Results Prior to the introduction of the Action Set 0% of doctors calculated the pre-OGD Rockall score. This increased to 33% following implementation (figure 1). The authors also noticed an increase from 25% to 100% of those patients who were admitted with a pre-OGD Rockall score of ‘zero’ and were correctly discharged with follow-up plans (figure 2). 34% of patients were correctly identified as not appropriate to receive a proton pump inhibitor (PPI) prior to OGD as compared to 15% previously. Inappropriate use of PPIs after OGD was reduced from 96% to 75%. Incorrect administration of intravenous PPI infusions dropped from 100% to 33%. Conclusion Several areas of deviation from the guidelines were identified. The authors emphasised the usefulness of pre/full-Rockall scores as a risk-stratifying tool in order to determine potential discharges, create more beds and improve health economics for the Trust. Appropriate use of PPIs can reduce rebleeding rates,4 improve mortality5 and reduce costs. The Action Set consists of a set of orders based on clinical evidence that can be used for the assessment and management of AUGIB. Local and SIGN guidelines and useful contacts/bleep numbers are incorporated in the workflow. The tool ‘captures’ patients with suspected AUGIB and records/time-stamps every event in the patient9s journey. Tests and procedures are automatically ordered and auditable data is streamed, collected and analysed weekly. The Action Set includes e-prescribing and nurse ordering functionality. Even with minimal use the authors noticed improvements in several areas including guideline adherence, clinical outcomes and cost-cutting.

A 62-year-old woman presented with abdominal pain and diarrhoea. She had a history of primary biliary cirrhosis and renal transplantation secondary to reflux nephropathy. Cross-sectional imaging and a colonoscopy demonstrated terminal ileal inflammation and ulceration, but histological biopsies were inconclusive and cytomegalovirus staining was negative. The patient subsequently developed spontaneous small bowel perforation due to deep ulceration, necessitating an emergency right hemicolectomy. Her postoperative period was complicated by several episodes of rectal bleeding. After a prolonged admission at her local hospital, the patient was referred to our unit for further management. On arrival, the patient's immunosuppression consisted of tacrolimus and low-dose prednisolone. Mycophenolate mofetil …

Introduction Travellers with inflammatory bowel disease (IBD) are at greater risk of travel-related morbidity. 1 ECCO recommend patients seek expert advice prior to travel, including information on vaccination and obtaining antibiotics for self-treatment of travellers diarrhoea. 2 Wasan et al. report only 3.5% of patients on immunosuppression therapy were counselled on avoiding particular live vaccines 3 and 30% of gastroenterologists would erroneously recommend live vaccines. 4 Methods We explored both patient and gastroenterology health care professionals (HCP) perceptions of IBD and travel: whether disease affected travel, interventions people took to travel, and whether ECCO guidelines were being followed. IBD patients attending our IBD clinic during November 2013 were asked to complete a questionnaire collecting demographic, disease specific and travel related information. Using N-ECCO and RCN IBD nurse network databases, HCP were asked to complete online questionnaire collecting information on perceptions of IBD and travel, confidence at providing travel advice, and the content of that advice. Results 136 IBD patients (67[49%] Crohn’s disease, 60[44%] male, median age 38 years[range 18–85]) and 105 HCP (98/105[93%] nurse specialists, 6/105[6%] consultant, 1/105[1%] registrar) responded. 85%[106/136] patients report feeling adequately prepared for travel, although only 24%[32/136] seek travel medical advice of any kind and only 11%[15/136] from the IBD team; all despite 60%[82/136] reporting their IBD affected travel. Despite recommendations, only 4%[5/136] had been prescribed antibiotics for self-medication of travellers diarrhoea. 52%[36/69] of immunosuppressed patients are unaware they should avoid live vaccines. 39%[53/136] patients buy travel insurance covering IBD, 70%[37/53] of which pay a premium. 70%[74/105] HCP felt IBD might limit travel in patients. 70%[74/105] HCP are confident giving travel advice, but 51%[38/74] refer them to a travel clinic. 90%[94/105] are confident giving advice on travellers diarrhoea, but only 54%[57/105] on vaccinations and 40%[42/105] on insurance. Conclusion Patients travel is affected by IBD, however, few seek expert medical advice prior to travel. HCP agree IBD affects travel and a majority are confident giving limited advice. It is concerning 52% of immunosuppressed patients are unaware they should avoid live vaccines, and only 54% of HCP are confident giving advice on vaccinations. Results support the need for further travel specific research and better education in both groups. References Soonwala et al . Inflamm Bowel Dis 2012;18(11):2079–85 Rahier et al . Journal of Crohn’s and Colitis 2009;3(2):47–91 Wasan et al . Inflamm Bowel Dis 2014;20(2):246–50 Wasan et al . Inflamm Bowel Dis 2011;17(12):2536–60 Disclosure of Interest None Declared.

