Andrew F Goddard

Guidelines for the management of iron deficiency anaemia

EDITOR,—I read with great interest the article by Hearing et al (Gut 1999;45:889–894) on the eVect of cholecystectomy on bowel function. In this elegant publication, however, the authors mistakenly assume that published estimates of the prevalence of postcholecystectomy diarrhoea derive from retrospective or uncontrolled data only. In this context I would like to draw attention to earlier publications derived from the Rotterdam Gallstone Study. 2 In the first paper the results are discussed of a prospective analysis of biliary and gastrointestinal symptoms (including diarrhoea) prior to and up to two years after gall stone therapy. Therapy consisted of either conventional cholecystectomy or extracorporeal shock wave lithotripsy (ESWL), allocated randomly. The second paper focused on surgery and reported on symptoms before and after conventional and laparoscopic cholecystectomy. This study was based on the same concept, and treatment depended on the availability of a laparoscopic set. Generally, we found that the reported incidence of diarrhoea before and after surgery did not change. In fact, there was no diVerence in the reported incidence of diarrhoea at any time between cholecystectomy and gall bladder preserving therapy (that is, ESWL). We also found that there were no diVerences in the reported incidence or severity of diarrhoea between laparoscopic and conventional cholecystectomy at any time. Although the study design of our two studies diVered largely from that of Hearing’s, the results and conclusions are in agreement, in that clinical diarrhoea seldom develops after cholecystectomy. O’Donnell is correct that objective assessment rarely demonstrates new onset diarrhoea after cholecystectomy. I agree with Hearing et al that postcholecystectomy diarrhoea is in fact an unproved entity. Given our and Hearing’s results, I doubt if more prospective studies are needed to solve this problem.

The management of gastric polyps

Background Gastric polyps are important as some have malignant potential. If such polyps are left untreated, gastric cancer may result. The malignant potential depends on the histological type of the polyp. The literature base is relatively weak and any recommendations made must be viewed in light of this. Definition Gastric polyps are sessile or pedunculated lesions that originate in the gastric epithelium or submucosa and protrude into the stomach lumen. Malignant potential Depending on histological type, some gastric polyps (adenomas and hyperplastic polyps) have malignant potential and are precursors of early gastric cancer. They may also indicate an increased risk of intestinal or extra-intestinal malignancy.

Guidelines for the management of iron deficiency anaemia. British Society of Gastroenterology.

Iron deficiency anaemia in men and postmenopausal women is most commonly caused by gastrointestinal blood loss or malabsorption. Examination of both the upper and lower gastrointestinal tract is therefore an important part of the investigation of patients with such anaemia. In the absence of overt blood loss or any obvious cause, all patients should have upper gastrointestinal endoscopy, including small bowel biopsy, and colonoscopy or barium enema to exclude gastrointestinal malignancy. Further gastrointestinal investigation is only warranted in transfusion dependent anaemia or where there is visible blood loss. Treatment of an underlying cause will cure the anaemia but even when no cause is detected the long term outlook is good.

Higher senior staffing levels at weekends and reduced mortality

The association is clear but the effects of the grade and specialty of key personnel are not

Use of CT colonography in the English Bowel Cancer Screening Programme

Objective To examine use of CT colonography (CTC) in the English Bowel Cancer Screening Programme (BCSP) and investigate detection rates. Design Retrospective analysis of routinely coded BCSP data. Guaiac faecal occult blood test (gFOBt)-positive screenees undergoing CTC from June 2006 to July 2012 as their first-line colonic investigation were included. Abnormalities found at CTC, subsequent polyp, adenoma and cancer detection and positive predictive value (PPV) were calculated. Detection rates were compared with those observed in gFOBt-positive screenees investigated by colonoscopy. Multilevel logistic regression was used to examine factors associated with variable detection. Results 2731 screenees underwent CTC. Colorectal cancer (CRC) or polyps were suspected in 1027 individuals (37.6%; 95% CI 33.8% to 41.4%); 911 of these underwent confirmatory testing. 124 screenees had CRC (4.5%) and 533 had polyps (19.5%), 468 adenomatous (17.1%). Overall detection was 24.1% (95% CI 21.5% to 26.6%) for CRC or polyps and 21.7% (95% CI 19.2% to 24.1%) for CRC or adenoma. Advanced neoplasia was detected in 504 screenees (18.5%; 95% CI 16.1% to 20.8%). PPV for CRC or polyp was 72.1% (95% CI 66.6% to 77.6%). By comparison, 9.0% of 72u2005817 screenees undergoing colonoscopy had cancer and 50.6% had polyps; advanced neoplasia was detected in 32.7%. CTC detection rates and PPV were higher at centres with experienced radiologists (>1000 examinations) and at high-volume centres (>175 cases/radiologist/annum). Centres using three-dimensional interpretation detected more neoplasia. Conclusions In the BCSP, detection rates after positive gFOBt are lower for CTC than colonoscopy, although populations undergoing the two tests are different. Centres with more experienced radiologists have higher detection and accuracy. Rigorous quality assurance of BCSP radiology is needed.

