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

Internet of Things (IoT) is usually associated with the acquisition of sensor node information and controlling of things. However, the inadequateness of location information of these sensor nodes compromises the intelligence of the IoT network. With an emphasis on indoor environments, localisation in IoT has become a very important area for research due to the fact that well-established positioning services such as the Global Positioning System (GPS) are not viable indoors. In essence, the difficulty for satellite signals of such existing systems to reach indoor environments causes huge localisation inaccuracies. Therefore, indoor localisation in recent time has been based on Wireless Sensor Networks (WSN). In this work, distributive indoor localisation accuracy and computational performance as implemented in real life towards IoT are of concern. Therefore, this work presents a methodology comprised of a mix of existing techniques to integrate indoor localisation of sensor nodes and IoT in a realistic environment and at an acceptable degree of localisation accuracy. The major contribution presented in this work is the attainment of an acceptable level of localisation accuracy while maintaining high computational efficiency on a developed hardware sensor node prototype. In achieving this, the implementation issues regarding the complexity of localisation algorithm and hardware computational capabilities are tackled. In ensuring that this work is aligned with the IoT context, an Internet and Intranet enabled connectivity for real-time access to the location information of sensor nodes is developed and presented. This work is also achieved through the use of a distributive online based localisation algorithm based on Kalman filtering Received Signal Strength Indicator (RSSI) and Gauss–Newton Algorithm (GNA). A sensor node prototype capable of handling complex computations is developed and presented. A gateway device and an IoT framework are also proposed and implemented based on Linux, Apache, MySQL, PHP (LAMP) server to provide global and local access to real-time location information of the sensor nodes. The algorithm is first simulated for pre-validation and then ported to the sensor node prototypes. The computational power of the hardware is analysed based on the time it takes to perform the GNA based localisation process towards convergence. The Root Mean Square Error (RMSE) is computed for analysing the accuracy level of the proposed concept. This work further presents findings based on the effect of node orientation changes as the localisation process is performed and logged, which is an issue of great concerned to be tackled in future works.

In recent years, the emergence of Industry 4.0 technologies has introduced manufacturing disruptions that necessitate the development of accompanying socio-technical solutions. There is growing interest for manufacturing enterprises to embrace the drivers of the Smart Industry paradigm. Among these drivers, human–robot physical co-manipulation of objects has gained significant interest in the literature on assembly operations. Motivated by the requirement for human dyads between the human and the robot counterpart, this study investigates recent literature on the implementation methods of human–robot collaborative assembly scenarios. Using a combination of strings, the researchers performed a systematic review search, sourcing 451 publications from various databases (Science Direct (253), IEEE Xplore (49), Emerald (32), PudMed (21) and SpringerLink (96)). A coding assignment in Eppi-Reviewer helped screen the literature based on ‘exclude’ and ‘include’ criteria. The final number of full-text publications considered in this literature review is 118 peer-reviewed research articles published up until September 2022. The findings anticipate that research publications in the fields of human–robot collaborative assembly will continue to grow. Understanding and modeling the human interaction and behavior in robot co-assembly is crucial to the development of future sustainable smart factories. Machine vision and digital twins modeling begin to emerge as promising interfaces for the evaluation of tasks distribution strategies for mitigating the actual human ergonomic and safety risks in collaborative assembly solutions design.

Background\ud \ud The Rome IV criteria for disorders of gut‐brain interaction define irritable bowel syndrome (IBS) as a functional bowel disorder associated with frequent abdominal pain of at least 1 day per week. In contrast, functional diarrhea (FD) and functional constipation (FC) are relatively painless. We compared differences in mood and somatization between Rome IV IBS and FC/FD.\ud \ud \ud Methods\ud \ud A total of 567 patients with Rome IV defined IBS or FD/FC completed a baseline questionnaire on demographics, abdominal pain frequency, mood (hospital anxiety and depression scale, HADS), and somatization (patient health questionnaire, PHQ‐12). The primary analysis compared differences in mood and somatization between IBS and FC/FD, and the relative influence of abdominal pain frequency on these extra‐intestinal symptoms. The secondary analysis evaluated differences across individual IBS subtypes, and also between FC and FD.\ud \ud \ud Key Results\ud \ud Patients with IBS—in comparison to those with FC/FD—had significantly higher mean PHQ‐12 somatization scores (9.1 vs. 5.4), more somatic symptoms (6.0 vs. 4.3), abnormally high somatization levels (16% vs. 3%), higher HADS score (15.0 vs. 11.7), and clinically abnormal levels of anxiety (38% vs. 20%) and depression (17% vs. 10%). Increasing abdominal pain frequency correlated positively with PHQ‐12, number of somatic symptoms, and HADS; p < 0.001. No differences in mood and somatization scores were seen between individual IBS subtypes, and nor between FC and FD.\ud \ud \ud Conclusion & Inferences\ud \ud Based on the Rome IV criteria, IBS is associated with increased levels of psychological distress and somatization compared with FD or FC. Patients reporting frequent abdominal pain should be comprehensively screened for psychosomatic disorders, with psychological therapies considered early in the disease course.

The templates for transcription and replication by respiratory syncytial virus (RSV) polymerase are helical nucleocapsids (NCs), formed by viral RNAs that are encapsidated by the nucleoprotein (N). Proper NC assembly is vital for RSV polymerase to engage the RNA template for RNA synthesis. Previous studies of NCs or nucleocapsid-like particles (NCLPs) from RSV and other nonsegmented negative-sense RNA viruses have provided insights into the overall NC architecture. However, in these studies, the RNAs were either random cellular RNAs or average viral genomic RNAs. An in-depth mechanistic understanding of NCs has been hampered by lack of an in vitro assay that can track NC or NCLP assembly. Here we established a protocol to obtain RNA-free N protein (N0) and successfully demonstrated the utility of a new assay for tracking assembly of N with RNA oligonucleotides into NCLPs. We discovered that the efficiency of the NCLP (N–RNA) assembly depends on the length and sequence of the RNA incorporated into NCLPs. This work provides a framework to generate purified N0 and incorporate it with RNA into NCLPs in a controllable manner. We anticipate that our assay for in vitro trackable assembly of RSV-specific nucleocapsids may enable in-depth mechanistic analyses of this process.