Introduction Travellers with Inflammatory bowel disease (IBD) are at greater risk of travel-related morbidity [1] ,with ECCO recommending expert consultation prior to travel, particularly for those on immunosuppression .2 The travel consult and patients pre-travel preparation have been found to be deficient .1 Here we present the development of a dedicated IBD travel advice website to enable informed, safe travel with IBD. Methods We conducted a literature review using Ovid databases and a search of existing online material using major internet search engines to identify existing research and resources regarding IBD and travel. Data was extracted from a recently reported prospective survey 3 of 136 IBD patients which examined pre-travel preparation and experiences of travelling with IBD. Results The database and Internet search revealed a paucity of research and resources available for IBD patients and professionals regarding travel and IBD. Our survey of 136 patients found 60% [82/136] reported IBD affected travel, however; pre-travel medical advice was only sought by 24% [32/136]. Disease-related travel knowledge was poor with 52% of immunosuppressed patients unaware of the need to avoid live vaccines; only 53/136 (39%) buy travel insurance covering their IBD and the majority of these (70%) pay a premium. 91% (124/136) would find a dedicated IBD travel website useful. As a result of this, IBDPassport™ was developed for both patients and professionals as non-commercial, IBD-specific travel resource, aimed at providing evidence-based information on all aspects of travel and IBD. The functionality of the website includes an interactive map of country specific advice including vaccinations and a ‘search and refer’ service for IBD professionals to refer to other IBD centres globally. Features also include practical information for travelling with IBD and specific information for the immunocompromised traveller. Conclusion We present the first comprehensive web-based travel resource created for both IBD patients and professionals to obtain evidence-based IBD and country specific travel information. IBDPassport™ needs to be formally evaluated by patients and healthcare professionals as part of a larger study and to inform further development. References 1 Rahir et al . ECCO 2009 2 Soonawala et al . Inflamm Bowel Dis 2012 3 Greveson et al . A Recent Flare of Disease does not Prohibit Travel: Early Results of a Single Centre Study in Inflammatory Bowel Disease and Travel. Abstract Number: A-1908. ECCO 9 th congress Copenhagen 2014 Disclosure of Interest None Declared.

Introduction Travellers with Inflammatory bowel disease (IBD) are at greater risk of travel-related morbidity. 1 Relapse and acquired infection are the main risks to IBD patients while abroad, and ECCO recommend expert consultation prior to travel, particularly for those on immunosuppression. 2 IBD limits a majority of patients choice of travel destination. 1 Despite this, there is limited data regarding IBD patients pre-travel preparation and travel experiences. Methods Patients attending our IBD clinic during November 2013 were asked to complete an anonymous questionnaire. We asked for demographic and disease specific information, in addition to detailed travel questions; including perceptions, pre-travel planning and recent travel experiences. Data was entered and analysed on an anonymised database. We hypothesised that patients with travel concerns and those who had flared within the last 6 months would be less likely to go abroad in that same period. Results A representative 136 IBD patients (67/136[49%] Crohn’s disease, 60/136[44%] male, age 18–85 years [median age 38 years]) responded. 51%[69/136] were immunosuppressed and 43%[49/136] had IBD related surgery. 62%[84/136] experienced an IBD flare in the last 6 months. 60%[82/136] reported IBD affected travel. 58%[79/136] travelled in the last 6 months, despite a majority of those (65%[51/79]) reporting IBD affected travel. 59%[47/79] of travellers had experienced a flare in the last 6 months, although again, most of those (77%[36/47]) reported IBD affected travel. Only 18%[14/79] travellers (71%[10/14] had a recent flare) sought pre-travel medical advice of any kind and only 41%[32/79] (69%[22/32] had a recent flare) had travel insurance, the majority (88%[28/32]) paid a premium. 20%[16/79] travellers reported a change in bowel habit while abroad, but of those only 27%[3/11] sought medical advice. We also report that 52%[36/69] of immunosuppressed patients are unaware of the need to avoid live vaccines. Conclusion A majority of IBD patients feel their disease affects travel. However, despite concerns, patients still travel abroad, even if they have suffered a recent flare. Our results suggest patients are not receiving the recommended travel medical advice, including the need to avoid live vaccinations if immunosuppressed, and are possibly under or not insured. The small numbers of travellers suffering a change in bowel habit abroad tend not to seek medical advice while away. Further detailed investigation in travel behaviour in IBD patients is required, but we suggest there is a need for greater IBD travel education. References Soonawala D, et al . Inflamm Bowel Dis November 2012;18(11):2079–85 Rahier JF, et al . J Crohn Col February 2009 Disclosure of Interest None Declared.