Can doctors be trained in a 48 hour working week

Andrew Hartle and Sarah Gibb find no evidence that implementation of the European Working Time Directive has led to a decline in the quality of training. But Andrew Goddard thinks that 48 hours doesn’t give sufficient time for some specialties and notes trainees’ dissatisfaction

Planning a consultant delivered NHS

Patient care is at risk unless workforce planning accounts for policy and financial limitations

Esomeprazole and aspirin in Barrett's oesophagus (AspECT): a randomised factorial trial

Summary Background Oesophageal adenocarcinoma is the sixth most common cause of cancer death worldwide and Barretts oesophagus is the biggest risk factor. We aimed to evaluate the efficacy of high-dose esomeprazole proton-pump inhibitor (PPI) and aspirin for improving outcomes in patients with Barretts oesophagus. Methods The Aspirin and Esomeprazole Chemoprevention in Barretts metaplasia Trial had a 2u2008×u20082 factorial design and was done at 84 centres in the UK and one in Canada. Patients with Barretts oesophagus of 1 cm or more were randomised 1:1:1:1 using a computer-generated schedule held in a central trials unit to receive high-dose (40 mg twice-daily) or low-dose (20 mg once-daily) PPI, with or without aspirin (300 mg per day in the UK, 325 mg per day in Canada) for at least 8 years, in an unblinded manner. Reporting pathologists were masked to treatment allocation. The primary composite endpoint was time to all-cause mortality, oesophageal adenocarcinoma, or high-grade dysplasia, which was analysed with accelerated failure time modelling adjusted for minimisation factors (age, Barretts oesophagus length, intestinal metaplasia) in all patients in the intention-to-treat population. This trial is registered with EudraCT, number 2004-003836-77. Findings Between March 10, 2005, and March 1, 2009, 2557 patients were recruited. 705 patients were assigned to low-dose PPI and no aspirin, 704 to high-dose PPI and no aspirin, 571 to low-dose PPI and aspirin, and 577 to high-dose PPI and aspirin. Median follow-up and treatment duration was 8·9 years (IQR 8·2–9·8), and we collected 20u2008095 follow-up years and 99·9% of planned data. 313 primary events occurred. High-dose PPI (139 events in 1270 patients) was superior to low-dose PPI (174 events in 1265 patients; time ratio [TR] 1·27, 95% CI 1·01–1·58, p=0·038). Aspirin (127 events in 1138 patients) was not significantly better than no aspirin (154 events in 1142 patients; TR 1·24, 0·98–1·57, p=0·068). If patients using non-steroidal anti-inflammatory drugs were censored at the time of first use, aspirin was significantly better than no aspirin (TR 1·29, 1·01–1·66, p=0·043; n=2236). Combining high-dose PPI with aspirin had the strongest effect compared with low-dose PPI without aspirin (TR 1·59, 1·14–2·23, p=0·0068). The numbers needed to treat were 34 for PPI and 43 for aspirin. Only 28 (1%) participants reported study-treatment-related serious adverse events. Interpretation High-dose PPI and aspirin chemoprevention therapy, especially in combination, significantly and safely improved outcomes in patients with Barretts oesophagus. Funding Cancer Research UK, AstraZeneca, Wellcome Trust, and Health Technology Assessment.

PWE-072 Current role of radiology as the first investigation in the English bowel cancer screening programme (BCSP)

Introduction The current BCSP pathway recommends radiological examination of the colon for people with a positive faecal occult blood test who are unable to undergo colonoscopy. The proportion of people undergoing radiological examination and polyp/cancer yield is unknown. Methods All patients undergoing lower gastrointestinal investigation following a positive faecal occult blood test within the English national Bowel Cancer Screening Programme (BCSP) in the first 4u2005years of the programme (August 2006–July 2010) were identified. The number, percentage, demographics and co-morbidity (as defined by ASA grade) of people having CT colonography, barium enema, and plain abdominal CT as the first investigation were recorded and variability between centres was assessed. Use of radiology and yield of cancer and high risk polyps were also recorded, and compared to colonoscopy. Outliers were determined using Tukey limit methods. Results Use of radiological tests as a first line investigation increased steadily with age from 0.99% in those aged <60u2005years to 6.04% in those aged >74u2005years. Radiological tests were used in more women than men (2.65% vs 2.35%, p<0.01). Radiological investigation increased with co-morbidity from 1.94% in people graded ASA 1 to 38.36% in ASA 4 (p<0.001). Cancer and high risk polyp detection rates for all first-line investigations are shown below. Detection rates for radiological tests were lower in this older, co-morbid sub-population than found for colonoscopy. There was considerable variation in the use of radiology between centres (0.3% to 9.1%), not related to age or co-morbidity. Two centres had a very low percentage of people having radiology tests and three very high. Conclusion The number of people having radiology tests as an alternative to colonoscopy in the BCSP is highly variable across England but is associated with increasing age and co-morbidity. Cancer and high risk polyp detection rates appear lower in this sub-population compared to colonoscopy yield. Accuracy of radiology data input and examination of the factors contributing to these data requires further investigation and analysis.Abstract PWE-072 Table 1 Colonoscopy Barium enema CT colonography Abdominal CT Number 94u2008135 253 1770 358 Cancer (%) 9.26 3.56 5.03 4.19 High risk polyps (%) 9.57 2.77 4.75 1.12 Competing interests None declared.