ObjectiveThe 2-week-wait (2ww) referral pathway is used in England to fast-track patients with suspected colorectal cancer (CRC). A two-stage triage pathway was used to prioritise lower gastrointestinal (LGI) endoscopy for suspected CRC during the COVID-19 pandemic.MethodAll patients referred for an LGI endoscopy via a 2ww referral pathway between March 2020 and July 2020 were assessed. The first stage triaged patients to high, standard or low risk of CRC based on symptoms and faecal immunochemical test (FIT), and offered CT scans to those at high risk. The second stage, endoscopy prioritisation (EP), incorporated the CT results, FIT and symptoms to triage into four groups, EP1–EP4; with EP1 being the most urgent and EP4 the least. The primary outcome measure was CRC detection.Results514 patients were included. The risk of CRC was triaged as high in 190/514 patients (37%), standard in 274/514 patients (53%) and low in 50/514 (10%) patients. 422/514 patients (82%) underwent endoscopy with triage to EP1 in 52/422 (12%), EP2 in 105/422 (25%), EP3 in 210/422 (50%) and EP4 in 55/422 (13%). CRC was detected in 23 patients (5.4%). CRC was significantly more frequent in the EP1 group (23.1%, relative risk (RR)=16.2) and EP2 group (6.7%, RR=4.7) compared with EP3 group (1.4%). All CRC lesions were identified by CT imaging when performed prior to LGI endoscopy.ConclusionThis triage pathway designated 83% of patients with CRC to either EP1 or EP2. During a period of limited endoscopy provision, this pathway effectively prioritises endoscopy for those at greatest risk of CRC.

Background\ud \ud A high prevalence of primary bile acid diarrhoea (BAD) has been reported for Rome III defined irritable bowel syndrome (IBS)-diarrhoea and functional diarrhoea. We determined whether this still applies under the contemporaneous Rome IV criteria, given that the latter characterises IBS-diarrhoea as having more frequent abdominal pain compared with previous iterations, whilst no longer recognising abdominal discomfort.\ud \ud \ud \ud Methods\ud \ud Patients referred for a 75SeHCAT test completed a baseline questionnaire comprising, i) demographic data, ii) risk factors for BAD (inflammatory bowel disease, bowel resection, cholecystectomy, microscopic colitis, celiac disease, abdominal-pelvic radiotherapy), iii) the Rome III and IV bowel disorder questionnaire, and iv) mood and somatisation scores. A diagnosis of BAD constituted a 75SeHCAT of ≤15%, with moderate to severe disease being defined as ≤10% and ≤5%, respectively.\ud \ud \ud \ud Findings\ud \ud Of 300 patients with complete dataset, 184 had no risk factors for BAD and fulfilled criteria for either IBS-diarrhoea or functional diarrhoea. The prevalence of primary BAD was 38% (n = 70/184), with almost half having moderate (n = 16) to severe (n = 17) disease. Using the Rome III criteria, the prevalence of primary BAD was 36% in IBS-diarrhoea (n = 63/173) and 64% (n = 7/11) in functional diarrhoea; p = 0.11. Using the Rome IV criteria, the prevalence of primary BAD was 38% (n = 53/139) in IBS-diarrhoea and 38% (n = 17/45) in functional diarrhoea; p = 0.97. Patients with primary BAD experienced more frequent loose stools (p = 0.01) and had a higher body mass index (p

Integral and crucial to performance of wireless sensor networks (WSNs), and specifically industrial wireless sensor network (IWSN) is stable, robust, reliable, and ubiquitous communication...

Nutrition support involves the use of oral supplements, enteral tube feeding or parenteral nutrition. These interventions are considered when oral intake alone fails to meet nutritional requirements. Special diets and oral supplements are usually the first approach to managing malnutrition; however, their role becomes limited when oral intake is restricted or if swallowing is unsafe. Enteral tube feeding or parenteral nutrition are alternative means of providing nutrition support for this select group of patients. Percutaneous endoscopic gastrostomy (PEG) feeding was introduced into clinical practice in 1980. It describes a feeding tube placed directly into the stomach under endoscopic guidance. It is an established means of providing enteral nutrition to those who have functionally normal gastrointestinal tracts, but who cannot meet their nutritional requirements due to inadequate oral intake. The intervention is usually reserved when nutritional intake is likely to be inadequate for more than 4–6 weeks. Although the benefits of PEG have been shown for a select group of patients, there currently exists concerns about the increasing frequency of this intervention, and also uncertainty about the long-term benefits for certain patients. The 2004 UK National Confidential Enquiry into Patient Outcome and Death report emphasised this concern, with almost a fifth of PEG being undertaken for futile indications that negatively influenced morbidity and mortality. The present review paper discusses the indications for, controversies surrounding and complications of gastrostomy feeding and provides practical advice on optimising patient selection for this intervention.

Background\ud \ud There is little data on the diagnostic yield of colonoscopy in patients with symptoms compatible with functional bowel disorders (FBDs). Previous studies have only focused on diagnostic outcomes of colonoscopy in those with suspected irritable bowel syndrome using historic Rome I-III criteria, whilst having partially assessed for alarm features and shown markedly conflicting results. There is also no colonoscopy outcome data for other FBDs, such as functional constipation or functional diarrhea.\ud \ud \ud Aims\ud \ud Using the contemporaneous Rome IV criteria we determined the diagnostic yield of colonoscopy in patients with symptoms compatible with a FBD, stratified diligently according to the presence or absence of alarm features\ud \ud \ud Methods\ud \ud Basic demographics, alarm features, and bowel symptoms using the Rome IV diagnostic questionnaire were collected prospectively from adults attending out-patient colonoscopy in 2019. Endoscopists were blinded to the questionnaire data. Organic disease was defined as the presence of inflammatory bowel disease, colorectal cancer, or microscopic colitis.\ud \ud \ud Results\ud \ud 646 patients fulfilled symptom-based criteria for the following Rome IV FBDs: IBS (56%), functional diarrhea (27%) and functional constipation (17%). Almost all had alarm features (98%). The combined prevalence of organic disease was 12%, being lowest for functional constipation and IBS-constipation (∼6% each), followed by IBS-mixed (∼9%), and highest amongst functional diarrhea and IBS-diarrhea (∼17% each); p=0.005. The increased prevalence of organic disease in diarrheal versus constipation disorders was accounted for by microscopic colitis (5.7% vs. 0%, p

Mucosal healing is important in celiac disease (CD) for the prevention of complications. However, obtaining duodenal biopsies is invasive, and there is currently no reliable surrogate marker for histological remission in clinical practice. We aimed to assess the role of a point-of-care test (POCT) based on IgA/IgG-deamidated gliadin peptide, in detecting persistent villous atrophy (VA) in CD.We prospectively recruited patients with CD attending endoscopy for the assessment of histological remission. All patients had IgA-endomysial (EMA) antibodies, IgA-tissue transglutaminase (TTG) antibodies, and the POCT performed, and completed a validated dietary adherence questionnaire. A gastroscopy was performed in all patients, with four biopsies taken from the second part of the duodenum and one from the duodenal bulb. We compared the diagnostic performance of the surrogate markers against duodenal histology as the reference standard.A total of 217 patients with CD (70% female, age range 16-83 years, median age 53 years) on a gluten-free diet (median duration 6 years) were recruited from 2013 to 2017. Eighty-five (39.2%) patients had persistent VA. The sensitivities of the POCT, TTG, EMA, and the adherence score in detecting VA were 67.1%, 44.7%, 37.7%, and 24.7% respectively (P=0.0005). The combination of the POCT and adherence score only marginally increased the sensitivity to 70.6% (59.7-80.0%).The sensitivity of the POCT was higher than the other surrogate markers in predicting VA. A POCT may provide the additional advantage of an immediate objective assessment of mucosal healing at the time of an office-based follow-up consultation.