Abnormalities in liver function tests, including transient and self-limiting hypertransaminasemia, cholestatic disease and hepatitis, can develop during treatment with anti-tumour-necrosis-factor (TNF) therapy. The optimal management of liver injury related to anti-TNF therapy is still a matter of debate. Although some authors recommend discontinuing treatment in case of both a rise of alanine aminotransferase more than 5 times the upper limit of normal, or the occurrence of jaundice, there are no standard guidelines for the management of anti-TNF-related liver injury. Bibliographical searches were performed in PubMed, using the following key words: inflammatory bowel disease (IBD); TNF inhibitors; hypertransaminasemia; drug-related liver injury; infliximab. According to published data, elevation of transaminases in patients with IBD treated with anti-TNF is a common finding, but resolution appears to be the usual outcome. Anti-TNF agents seem to be safe with a low risk of causing severe drug-related liver injury. According to our centre experience, we found that hypertransaminasemia was a common, mainly self-limiting finding in our IBD cohort and was not correlated to infliximab treatment on both univariate and multivariate analyses. An algorithm for the management of liver impairment occurring during anti-TNF treatment is also proposed and this highlights the need of a multidisciplinary approach and suggests liver biopsy as a key-point in the management decision in case of severe rise of transaminases. However, hepatic injury is generally self-limiting and drug withdrawal seems to be an exception.

Introduction Iron deficiency anaemia accounts for 4–13% of gastrointestinal referrals occurring in 2–5% of adult men and post menopausal women. Current guidelines suggest that the work up of asymptomatic anaemia remains incomplete and often inappropriate with important diagnoses of malignancy and malabsorption being missed. In an effort to improve our handling of these patients from primary care and reconfigure services, a nurse led clinic was established in 2009 with the aim to provide rapid access to appropriate investigations and management. Methods All clinic patients between 01/06/2009–05/07/2010 were included in the study. Patients were triaged into the clinic via the GP referral letter. End points examined were:patient demographics, anaemia, microcytosis and iron deficiency, whether oral iron preparations were being used, investigations (OGD/colonoscopy), wait times for investigations and pathology identified. Data were collected using patient notes, pathology results database, clinic letters and endoscopy reports. Anaemia was classified as an Hb of Results 110 patients were included (no exclusions); 81 female and 29 male (73.6%,43.2%).Age range 21 –90yrs, mean 57yrs, median 58yrs.62% were made up of men (29) and post-menopausal women (47); 33%(13) menstruating females with GI symptoms and 46%(21) menstruating females without GI symptoms.62% were in receipt of oral iron supplementation at referral.66% of referrals included the blood results revealing 92% anaemic; 54% microcytic; 50% iron deficient. This compared to 68% of patients anaemic bled in the clinic of whom 20% were not anaemic but on iron supplementation leaving 12% neither anaemic nor on iron supplements. Of those not on iron (42 –13men,29 women)21% had renal disease (GRF Conclusion Of the cohort a total of 55%(61) underwent endoscopy with an overt GI pathology yield (deemed causative for the anaemia) in 26(42%).The nurse led clinic has facilitated a decreased waiting time to appropriate test so improving patient outcomes in terms patient satisfaction, time to diagnosis and management strategy implementation, decreased clinic and investigation waiting times, reduced pressure on physicians lists and most importantly morbidity and mortality. Disclosure of Interest None Declared.

