Ikram Nasr

PWE-007 When to use hemospray? a single centre experience

Introduction Hemospray is an inorganic nanopowder produced by Cook Medical and is licensed in Europe and Canada for the management of nonvariceal upper gastrointestinal bleed (NVUGIB). The powder adheres to liquid and forms a coagulum which concentrates clotting factors and stimulates the internal clotting cascade. There are numerous reports of successful haemostasis with hemospray, some reporting success rates of 85%.1However, the knowledge of which lesion is most suitable for hemospray use remains unclear. We report our experience at Guys and St Thomas’ NHS trust to establish the lesions most likely to benefit from hemospray either as a primary intervention or an add-on strategy. Method A retrospective review of endoscopic procedures that required hemospray was performed and the data was extracted from our endoscopy reporting system between December 2013 and February 2015 (14 months). We identified 32 patients who received hemospray, and excluded 2 where hemospray was applied blindly and the bleeding lesion was missed. The primary outcome was achieving primary haemostasis. Cases where primary haemostasis was not achieved or bleeding recurred requiring further endoscopic or radiological intervention were considered unsuccessful. Results The 30 procedures were divided according to the procedure performed. Procedure induced bleeding: 9/30 (7 post Barrett’s endoscopic mucosal resection (EMR), 1 post gastric polypectomy and 1 iatrogenic bleed post nasojejunal tube insertion). NVUGIB: 17/30. Enteroscopy small bowel bleed: 2/30. Colonoscopy: 2/30. Primary haemostasis was achieved in 80%, of which 10% required further endoscopic procedure or interventional radiological intervention (Table 1). The coagulum was not seen on second endoscopy.Abstract PWE-007 Table 1 Results of hemospray use Procedure induced upper GI Forrest 1a Forrest 1b Forrest 2a Forrest 2b Distal ileum (Enteroscopy) Colonic bleed Total Primary haemostasis achieved and sustained 9 0 5 2 3 1 1 21 Primary haemostasis achieved but NOT sustained 0 2 0 0 0 1 0 3 Primary haemostasis NOT achieved 0 4 1 0 0 0 1 6 Total 9 6 6 2 3 2 2 30 Conclusion Hemospray provides good hemostasis for post procedure, in particular post EMR bleed, as a single agent or where coagulation alone failed. Bleeding from Forrest 1b, 2a and 2b responded well to hemospray as a second modality, or single modality when the lesion was inaccessible. Forrest 1a had a poor response to hemospray and all cases required further endotherapy or interventional radiology. Further evidence is required to establish the value of hemospray in colonic and variceal bleed. Disclosure of interest None Declared. Reference Smith et al. Hemospray application in nonvariceal upper gastrointestinal bleeding: results of the survey to Evaluate the application of hemospray in the luminal tract. J Clin Gastroenterol. 2014 Nov-Dec;48(10):e89-92

Sa1255 Higher Red Blood Cell Methotrexate Polyglutamates Correlate With Increased Disease Activity, and Are Useful in Assessing Adherence

Introduction Methotrexate (MTX) is commonly used in patients with inflammatory bowel disease (IBD). Within red blood cells (RBC), MTX is activated by sequential addition of glutamic acid residues to form polyglutamates (MTXPG 1–5 ). In rheumatoid arthritis, low [MTXPG] has been associated with active disease, whereas other studies have demonstrated an inverse relationship, including the only published data in IBD. The aim of this study was to determine if RBC [MTXPG] reflect clinical response in IBD patients and whether they are useful in assessing adherence. Methods This was a single-centre, retrospective pilot study of 21 IBD patients treated with weekly MTX. RBC MTXPG 1–5 was measured using high-performance liquid chromatography. Clinical status (active disease or remission) was assessed by 2 IBD physicians blinded to [MTXPG], using a combination of prospectively recorded clinical activity indices (Simple Colitis Activity Index, Harvey Bradshaw Index), endoscopy, faecal calprotectin and C reactive protein (CRP). Pearson correlation coefficient, r was calculated to assess the relationship between MTX dose and [MTXPG]. Association between [MTXPG] and clinical response was analysed with unpaired t-test. Results 4/21(22%) patients (3 of whom admitted non-adherence) had undetectable MTXPGs and were excluded from further analysis. MTXPG 2–4 were detected in all adherent patients. PG 3 was the predominant polyglutamate accounting for a mean of 43% of total MTXPG. A linear relationship between dose of MTX and PG 1–5 was observed. 12/21(57%) patients were assessed as having active disease. No significant difference in mean [MTXPG n ] was observed between those with active disease and remission. For each MTXPG n , a non-significant trend towards a higher concentration was observed in patients with active disease. Conclusion In this study, the largest to date in IBD, measuring RBC MTXPG was useful in assessing adherence to MTX. A trend towards higher PG concentrations was associated with active disease confirming the findings in the only other study in IBD. Whether this is confounded by higher doses being used in patients with more active disease warrants further study in larger, prospective trials. Reference Disclosure of Interest None Declared.