Background & Aims Gastrostomies are widely used to provide long-term enteral nutrition to patients with neurologic conditions that affect swallowing (eg, following a cerebrovascular accident or for patients with motor neuron disease) or with oropharyngeal malignancies. The benefits derived from this intervention are uncertain for patients and caregivers. We conducted a prospective, multicenter cohort study to determine how gastrostomies affect health-related quality of life (HRQoL) in recipients and caregivers. Methods We performed a study of 100 patients who received gastrostomies (55% percutaneous endoscopic gastrostomy, 45% radiologically inserted) at 5 centers in the United Kingdom, 100 caregivers, and 200 population control subjects. We used the EuroQol-5D (comprising a questionnaire, index, visual analogue scale) to assess HRQoL for patients and caregivers before the gastrostomy insertion and then 3 months afterward; findings were compared with those from control subjects. Ten patients and 10 caregivers were also interviewed after the procedure to explore quantitative findings. Findings from the EuroQol-5D and semi-structured interviews were integrated using a mixed-methods matrix. Results Six patients died before the 3-month HRQoL reassessments. We observed no significant longitudinal changes in mean EuroQol-5D index scores for patients (0.70 before vs 0.710 after; P = .83) or caregivers (0.95 before vs 0.95 after; P = .32) following gastrostomy insertion. The semi-structured interviews revealed problems in managing gastrostomy tubes, social isolation, and psychological and emotional consequences that reduced HRQoL. Conclusions We performed a mixed-methods prospective study of the effects of gastrostomy feeding on HRQoL. HRQoL did not significantly improve after gastrostomy insertion for patients or caregivers. The lack of significant decrease in HRQoL after the procedure indicates that gastrostomies may help maintain HRQoL. Findings have relevance to those involved in gastrostomy insertion decisions and indicate the importance of carefully selecting patients for this intervention, despite the relative ease of insertion.

Introduction Microscopic colitis (MC) is a common cause of chronic, non-bloody watery diarrhoea that impacts health-related quality of life. No UK guidelines currently exist for MC. This has potential negative sequelae to patients as misdiagnoses and use of inappropriate treatments have been reported. This study examines UK provision of care for MC patients, with the ambition of developing a consensus document to support health care professionals in the future. Methods This qualitative study involved four focus groups, and was conducted between March and October 2018. It involved a total of 27 expert participants IBD-specialist nurses (n=8), gastroenterologists (n=7), general practitioners (n=5), colorectal surgeons (n=2), pharmacists (n=2), a histopathologist (n=1) and clinical commissioning experts (n=2). All participants were given pre-sessional information. Facilitated discussion was then undertaken between experts on key topic areas, and culminated in key themes, which were then further analysed. Results The following themes were identified to influence patient care and outcomes: 1) Awareness. A lack of awareness particularly in primary care, and perceptions that MC is less common than conventional inflammatory bowel diseases were felt to be factors influencing diagnosis and management. 2) Symptom overlap with IBS. As symptomatology for both MC and IBS are similar, the expert group felt referrals to secondary care are likely to be restricted, leading to increased GP visits, enhanced use of over the counter medications, and diminished quality of life. 3) Faecal calprotectin (FC). The expert group felt referral practice from primary care was too reliant on FC as a discriminator, as active MC can have FC levels below the conventional referral thresholds. 4) Biopsies. The expert group identified that the diagnosis of MC may be missed as endoscopists neglect to take colonic biopsies, either through a lack of awareness, or determined by time and cost restrictions. 5) Treatment. This theme demonstrated significant variations in clinical practice, with an array of therapeutic interventions used to manage MC. Clinicians frequently lacked awareness of MC treatments and were not aware that budesonide is the only established treatment, as evidenced in randomised-controlled trials. Conclusions This is the first study to examine service provision for MC in the UK. Key themes have been identified through expert opinion, demonstrating why optimal diagnosis and management of MC has been difficult to operationalise in the UK. These findings will be used to develop a consensus document that has benefits to healthcare professionals and patients.

Introduction Coeliac disease (CD) is common, but is underdiagnosed in the elderly due to lack of physician awareness and heterogeneity of presentation. We aimed to establish whether there has been a change in the diagnosis of CD in the elderly (over 65 years old) from 1990 until present day, as well as the clinical and histopathological features of CD in old vs. young adults. Methods Newly diagnosed CD patients were prospectively recruited from the Coeliac Specialist Clinic at the Royal Hallamshire Hospital, Sheffield, between 2008 and 2017. All patients had villous atrophy (VA) on biopsy, positive coeliac serology (IgA-tissue transglutaminase and IgA-endomysial antibodies) and compatible Human Leukocyte Antigen (HLA) typing. Additionally, patients were retrospectively identified from 1990 to 2008 to determine the trend in elderly CD diagnostic frequency over time. Results 1605 patients with CD were recruited (n=644 prospectively, n=961 retrospectively). Of these, 208 patients (13.0%) were diagnosed over the age of 65 years between 1990 and 2017. The proportion of elderly CD diagnoses increased from 0% (n=0/11) in 1990–1991 to 18.7% (n=41/232) in 2016–2017 (p Conclusions Coeliac disease is common in elderly patients but gastrointestinal symptoms occur less frequently than in younger individuals. Elderly patients tend to present with a milder degree of VA. This questions the utility of active case finding in this age group, as a gluten free diet may not be the most appropriate management in this cohort.