Introduction With the increasing use of biologic therapy in the treatment of inflammatory bowel disease (IBD) there has been a reported increase in dermatological conditions associated with therapy in patients with IBD. We carried out a prospective audit to identify the proportion of IBD patients at The Royal Free Hospital on anti-TNF therapy developing therapy related inflammatory skin pathology Methods 141 IBD patients on anti-TNF therapy (either infliximab or adalimumab) were sent a postal questionnaire to identify patients who had experienced identifiable and associated skin conditions. The questionnaire included information regarding the body site affected, dermatology opinion and whether therapy had to be stopped. Data for infliximab and adalimumab were analysed. Results Of 141 patients, 105 replied (71 (74%) infliximab and 34 (74%)adalimumab).In both groups 32% of patients described new skin complaints attributable to anti-TNF therapy (n = 23 in infliximab group, n = 11 in adalimumab group). Sites of skin inflammation were common to both groups; face (29%), trunk (21%), legs (14%) and arms (14%). Combined data showed only 44% of patients were reviewed by a dermatologist and received a formal diagnosis. No patients on adalimumab stopped treatment, while 3 stopped therapy in the infliximab group (9% overall). Conclusion Although IBD is itself associated with skin pathology, recent studies have demonstrated that patients on anti-TNF therapy develop inflammation of the skin (1), and our data support the concept that paradoxical skin inflammation related to anti-TNF therapy is a class effect. [c1] In our cohort few patients had to stop therapy which is similar to some (1), but not all reported studies (2,3). Less than half of affected patients received consultant dermatological review. [c1]Can’t just give a figure ‘if’ they had responded. Disclosure of Interest None Declared. References Cleynen I, Vermeire S. Paradoxical inflammation induced by anti-TNF agents in patients with IBD. Nat Rev Gastroenterol Hepatol. 2012 Sep; 9(9):496–503. Cullen, G., Kroshinsky, D., Cheifetz, A. S. & Korzenik, J. R. Psoriasis associated with anti-tumour necrosis factor therapy in inflammatory bowel disease: a new series and a review of 120cases from the literature. Aliment. Pharmacol. Ther. 34, 1318–1327 (2011). Baumgart, D. C., Grittner, U., Steingraber, A., Azzaro, M. & Philipp, S. Frequency, phenotype, outcome, and therapeutic impact of skin reactions following initiation of adalimumab therapy: experience from a consecutive cohort of inflammatory bowel disease patients. Inflamm. Bowel Dis. 17, 2512–2520 (2011).

Introduction Inflammatory bowel disease (IBD) can have a significant impact on physical, psychological and social wellbeing. We aimed to survey the impact of IBD on our patients’ lives and their perceptions of psychological support use and availability. Methods Inflammatory bowel disease (IBD) can have a significant impact on physical, psychological and social wellbeing. We aimed to survey the impact of IBD on our patients’ lives and their perceptions of psychological support use and availability. Results 6 patients were excluded as they had not completed the questionnaire. 94 patients were included (43 male, 51 female, average age 42 years, range 17–76). 46 had a diagnosis of Crohn’s disease, 41 ulcerative colitis and 7 indeterminate colitis. Average disease duration for these patients was 15 years (range 1–51 years). Over the past 6 months 20 had symptoms constantly, 16 often, 17 occasionally, 10 sometimes, 13 rarely and 18 never. The average SIBDQ score was 48 (range 21–70). The average HAD score was 12.6 (range 0–33). When separated into HAD A (anxiety) and HAD D (depression) scores were 8.1 (range 0–18) and 4.8 (range 0–15) on average respectively, a score of 8 to 10 for either subscale being suggestive of the presence of the respective state. They were also asked which services they had previously used as forms of support. Of the 86 patients who answered this portion of the questionnaire, 13 (15%) said they had previously had counselling or psychological input, and 32 (37%) said they would like counselling or psychological input in the future if it was available. Conclusion Our survey suggests there may be a higher rate of anxiety in patients with IBD, and that over a third of our patients would like access to psychological and counselling services if they were available. Psychological support is important to patients with IBD and should be incorporated into their management. Disclosure of Interest None Declared.

Introduction The role of infliximab (IFX) in the salvage treatment of acute severe ulcerative colitis (UC) is well established and both licenced and approved in the UK. Studies have demonstrated that IFX IS effective in the treatment of chronic steroid dependent/refractory UC (1) In the UK IFX is not routinely approved for the treatment of chronic steroid-dependent colitis. Our aim was to assess the long-term outcomes of patients treated with IFX for chronic active UC in a single UK IBD centre. Methods A retrospective single centre review was undertaken of patients with severe active UC who received IFX (5mg/kg) between May 2008 and April 2012. Clinical remission was defined as complete steroid withdrawal, normalisation of bowel frequency and absence of blood with defecation. Treatment with IFX was only continued if steroid free remission was maintained. Results 23 patients were included.10 (43%) of patients were treated with induction therapy only (0, 2 & 6 wks) due to funding constraints. 6 (60%) of this group were not on thiopurines, having been either unresponsive or intolerant. 5 (50%) entered clinical remission-median follow up 18 months (IQR 15–25) & 2 (20%) had colectomy. 13 (57%) were treated with induction and maintenance therapy. Of these 7 (85%) were already established on a thiopurine without clinical response. All 13 (100%) entered clinical remission as defined, median follow up 21 months (IQR 11–26). 1 patient required dose escalation to 10mg/kg. None of the patients in the maintenance group were admitted during this time. No significant side effects were reported in either group. Conclusion In our patients treated with IFX for chronic active UC, IFX maintenance therapy appears to have more sustained steroid free remission rates compared with induction therapy only. All patients treated this way avoided colectomy, hospital admission and had complete steroid free remission during follow-up. Experience of maintenance IFX therapy for UC in the UK is limited due to funding constraints but our data confirms the efficacy of this approach in carefully selected patients the response rate may be higher than in other published series. Disclosure of Interest None Declared. Reference Rutgeerts P, Sandborn WJ, Feagan BG, et al. Infliximab for induction and maintenance therapy for ulcerative colitis. N Engl J Med. 2005; 353:2462–2476.

The sharp demarcation between diseased and normal mucosa often observed in ulcerative colitis remains unexplained by current hypotheses of disease pathogenesis. To investigate whether this demarcation occurs at the watershed of vascular territories, the colonic arterial anatomy of 10 patients with ulcerative colitis was studied by in-vitro angiography and macroscopic and histological examination of total colectomy specimens. Of the 10 perfusion-fixed colectomy specimens studied, 7 had pancolitis associated with a complete marginal artery (Arteria marginalis coli) that spanned the entire length of the large bowel. 3 specimens had sharply demarcated disease in which the marginal artery arose from the inferior mesenteric artery and ended abruptly at the point of mucosal demarcation. The colon proximal to this point was histologically normal. These findings suggest that the proximal extent of colitis is determined by the limit of the marginal artery. We suggest that some characteristic of the mucosal microvasculature in the territory of the inferior mesenteric artery, possibly embryological in origin, predisposes the dependent colon to develop ulcerative colitis.