An “author pays” publishing model is the only fair way to make biomedical research findings accessible to all, say Matthew Kurien and David S Sanders, but James J Ashton and R Mark Beattie worry that it can lead to bias in the evidence base towards commercially driven results

We wish to highlight the readers the benefits of making their work open access. Advances in the internet have enabled a rapid growth in open access publishing.1 However, most scholarly articles still remain behind paywalls.2 Open access publishing has numerous benefits. First, open access publishing enables equity of access, with access not dependent on income. Anyone with an internet connection has the opportunity to access research published via the open access route and possibly use this in novel ways not conceived by academic institutions.3 It is also important that the public have access to newly published research, as a lot of research activity receives public funding, with a moral obligation for reciprocity. …

Coeliac disease is a common digestive disorder that affects 1% of adults. It is characterised by mucosal damage of the small intestine caused by dietary gluten. The main treatment for coeliac disease is a lifelong gluten-free diet, which can reduce morbidity and mortality and also improve quality of life. Despite the benefits, adhering to this diet is often challenging, with patients often struggling to sustain dietary restriction. Structured follow-up for coeliac disease is recommended in international guidelines for improving adherence and for detecting complications;however, uncertainty exists concerning exactly who should be administering this follow-up care. Here, we undertake a review of the current approaches described in the literature to follow-up patients with coeliac disease, and assess the efficacy of these differing models. We also explore future directions for the care of these patients in the context of the UK National Health Service (a publicly funded healthcare system). Although the focus of this review pertains to follow-up within the UK healthcare system, these problems are recognised to be international, and so the findings of our review are likely to be of interest to all healthcare professionals seeing and managing patients with coeliac disease.

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.

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 & Aims: Diet appears to play a pivotal role in symptom generation in Irritable Bowel Syndrome (IBS). First line dietary therapy for IBS has focused on advice concerning healthy eating and lifestyle management. Research recently has focused on the role of a diet low in fermentable oligo-, di-, and monosaccharides and polyols (FODMAPs), gluten free (GFD) and wheat free (WFD) diets for the relief of symptoms in IBS.Methods: A round table discussion with gastroenterologists and dietitians with a specialist interest in dietary therapies in IBS was held in Sheffield, United Kingdom in May 2017. Existing literature was reviewed. PubMed and EMBASE were searched with the MeSH terms irritable bowel syndrome/diet/diet therapy/gluten/low FODMAP in different combinations to identify relevant articles. A consensus on the application of these dietary therapies into day-to-day practice was developed. Results: Fourteen randomized trials in IBS evaluating the low FODMAP diet (n studies = 9), GFD (n = 4) and WFD (n = 1) were included in this review. The total number of patients recruited from randomized trials reviewed was: n=580 low FODMAP diet (female, n=430), n=203 GFD (female, n=139), n=276 WFD (female, n=215). There was no significant difference in the gender of patients recruited for both the low FODMAP and GFD randomized studies (p=0.12). The response rate in the literature to a low FODMAP diet ranged between 50-76%, and to GFD ranged between 34-71%. Percentage of IBS patients identified as wheat sensitive was reported as 30% in the literature. Conclusion: There are no head-to-head trials to date utilizing the low FODMAP diet, GFD and WFD for dietary treatment of IBS and still a number of concerns for diets, including nutritional inadequacy and alteration of the gut microbiota. The consensus suggests that there is evidence for the use of the low FODMAP diet, GFD and WFD as dietary therapies for IBS; the decision-making process for using each individual therapy should be directed by a detailed history by the dietitian, involving the patient in the process.

The Department of Health and Social Care has recently published their consultation outcome regarding the availability of gluten-free foods (GFF) on NHS prescriptions.1 Following an unprecedented number of responses from patients, healthcare professionals, and professional bodies, the Government has decided to continue to provide GFF on prescription but restrict the products available to breads and mixes. This favoured option by the majority of consultation responders has now proceeded to formal ratification, through an amendment to the NHS Regulations 2004, Schedule 1. In this editorial, we discuss the controversies that have existed regarding prescription of GFF in coeliac disease where the gluten-free diet is the treatment, and discuss the future implications that this decision may have on both patients and the NHS. GFF products have been available in the UK via prescription for those medically diagnosed with coeliac disease for >50 years, with the aim of supporting dietary adherence and reducing complications. In recent years, these prescriptions were restricted to staple foods, approved by the Advisory Committee on Borderline Substances (ACBS). The National Prescribing Guidelines endorsed by both the Primary Care Society for Gastroenterology and the British Dietetic Association set out recommendations to healthcare professionals on the quantity of gluten-free staple foods that may be prescribed.2 These allowances (in units) were determined by an individual’s age and sex (for example, male 19–59 years = 18 units, female 19–74 years = 14 units) and based upon

Introduction A gluten free diet (GFD) is essential in the management of coeliac disease, as well as several studies demonstrating its utility as a dietary therapy in patients with irritable bowel syndrome. The aim of this double-blind placebo-controlled study was to assess the role of a GFD in a healthy population who take a GFD as a lifestyle choice (‘lifestylers’). Methods Subjects were recruited via an advert, following exclusion criteria including coeliac disease. Following selection, subjects were commenced on a 2 week GFD following evaluation by a dietitian. Participants were then randomised to receive either organic gluten (Group A, Vital Gluten 14 g gluten protein/day) or gluten free flour (Group B) in pre-made bags, over a 2 week period. These were sprinkled on their food twice daily. Gastrointestinal Symptom Rating Scale (GSRS) scores were assessed at baseline (following 2 weeks GFD) and after 2 weeks of randomization. Data was analysed using SPSS version 22. Results 45 subjects were identified with 28 participants recruited into the trial (Group A; n≥14, Group B; n≥14) following exclusion criteria. Median age was 36.5 years (range: 19–63) and 21 (75%) were female. There was no significant difference in baseline demographics between both groups (p≥0.54). Over a 2 week period there was no significant difference in gastrointestinal symptoms or fatigue in either group, as seen in table 1. Conclusion This study demonstrates that gluten is unlikely to be the culprit agent for gastrointestinal symptoms or fatigue in healthy individuals. A GFD has no evidence base in individuals who do not have coeliac disease or IBS. The public should be discouraged from considering a GFD of their own volition.