Introduction Two commercial Interferon Gamma release assays (IGRA) are approved in the UK by NICE to detect M tuberculosis (Mtb) infection. They use different test platforms. Both may provide borderline (neither clear positive or negative) or indeterminate (failure of control samples) results, especially in people taking immunomodulatory therapy. Since 2008, we have applied a standard IGRA-based assessment for latent Mtb infection in inflammatory bowel disease (IBD) patients being considered for anti-TNFα therapy. Initially this involved T-Spot.TB (TSTB) but in December 2010, our service switched to Quantiferon Gold In-tube (QFGIT). Here we review the performance and cost-effectiveness of these assays within our protocol. Method Adult IBD patients were assessed using symptom review, chest radiograph (CXR) and IGRA Indeterminate/borderline IGRA were repeated and patients with persistently indeterminate/borderline results plus TB risk factors, or a positive result were referred to TB services. Cost per patient assessment used the average of assay costs and repeated assays plus onward referrals for those with indeterminate/borderline tests. Appointment costs were taken from standard NHS tariffs. Immunomodulators were defined as thiopurines, methotrexate or prednisolone >20mg/day. Results Between October 2008 and November 2010, 90 patients were tested with TSTB, of which 2 had a positive TSTB result and 5 borderline/indeterminate. From December 2010 until July 2012, 82 patients were tested with QFGIT, of which 3 had a positive result and 12 indeterminate/borderline (Table). 170 (99%) had normal CXR and a negative clinical assessment. 4 of 13 patients had two sequential indeterminate IGRA and also required assessment in TB clinic. The average price per patient was £60.66 for TSTB and £52.41 for QFGIT. 88% (152/172) have subsequently received treatment with either infliximab or adalimumab. No subjects have gone on to develop active tuberculosis. Conclusion Using either platform, we find a comparable, low rate of LTBI in our IBD population. There appears to be a higher frequency of indeterminate results using QFGIT. This raises the average cost per patient, but overall, QFGIT remains more cost-effective than TSTB. Despite differing length of follow-up, the average time was sufficient in both, otherwise comparable, cohorts to detect likely development of active TB disease.

Introduction Ileal pouch anal anastomosis (IPAA) is the standard restorative procedure for ulcerative colitis (UC) following colectomy. This operation is, however, associated with distinct rates of failure and complications. We performed a survey to evaluate the quality of life (QoL) after IPAA comparing patients followed up in two different teaching Hospitals in London (L), UK and Bologna (B), Italy. Methods A total of 126 (71L+55B) UC patients received the questionnaire by mail or during clinic. The questionnaire was done according to the IBDQ and it was designed to assess pouch function, disease-specific adjustment, lifestyle aspects and psychological factors. 85 (43L+42B) patients (67%) returned it (M/F= 46/39; age 41±16 years); average pouch duration was 5–7 years. Results There was no significant difference between L and B in terms of age, gender, marital status, pouch duration, bowel frequency (median 3–6 motions per day and 1–2 per night), experience of leakage (30% more than once a week) and need of additional surgery (0.05%). In L there were significantly more patients who had at least one episode of pouchitis (72%) compared to B (33%). L used significantly more alternative remedies (L 11% vs B 0%), antimotility drugs (L 44% vs B 30%), antibiotics (L 65% vs B 29%) and steroids (L 16% vs B 7%). No difference in immunosuppressant (18%) and VSL#3 use (22%). L patients regret having IPAA significantly more frequently (L 13% vs B 0.02%), cope less with the stoma (in L 39% hated it vs 0% in B), suffer more of unpredictability (L 51% vs B 19%), are less capable to hold the stool for more than 1 h (L 62% vs B 88%) and have more worrying thoughts (L 30% vs B 9%). B patients play sport significantly more frequently (B 76% vs L 53%). L and B reported similar QoL, well being, cheerfulness, ability to work, go on holiday and enjoy things they used to do; similar confidence in doing whatever they want and level of concern in finding a toilet. Conclusion Our survey showed that in London patients developed more pouchitis and therefore used more medications. They cope worse with the pouch and regret more having had surgery. Interestingly in Italy patients play more sport, but the overall quality of life was the same. Extent and severity of disease prior to surgery, smoking and association with primary sclerosis cholangitis may play a role in the increase incidence of pouchitis in London, but these data were not available in our anonymous questionnaire. Different biologic behaviour and/or genetic background may contribute in this difference. Competing interests None declared.

Introduction Two commercial Interferon Gamma release assays (IGRA) are approved in the UK by NICE and US FDA to detect M tuberculosis (Mtb) infection. The T-Spot.TB (TSTB) and Quanitferon Gold In-tube (QFGIT) use different test platforms, with the potential for slightly different results when used in clinical practice. Since 2008, we have used a standard IGRA-based assessment for Mtb infection in inflammatory bowel disease (IBD) patients. Initially this involved TSTB but in December 2010, switched to QFGIT. Here we review the performance of these assays within our protocol. Methods We prospectively screened 148 adult IBD patients considered for anti-TNfα agents with symptom review, chest radiograph and IGRA. Between October 2008 and November 2010, 91 patients were tested with TSTB, and between December 2010 and November 2011, 57 with QFGIT. IGRA results were reported as positive, negative or indeterminate. Positive and indeterminate results were referred to TB services. Results All subjects had normal chest radiographs and a negative clinical assessment. Overall 82% (121/148) subjects tested were BCG vaccinated and 13% (19/148) had risk factors for Mtb. 74% (109/148) were taking immunomodulators. 98% (89/91) patients in the TSTB group had an unequivocal result [1% (1/91) positive: 97% (88/91) negative], and 1% (1/91) had an indeterminate result, compared with 86% unequivocal [0% positive/86% negative] and 14% (8/57) indeterminate in the QFGIT group, respectively (p=0.002). 12% indeterminate results occurred in subjects taking immunosuppression. 85% (126/148) of the anti-TNFα naive group have subsequently received treatment with either infliximab or adalimumab. None have gone on to develop tuberculosis. Median follow-up from start of therapy in the TSTB group is 21 months (IQR 15–26 months); and that of the QFGIT group 7 months (IQR 4–9). Conclusion We find little evidence for Mtb infection within our IBD population. To date none have developed active TB after starting anti-TNFα therapy. Given the reasonable median follow-up (21 months for TSTB and 7 months for QFGIT) compared to the reported time of onset of active TB following anti-TNFα agents ( Competing interests None declared.

Introduction Ileal pouch anal anastomosis (IPAA) is the standard restorative procedure for ulcerative colitis (UC) following colectomy. This operation is, however, associated with distinct rates of failure and complications. Iron deficiency anaemia (IDA) is common in this group of patients although it is not clear to what degree this is secondary to ongoing inflammation or other mechanisms. The authors therefore performed a systematic audit of the patients after restorative proctocolectomy coming to the Inflammatory Bowel Disease (IBD) Clinic in our department. Methods 74 patients (37 male, 37 female, mean age 47 years) with IPAA were recruited from the Inflammatory Bowel Disease Clinic. Demographic and medical data were collected retrospectively from medical notes. Clinical signs of pouchitis were increased stool frequency, urgency, tenesmus, incontinence, abdominal pain, pelvic discomfort and nocturnal seepage. Results Among 74 patients with IPAA and IBD (66 patients with UC, 4 Crohn9s disease and 4 indeterminate colitis), 24 patients (30%) had anaemia and/or low iron indices. Seven of these 24 patients (30%) had clinical signs of pouchitis, two had β-thalassemia and one celiac disease. A sigmoidoscopy of the pouch was performed in 56 of the patients (75%). Only 23 patients had an oesophageal-gastro-duodenal endoscopy (OGD) but of the remaining 51 patients, 20 had negative antitissue transglutaminases antibody (TTG). The OGDs were all normal, including the duodenal biopsies. The authors performed capsule endoscopy in 11 patients with anaemia: 4 patients had small bowel erosions, 5 patients had erosions at the anastomotic site (4 with active bleeding), 2 had pouchitis, 1 angiodysplasia and 1 was normal. Considering all 75 patients with IPAA, 37 patients developed pouchitis (50%), 5 fistula (7%), 2 had PSC (4%), 2 of whom had OLT. Conclusion In this series of patients who underwent IPAA, nearly one third developed anaemia. In these patients, the most common findings at capsule endoscopy were erosions in the small bowel and at the anastomosis, which though contributory are unlikely to represent the cause of their anaemia. The most frequent complication in this group of anaemic patients was pouchitis. This audit suggests that iron deficiency anaemia is common in patients with IPAA and that further studies are required to investigate the mechanism of iron deficiency in this particular group of patients.