Introduction In recent years there has been a renewed interest in dietitian-led nutritional treatments for Irritable Bowel Syndrome (IBS)-specifically the Low FODMAP (LFD) and Gluten Free Diets (GFD). Increases in diagnosis and a lack of suitably trained dietitians to deliver these modalities mean many patients only receive nutritional information from General Practitioners (GP’s) and Gastroenterologists (GE’s). Since the LFD and GFD are dietitian-led, the aim of this research was to qualitatively explore how people with IBS use and apply dietary information from GP’s and GE’s in IBS self management. Methods An initially sample of 33 people (7 male) responded to a research request from the staff and student body of Sheffield University. 10 participants with a median age of 45 years (range 24–64, 2 male) matched the inclusion criteria-diagnosed with IBS (ROME IV) and used diet as their primary treatment. There were no differences in baseline demographics between patients who participated in the study and those who did not (gender p=1.0, age p=0.9). All participants had received dietary information from GP’s and GE’s for self managing their IBS symptoms; primarily advice on the LFD. Semi-structured interviews were conducted (minimum an r duration) and evaluated using Interpretive Phenomenological Analysis (IPA). IPA is a qualitative research method that employs phenomenological, and idiographic techniques to explore and explain participants lived experience. IPA is particularly suited to examine and understand how people with IBS make sense of the dietary information they are given and how this relates to the self-management of their symptoms. Findings The providence of nutritional information was important for the participants, information from GP’s and GE’s was valued as evidenced based. However, the information was seen as very simplistic, often just ‘food lists’ with little or no personalisation to meet individual needs of the participants (figure 1). Digital online and resources were used to supplement the dietary information received form GP’s and GE’s, however this required additional interpretation and personalisation and led to negative effects on both the participants social and food-related quality of life. Conclusion The participants found much of the nutritional information provide by GPS’ and GE’s to be overly generic and incomplete; in that it was difficult to apply in ‘real life’. The findings in this study support the current clinical guidelines proposed by the both by NICE and the BDA that LFD and GFD’s should still be considered second-line dietitian-led only interventions.

Introduction Patients with coeliac disease (CD) symptoms usually respond to a gluten free diet (GFD). However up to a quarter of adults with CD have persistent gastrointestinal (GI) symptoms despite strict adherence to a GFD and complete intestinal healing. Overlap between CD and irritable bowel syndrome (IBS) may explain this symptomology. Over the last decade there has been a renewed interest in dietary treatments in IBS particularly the low FODMAP diet (LFD) which temporally restricts fermentable carbohydrates. The aim of this prospective study was to investigate the efficacy of the LFD in patients with CD and IBS. Methods We conducted a prospective study of the LFD as an intervention in patients with treated-CD and persisting IBS symptoms. All CD patients met the ROME IV criteria, had negative coeliac serology and normal duodenal biopsy. All patients were reviewed by a specialist GI dietitian with experience in delivering the LFD. Symptom response was assessed using the validated Gastrointestinal Symptom Rating Scale (GSRS) from base-line to follow up. Results 24 patients with a mean age of 44 years (SD=15.2) met the inclusion criteria. 8 patients chose not to pursue treatment and 2 were unable to complete the minimum treatment period. 14 patients (2 males) completed four weeks of a LFD. There were no differences in baseline demographics between patients who chose to participate in the study and those who did not, or who were unable to complete the study protocol (p=0.7). Global symptom relief of gut symptoms was reported by 8/14 patients (57% p=0.007 figure 1). A sub-group analysis demonstrated a significant reduction in both abdominal pain (p=0.001 figure 2) and distension (p=0.02 figure 3) respectively. There were no significant differences to anthropometric and biochemical features at follow up compared with baseline. Conclusion This is the first study to demonstrate that a LFD is an effective dietary treatment for patients with biopsy confirmed treated-CD and on going GI symptomology. Such patients should be seen by a specialist dietitian to improve adherence, ensure nutritional adequacy and appropriate reintroduction of FODMAP containing foods. Disclosure of interest: None Declared

Introduction Paediatric ESPGHAN guidelines support a diagnosis of coeliac disease (CD) when immunoglobulin-A anti-tissue transglutaminase (IgA tTG) antibody titres are >10 times the upper limit of normal (ULN) and combined with supportive criteria. This study examines whether serological testing alone could be sufficient for diagnosis in adult patients, thus avoiding the need for duodenal biopsies. Methods We performed a prospective analysis of CD patients diagnosed in a University hospital. Symptoms of CD, villous atrophy (VA) on biopsy, IgA-endomysial (IgA-EMA) antibodies, tTG and Human Leukocyte Antigen (HLA) genotype were used for analysis. We then compared the TTG antibody level against small bowel histology. Results 443 CD patients (66.8% female, median age 41 years, range 15–84 years) were diagnosed between 2008 and 2016. 56.9% (n=252, 95% CI=52.12–61.53) had a tTG value of greater than 10 times the ULN. 292 fulfilled ESPGHAN guidelines for features of malabsorption (diarrhoea=157, weight loss=45 and anaemia=190). Of these symptomatic patients, 70.4% (n=179, 95% CI=64.86–76.08) had a tTG value 10 x ULN. The proportion reaching the 10 x tTG threshold was 55.4% (n=87, 95% CI=47.64–63.19) for diarrhoea, 60.0% (n=27, 95% CI=45.69–74.31) for weight loss, and 74.2% (n=141, 95% CI=67.99–80.43) for anaemia. Of the 151 patients who did not experience malabsorptive features, 49.0% met the 10 x ULN tTG level (n=74, 95%CI=41.03–56.98). The sensitivity of tTG antibodies and EMA antibodies for predicting VA was 93.2% (95% CI=90.89–95.57) and 90.7% respectively (95% CI=88.05–93.44). Combined tTG and EMA was 98.6% (95% CI=97.67–99.72). All patients had compatible HLA typing, thereby failing to add any further diagnostic value. Conclusions 56.9% of patients would have been correctly diagnosed with CD and avoided a duodenal biopsy using an IgA tTG threshold of >10 times the ULN. Symptoms and HLA typing did not add any supportive information. This study provides evidence that a biopsy avoidance strategy may be implemented into adult gastroenterological practice.

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.

Introduction The duodenal bulb (D1) has been shown to be a sensitive site for detecting villous atrophy (VA) in newly diagnosed coeliac disease (CD), however there is a scarcity of data from those with established CD. In patients with established CD, we aim to establish whether D1 biopsies improved the identification of VA compared to biopsies from the second part of the duodenum (D2) alone. Methods 251 patients with established CD were prospectively recruited from the endoscopy department at the Royal Hallamshire Hospital between 2013 and 2017. These patients were undergoing repeat gastroscopy to assess dietary adherence. All patients underwent a gastroscopy, with one biopsy taken from the duodenal bulb and four from D2. Biopsies were classified according to Marsh criteria. We assessed concordance of histology between the D1 and D2 sites, and 95% confidence intervals were calculated for all results using a binominal distribution. Results 251 patients were recruited (70.5% female, age range 17–81 years, median age 53 years) having been on a gluten-free diet for a median duration of 6 years. Concordant results: 35.1% (n=88, 95% CI: 29.16 to 40.96) had normal duodenal biopsies in both D1 and D2; 32.3% (n=81, 95% CI: 26.49 to 38.05) had VA in D1 and D2; 18.3% (n=46, 95% CI: 13.54 to 23.11) had raised intra-epithelial lymphocytes (IELs) only in both D1 and D2. Disconcordant results: 4.4% (n=11, 95% CI: 1.85 to 6.91) had VA in D1 but not D2; 2.4% (n=6, 95% CI: 0.50 to 4.28) had raised IELs in D1 but normal histology in D2. 2.8% (n=7, 95% CI: 0.75 to 4.83) had VA in D2 but normal histology in D1; 4.8% (n=12, 95% CI: 2.14 to 7.42) had IELs in D2 but normal histology in D1. Conclusions VA was confined to the duodenal bulb in 4.4% of patients with established CD. Thus a D1 biopsy in addition to distal duodenal biopsies increases the likelihood of detecting VA, although the significance of isolated VA in the bulb in patients on a gluten-free diet is yet to be determined.