Introduction Oesophageal capsule endoscopy (ESO 2) has been developed to image the oesophageal mucosa and compares with endoscopy (OGD).1 With a battery life of 30 min, the capsule transmits gastric and even duodenal images beyond its designated function. Trituration causes the capsule to tumble back and forth between fundus and antrum, before passing through the pylorus. With its fore and aft cameras providing a 312 degree field of vision, it is likely that ESO could visualise most, if not all the gastric mucosa. The authors9 aim was to compare accuracy of ESO versus OGD for detecting mucosal pathology in patients with uncomplicated dyspepsia and/or heartburn, and patient discomfort. Methods 50 consecutive outpatients, referred with dyspepsia and/or heartburn ingested an ESO 2 PillCam and underwent OGD 4 h later. ESO was reported independently by 2 experienced capsule readers and OGD was performed by an expert endoscopist, blinded to ESO results, and recorded on DVD. At the end of the study, a final report was agreed by 2 gastroenterologists viewing ESO and recorded OGD simultaneously, side by side, with biopsy results. This defined benchmark against which to judge the initial ESO and OGD reports. Each patient completed a questionnaire assessing ESO versus OGD discomfort. Results 50 patients (mean age 56±15; M/F: 17/33) had OGD, 35 without sedation. ESO was ingested by 49 patients (1 unable to swallow the capsule). The duodenum was visualised in 30 of 49 (61%). The final (benchmark) reports identified major pathology in 15 patients (6 Barretts, 1 pyloric channel ulcer, 5 oesophagitis, 6 erosive gastritis and 4 large hiatus hernia) and in 17 minor pathology (13 superficial gastritis, 10 small hiatus hernia and 4 hyperplastic fundal polyps). 17 patients had normal finding. Compared with the benchmark report, sensitivity and specificity of the initial report for major pathology was 93% and 100% for ESO and 87% and 100% for OGD. ESO failed to report 1 oesophagitis and OGD failed to detect 1 pyloric ulcer and 1 Barretts oesophagus. Sensitivity and specificity for minor pathology was 76% and 97% for ESO and 76% and 78% for OGD. ESO had reduced sensitivity for small hiatus hernia and OGD had poor specificity for superficial gastritis. Median patient discomfort (scale 0–10) was 0 for ESO and 4.5 for OGD. Conclusion This pilot study suggests that ESO provides an accurate and well-tolerated method to visualise oesophageal and gastric mucosa, and in 61%, duodenal mucosa. An ESO capsule programmed to broadcast for up to 2 h could offer a minimally invasive method for imaging the oesophagus, stomach and duodenum. Further studies are necessary to fully evaluate the role of capsule OGD in investigating foregut symptoms.

Introduction It is widely accepted that smoking predisposes to Crohn9s disease (CD) but is protective against ulcerative colitis (UC). The precise impact of stress, the influence of diet and the efficacy of complementary medicines on the course of inflammatory bowel disease (IBD) are unclear (ECCO guidelines). The study aim was to assess our IBD patients9 knowledge about the association between IBD and smoking and to evaluate which factors they consider important in controlling bowel disease. Methods During a 6 weeks interval the authors prospectively recruited all patients attending the IBD clinic in our Institution. Patients were asked to complete an anonymous questionnaire which assessed basic demographics, smoking history and patient knowledge about their disease. Patients were asked to rank (in a scale from 0 to 10) the importance, in their opinion, of the following factors in controlling IBD activity: drugs, surgery, diet, stress control, stopping smoking and alternative therapy. Results The authors surveyed 199 patients (median age 44 years; M/F: 92/107) with IBD: 101 (51%) had CD, 86 (44%) had UC and 12 (5%) had IBD-unclassified. Median IBD duration was 12 years (range 1–60). 89% of CD patients were non-smoker compared to 95% of UC (p=0.015). 69% of CD patients reported to be aware of the negative association between smoking and CD; while only 36% of UC patients were aware of the positive association with UC. CD patients rated medications (mean value 7.8), followed by stress control (7.6) and even diet (7.4) as the most important factors able to influence their disease activity. Smoking cessation (7.0) and surgery (6.5) were considered less effective. Alternative treatment (3.6) was considered only marginally effective in IBD. There was a strong correlation between stress and diet (p Conclusion Only two thirds of CD patients recognise the importance of smoking cessation on disease activity, and one third of UC patients are aware of the positive association with smoking. IBD patients consider stress and diet as effective as drugs in controlling bowel disease; moreover, CD patients value stress and diet as more important than smoking in affecting disease activity. Clinicians should always consider the perceptions and beliefs of the patient when discussing treatment strategy in IBD.