Introduction Recent work has suggested that an IgA-tissue transglutaminase (tTG) Methods We undertook a prospective analysis of known Coeliac disease (CD) patients diagnosed in a University hospital. All patients underwent a gastroscopy, with four biopsies taken from the second part of the duodenum, and one from the duodenal bulb. Serological markers were assessed at the time of endoscopy tTG, IgA-endomysial antibodies (EMA), IgA-antigliadin antibody (IgA AGA) and IgG-anti-gliadin antibody (IgG AGA), and their performances in isolation and in combination compared to histological outcomes. Results 107 patients (67.3% female, median age 53 years (20–81 years)) that were on a gluten-free diet for a median duration of 6 years were included. The performance of the different serological markers to detect VA, both in isolation and in combination are shown in table 1. The performance of tTG using the previously used cut-off of Conclusions This study is the first study to evaluate the combination of serological markers to detect VA in patients with established CD. Our findings oppose recent work that serology may be used as a surrogate marker of mucosal healing in known CD.

We read with interest the study by S Kumar et al that noted that patients with new gastrointestinal (GI) bleeding during admission to the intensive care unit (ICU) were more likely to die during hospitalisation.1 GI bleeding cannot always be controlled or identified at gastroscopy; therefore, guidelines recommend radiological intervention.2 3 Radiological intervention may be of value in uncontrolled GI bleeding where a lesion has already been identified at endoscopy or if no lesion has been detected endoscopically but the patient continues to be haemodynamically unstable. Fluoroscopic angiography (FA) is time consuming, requires significant expertise and has significant ionising radiation exposure. However, the recent advent of CT angiography (CTA) potentially offers a sensitive, rapid and accurate diagnosis of the source of persisting GI bleeding and has a lesser risk of vessel dissection or damage than catheter angiography. For these …

PURPOSE OF REVIEW: The aim of this review is to summarize some of the key dietary interventions recommended for common gastrointestinal disorders and to discuss recent evidence regarding their nutritional implications. RECENT FINDINGS: The gluten-free diet has been shown to negatively influence overall diet quality. The gluten-free diet is essential in celiac disease, although it is increasingly used for other perceived health benefits for which an analysis of perceived benefit should be weighed against any nutritional risks. Evidence from short-term controlled trials of a diet low in fermentable oligosaccharides, disaccharides, monosaccharide and polyols in irritable bowel syndrome suggests compromised intake of nutrients such as fiber, iron, and calcium, although findings vary across studies. Meanwhile long-term uncontrolled trials suggest dietary adequacy improves with reintroduction and personalization. Although high-fiber diets may be beneficial in diverticular disease and constipation, it may lead to reductions in energy intake and nutrient absorption in at-risk populations. SUMMARY: The role of therapeutic diets in the management of gastrointestinal disorders is increasingly recognized, but there are limited studies investigating their nutritional implications. The judicious use of dietetic expertise should minimize potential nutritional deficits, however further prospective trials are needed to identify the individuals and nutrients most at risk.

Celiac disease (CD) may influence metabolic control in type 1 diabetes (T1D). This work examines whether CD in T1D influences hospital admissions due to coma, ketoacidosis and hypoglycemia.In population-based cohort study, individuals with CD were identified using biopsy data (1969-2008) from Sweden's 28 pathology departments. T1D was defined as a recorded diagnosis of T1D at age ≤30 years in the Swedish National Patient Register between 1964 and 2009. In total, 906 individuals had both T1D and CD and were matched for sex, age and calendar period with 4303 reference individuals. Through stratified Cox regression analysis, we modeled CD as a time-dependent covariate and estimated the risk of future coma, ketoacidosis and hypoglycemia, defined by relevant international classification of disease codes among T1D patients with and without CD.During follow-up, patients with both T1D and CD had 49 hospital admissions with diabetic coma, 91 episodes of ketoacidosis and 25 hypoglycemic events. Among patients with T1D, CD did not influence the risk of coma (adjusted HR 0.97; 95 % CI 0.72-1.32), ketoacidosis (adjusted HR 1.08; 95 % CI 0.86-1.34), or hypoglycemia (adjusted HR 1.34; 95 % CI 0.87-2.05). The absolute risk of coma was 621/100,000 person-years in T1D and CD (637 in controls). Corresponding figures for ketoacidosis were 1175/100,000 person-years in T1D and CD (1092 in controls) and for hypoglycemia 316/100,000 person-years (236 in controls). HRs for metabolic emergencies in T1D were similar in the first 5 years after T1D diagnosis as thereafter.Having a diagnosis of CD is unlikely to influence the risk of coma, ketoacidosis and hypoglycemia in T1D patients.

The aim of this study was to evaluate UK trainee experience in endoscopy for acute upper gastrointestinal bleeding (AUGIB).Data was prospectively collected from all patients presenting to South Yorkshire Hospitals with AUGIB from September 2011 to December 2011 and compared with data from 1996. Concurrently, all gastroenterology trainees registered with the British Society of Gastroenterology were invited to respond to a web-based questionnaire regarding their experience in AUGIB management.77% (589/766) of the patient cohort underwent endoscopy for AUGIB; 15% (90/589) were performed by trainees. 7.2% (9/125) of the out of hours endoscopy case load was performed by trainees; all were low-risk or medium-risk cases (pre-endoscopy Rockall score ≤4). During the study period, dual therapy was delivered by a trainee on only four occasions. Comparison with the 1996 cohort demonstrated a marked reduction in the number of trainee performed endoscopies (76% vs 15%; p0.001). Questionnaires were returned by 51% (245/478) of British Society of Gastroenterology trainees. 81% (198/245) thought that10% of the gastroscopies they had performed involved therapeutic intervention. 23% (57/245) felt they would not be competent in AUGIB endoscopy by completion of specialty training.This study demonstrates the decline over time in trainee experience in AUGIB endoscopy. It also highlights a lack of trainee exposure to more challenging cases, out of hours endoscopy and therapeutic procedures. Furthermore, trainees are concerned that a level of competency may not be attained during specialty training. We advocate reviewing UK endoscopic training provision for AUGIB to ensure that experienced endoscopists are produced to meet future service needs.

Gluten-related disorders have recently been reclassified with an emerging scientific literature supporting the concept of non-celiac gluten sensitivity (NCGS). New research has specifically addressed prevalence, immune mechanisms, the recognition of non-immunoglobulin E (non-IgE) wheat allergy and overlap of NCGS with irritable bowel syndrome (IBS)-type symptoms. This review article will provide clinicians with an update that directly impacts on the management of a subgroup of their IBS patients whose symptoms are triggered by wheat ingestion.

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.

OBJECTIVE: Abstracts presentations at scientific meetings enable rapid dissemination of novel research. The percentage of abstracts that proceed to full publication from differing medical specialties is highly variable. This study aims to evaluate the outcomes of abstracts presented at the United European Gastroenterology Week (UEGW). MATERIALS AND METHODS: All abstracts presented at UEGW between 2009 and 2011 were assessed. Cross-referencing of the first author, senior author and at least one keyword of the abstract was performed using PubMed and EMBASE databases. Abstracts and possible resultant full publications were then examined in tandem to ensure that they represented the same study. Data were also collected on lag time to publication, journal impact factors, country of the author and factors influencing subsequent publication. RESULTS: A total of 6785 abstracts (1438 oral and 5347 poster presentations) were presented during the period assessed. Of these, 2099 (30.9%) proceeded to full publication in indexed journals. Oral abstract presentations were most likely to proceed to full publication compared with poster presentations (odds ratio: 1.38, 95% confidence interval: 1.22-1.56) and were more likely to achieve publication in higher impact journals (median impact factor 4.78 vs. 2.89, P

Celiac disease (CD) is associated with an increased risk of developing epilepsy, a risk that persists after CD diagnosis. A significant proportion of patients with CD have persistent villous atrophy (VA) on follow-up biopsy. The objective of this study was to determine whether persistent VA on follow-up biopsy affected long-term epilepsy risk and epilepsy-related hospital emergency admissions.This was a nationwide cohort study. We identified all people in Sweden with histological evidence of CD who underwent a follow-up small intestinal biopsy (1969-2008). We compared those with persistent VA with those who showed histological improvement, assessing the development of epilepsy and related emergency hospital admissions (defined according to relevant International Classification of Diseases codes in the Swedish Patient Register). Cox regression analysis was used to assess outcome measures.Villous atrophy was present in 43% of 7590 people with CD who had a follow-up biopsy. The presence of persistent VA was significantly associated with a reduced risk of developing newly-diagnosed epilepsy (hazard ratio, 0.61; 95% confidence interval, 0.38-0.98). On stratified analysis, this effect was primarily amongst males (hazard ratio, 0.35; 95% confidence interval, 0.15-0.80). Among the 58 patients with CD with a prior diagnosis of epilepsy, those with persistent VA were less likely to visit an emergency department with epilepsy (hazard ratio, 0.37; 95% confidence interval, 0.09-1.09).In a population-based study of individuals with CD, persisting VA on follow-up biopsy was associated with reduced future risk of developing epilepsy but did not influence emergency epilepsy-related hospital admissions. The mechanism as to why persistent VA confers this benefit requires further exploration.

Introduction Coeliac disease (CD) is common yet underdiagnosed. 12.4% CD patients had a gastroscopy within 5 years without duodenal biopsies taken, and coeliac serology was performed in only 30% of patients with anaemia or suspected CD. A pre-endoscopy point of care test (POCT) could potentially fill this gap. We aimed to evaluate the diagnostic accuracy and acceptability of the POCT, Simtomax (IgA/IgG-deamidated gliadin peptide, Tillotts Pharma, Rheinfelden, Switzerland), in detecting CD. Method Group 1: Patients attending for a gastroscopy were prospectively recruited from 2013–17. We excluded patients with a high pre-test probability of CD: positive endomysial antibody (EMA) referrals, previous villous atrophy, self-reported gluten sensitivity, those on a gluten free diet (GFD), suspected gluten ataxia; and known CD. Group 2: Patients who self-reported gluten sensitivity were prospectively recruited. All patients underwent the POCT, tissue transglutaminase antibodies (TTG), EMA and duodenal biopsies. The sensitivities of the POCT were compared to TTG and EMA, measuring against histology as the reference standard. Questionnaires regarding patient preference to the modality of antibody testing were given out. Results Group 1: 1000 patients were recruited (585 females, 58.5%; age range 16–91, median age 57). Forty-one patients (4.1%) were diagnosed with CD. Group 1: Group 2: Seventy patients who self-reported gluten sensitivity were recruited (51 females, 82.9%; age range 17–73, median age 35). Nine patients on a self-imposed GFD were excluded. Of the remaining 61 patients, 42 (68.9%) were diagnosed with non-coeliac gluten sensitivity (NCGS), 17 (27.9%) with CD and 2 (3.3%) with potential CD. Group 2: Five hundred patients responded to the POCT acceptability questionnaire. 90.8% preferred a POCT, 2.8% preferred venepuncture, and 6.8% had no preference. Conclusion The POCT had comparable diagnostic performance to conventional serology. It also correctly identified all cases of CD in a gluten sensitive cohort. The POCT could serve as a valuable and convenient case finding tool, with the advantage of providing antibody results rapidly at the point of endoscopy to target duodenal biopsy sampling for those with a positive POCT. Disclosure of Interest M. Lau: None Declared, P. Mooney: None Declared, W. White: None Declared, M. Rees: None Declared, M. Burden: None Declared, S. Wong: None Declared, M. Kurien: None Declared, D. Sanders Conflict with: Professor Sanders has received educational research grants from Dr Schaer (a gluten-free food manufacturer) and Tillotts Pharma (producer of a point of care test for celiac disease) for investigator led studies. Dr Shaer and Tillott’s Pharma did not have any input in the study design, access to study data, interpretation of the findings or drafting of the manuscript.

Introduction Gastrostomies are widely used to provide enteral nutrition support. Buried Bumper Syndrome (BBS) is a recognised complication seen following gastrostomy insertion, describing the migration of the internal bumper along the stoma tract towards the skin. The consequences of BBS can be fatal. Currently, there is a paucity of knowledge about the incidence and predictors of BBS, which is addressed in this study by systematically reviewing the medical literature. Method A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Guidelines (PRISMA). Four databases (EMBASE, MEDLINE, CINHAL, Web of Science) were utilised, and studies identified by searching for key terms relating to gastrostomy and BBS (Jan 1980 -Dec 2016). Unpublished studies were identified from conference abstract booklets. Two independent reviewers screened studies to identify those that included description of adult patients with BBS. Data was extracted relating to patient demographics, incidence, time to presentation and factors associated with BBS. Results 434 studies were initially identified (database search and grey literature). Of these, 299 (68.9%) were excluded following screening review of title and abstract (Kappa coefficient of reviewers=0.753). Of the remaining 135 studies, 85 met inclusion criteria (35 case studies, 11 case series and 39 cohort studies). No controlled trials were retrieved. In total, 16 627 patients were described post gastrostomy placement. 473 cases of BBS were reported in the literature, giving a pooled estimate incidence of 2.8% (0.46%–8.80%). The median age of presentation was 66 years, with 59.1% being in males. BBS was most frequently associated with gastrostomy tubes with thinner internal bumpers (40.7% of all reported cases), however reporting bias may have heavily influenced this outcome. The time to BBS presentation ranged from 3 days to 7 years. Common predictors of BBS reported in the literature include tight external bumpers and increased external traction made directly by the patient or during gastrostomy care. Conclusion This is the first study to systematically review the incidence of Buried Bumper syndrome and assess factors predicting its development. The paucity of high quality studies identified in this systematic review, provides the impetus to develop a national gastrostomy registry accurately assessing gastrostomy outcomes. Healthcare professionals, patients and their caregivers need to be appropriately educated about BBS, considering factors such as tightness of external bumpers and minimising external traction. Disclosure of Interest None Declared

Introduction Clinicians’ knowledge and practice may directly affect patients’ diagnostic pathway. An Endomysial antibody (EMA) has a>90% positive predictive value for coeliac disease. Furthermore NICE have recommended that patients with suspected coeliac disease should have an endoscopy and biopsy within 6 weeks. This should serve to reduce the temptation by the patient to start a Gluten free diet (GFD). We aimed to determine GI Consultant practice by assessing their ‘grading’ for patients referred from primary care with a positive EMA. In addition, we sought to determine Gastroenterologists’ views about coeliac disease. Method Data regarding time to diagnostic endoscopy was collected from adult patients who had a positive EMA test in primary care from 2 centres (n=151). As a comparator cohort, we collected data regarding the time from symptom presentation in primary care to index endoscopy in adults referred with suspected IBD (n=92). In addition, an unselected cohort of Gastroenterology consultants and specialist registrars (n=50) completed a questionnaire regarding coeliac disease. Results The median time from positive EMA identified in primary care to referral for diagnostic endoscopy was 23 (12-35) days; the time from referral to endoscopy was 55 (26-90) days. Overall, coeliac patients waited significantly longer from referral to endoscopy than patients who were diagnosed with IBD (34.5 [18-70] days; p=0.006). Overall time from EMA positive blood test to endoscopy was 78 (58-120) days. 32% (16) of Gastroenterologists failed to identify that coeliac disease was more prevalent in the adult population than IBD. 16% (8) of respondents felt that a diagnosis of coeliac disease does not significantly impact patient quality of life. 36% (18) felt that doctors were not required for the adequate management of coeliac disease. Conclusion There are delays in diagnosis for patients with coeliac disease. This may impact treatment intensification and thus patient related outcomes. Our data suggest that provider-related beliefs may contribute to clinical inertia in this condition. We advocate enhancing both undergraduate and postgraduate training about coeliac disease to help reduce this effect. Disclosure of Interest None Declared

INTRODUCTION: \ud \ud Celiac disease (CD) is common, affecting approximately 1% of the population. The cornerstone of management is a gluten-free diet, with dietetic advice being the key to aiding implementation. The aim of the study was to assess group clinics in comparison with traditional individual appointments.\ud \ud METHODS: \ud \ud Patients with a new diagnosis of CD, confirmed histologically, were prospectively recruited over 18 months in Sheffield, United Kingdom. Patients received either a group clinic or traditional one-to-one appointment, led by a dietitian. Quality-of-life questionnaires were completed at baseline, as well as biochemical parameters being recorded. Patients were followed up at 3 months, where adherence scores were assessed as well as biochemical parameters and quality of life questionnaires being completed.\ud \ud RESULTS: \ud \ud Sixty patients with CD were prospectively recruited and received either an individual (n = 30) or group clinic (n = 30). A statistically significant reduction in tissue transglutaminase was noted following group clinics (mean 58.5, SD 43.4 U/mL vs mean 13.2, SD 5.7 U/mL, P < 0.01). No significant differences in baseline and follow-up biochemical parameters between one-to-one and group clinics were noted. At follow-up, there was no statistically significant difference between mean gluten-free diet adherence scores (mean 3.1, SD 0.4 vs mean 3.1, SD 0.7, P = 0.66) between one-to-one and group clinics.\ud \ud DISCUSSION: \ud \ud This first study assessing group clinics in CD demonstrates they are as effective as traditional one-to-one clinics, with the added benefits of peer support and greater efficiency, with an estimated 54% reduction of dietetic resources.

Background There have been limited studies evaluating capsule endoscopy (CE) in equivocal celiac disease (CD). Objective To determine the role CE may have in equivocal CD cases, compared with patients with biopsy-proven and serology-proven CD who have persisting symptoms. Design Prospective cohort study. Setting University hospital. Patients A total of 62 patients with equivocal CD and 69 patients with nonresponsive CD. Intervention CE. Main Outcome Measurements Diagnostic yield of CE in equivocal cases and accuracy of mucosal abnormality detection in patients with nonresponsive CD. Results Equivocal cases (n = 62) were divided into two subgroups: group A (antibody-negative villous atrophy, n=32) and group B (Marsh 1-2 changes, n=30). In group A, CE secured a diagnosis of CD or Crohn's disease in 28% (9/32), significantly higher than the diagnostic yield in group B (7%; P = .044). In patients with CD with persisting symptoms, significant CE findings were identified in 12% (8/69), including 2 cases of enteropathy-associated lymphoma, 4 type 1 refractory disease cases, 1 polypoidal mass histologically confirmed to be a fibroepithelial polyp, and 1 case of ulcerative jejunitis. This outcome was significantly lower than the diagnostic yield of CE in antibody-negative villous atrophy ( P = .048). Limitations Single center. Conclusion There have been no previous reports systematically evaluating equivocal CD by using CE. The diagnostic yield of CE in patients with antibody-negative villous atrophy is better than that of CE in patients with CD with persisting symptoms. We advocate the use of CE in equivocal cases, particularly in patients with antibody-negative villous atrophy.