Su1101 Indeterminate and Inconclusive Results Are Common When Using Interferon Gamma Release Assay As Screening for TB in Patients With IBD

Introduction Anti-TNF treatment is widely used in inflammatory bowel disease (IBD) but has been linked with reactivation of tuberculosis (TB). Screening for active and latent TB prior to initiation of anti-TNF therapy is therefore mandated. ECCO recommends interferon gamma release assays (IGRAs) as, unlike tuberculin skin test, positive tests are not caused by previous Bacillus Calmette–Guerin (BCG) vaccine. However, immunosuppressive agents can result in indeterminate or unreportable results[i] and there is no clear guidance on managing them. We quantified the prevalence of indeterminate or unreportable TB IGRA Elispot results in a large tertiary centre cohort of patients with IBD. Methods A single centre retrospective study of IGRA tests performed on IBD patients prior to commencement of anti-TNF therapy between Oct 2010 and Oct 2013. Results We included 140 patients (median age 34, range 24–86, 50% males). 92% had Crohn’s disease, 4% ulcerative colitis, and 4% IBD-unclassified. At the time of IGRA testing, 115 patients were on immunomodulators and 6 on prednisolone. 3 were positive for latent TB and were referred to infectious disease (ID) department prior to anti-TNF therapy. 3 had indeterminate results; all were on immunosuppressants (2=azathioprine, 1=methotrexate). 2 had a lymphocyte count 10 had unreportable results, 9 of whom were on azathioprine. On repeat testing, 4 were negative, and the remainder were still unreportable, one of whom had risk factors for TB and was treated with isoniazid chemoprophylaxis on the advice of the ID team. The remaining 5 patients started anti-TNF based on the absence of risk factors for TB. No patient had reactivation of latent TB at follow up (range 1–18 months). Lymphopaenia was found to be associated with non-reportable cases as compared to the reported cases (median lymphocyte count unreportable = 0.4, reportable = 1.2; p = 0.015). Conclusion Our results demonstrate TB IGRA is a useful test to screen for latent infection before initiating anti-TNF therapy. However, a minority of results are indeterminate or unreportable. In such cases repeat testing can produce definitive results. Low lymphocyte counts in association with immunosuppression may contribute to unreportable and indeterminate results; clinical risk stratification appears to be a safe way of managing such cases in this small cohort. Reference Papay P et al . Predictors of indeterminate IFN-γ release assay in screening for latent TB in inflammatory bowel diseases. Eur J Clin Invest. 2011 Disclosure of Interest None Declared.

Sa1300 Clinical and Diagnostic Value of 96 Hours Wireless Reflux Monitoring Off/On PPIs

Introduction Prolonged catheter-free pH monitoring with Bravo capsule up to 96 hours has become possible and enables extended physiological evaluation of gastroesophageal reflux disease (GERD) and response to therapeutic interventions. Aim of the present study was to determine the feasibility of 96 hrs recordings using Bravo capsule that would encompass time periods both off and on therapy with Proton Pump Inhibitors (PPIs). Methods A total of 432 patients reporting symptoms of GERD refractory to conventional therapy underwent 96 hours of Bravo capsule recordings. Patients identified with abnormal acid exposure during the 1st 48 hrs of recordings (off PPIs) underwent the 2nd 48 hrs of recording on twice daily PPIs. The parameters subjected to analysis were percent of time ph Results 132/436 (30.3%) of patients had abnormal acid exposure in the 1st 48 hrs (70 males, mean age 49, range 17–81 years) and the second 48 hrs of recordings was performed on PPIs.98/132 (74.2%) had normal acid exposure on PPIs whereas 34/132 (23.5%) had abnormal acid exposure despite high dose of PPIs. The overall number of symptoms reported in the 2nd 48 hrs was reduced by 68.4% (responsive 76.7% vs refractory 49.9%, p Conclusion Extended pH recording improves the detection of abnormal acid reflux. Combined off and on PPI therapy pH testing provides additional information which can be helpful in the management of patients with PPI refractory GERD. Disclosure of Interest None Declared

Sa1217 A Protocol to Avoid Corticosteroid Exposure Prior to Crohn's Disease Requiring Luminal Surgery

Introduction Corticosteroids (CS) are prescribed to control inflammatory and obstructive symptoms in Crohn’s disease (CD). Preoperative CS are associated with higher risk of all complications post-operatively including sepsis, anastomotic breakdown and venous thromboembolic disease.High doses of CS also preclude a primary anastomosis. In our institution, we have implemented a protocol to prevent CS administration or permit a rapid wean in patients requiring ileal/ileocaecal resection, maximising the use of exclusive enteral nutrition (EEN) or parenteral nutrition (PN). This study aimed to determine the achievability of CS avoidance in this setting. Method In patients selected for ileal/ileocaecal resection, EEN (with either Modulen IBD Nestle or Fortisip Nutricia, as tolerated) was prescribed to a target dose of 30 kcal/kg. Acute sepsis was controlled with intravenous and/or oral antibiotics. If EEN was not tolerated because of obstructive symptoms, PN was instituted or surgery expedited. Patients were not offered this protocol if they had minimal symptoms, adequate nutritional status and no CS exposure. Results In total, 39 patients with CD had IC resection over a period of 20 months from January 2013. 9 of these underwent urgent surgery due to symptom severity (severe obstruction or suspected cancer where delay not possible [4 of 9 on CS (45%)]. 8 patients with stable symptoms secondary to fibrotic stricture (4 on biologic, 4 on immunomodulator), adequate nutritional status and CS free were not suitable for the protocol. 22 patients with acute symptoms were therefore included. All had penetrating and/or stricturing disease. 8 patients were receiving CS of whom 7 (88%) successfully weaned off CS for greater than 4 weeks using EEN. 1 did not tolerate EEN and proceeded to surgery on CS. A further 11 of 22 patients successfully treated via protocol to avoid CS (EEN n = 7, PN n = 4) 3 patients did not tolerate/declined EEN/PN and proceeded to expedited surgery. Hence, in all patients suitable for the protocol, CS were successfully avoided (14/14 patients, 100%) and wean >4 weeks successful in majority (7/8 patients, 87.5%). CS exposure was successfully avoided in 21 patients via protocol (95.5%). Conclusion Aggressive use of EEN or PN provides an effective approach to avoid CS exposure, optimise nutrition and control acute symptoms in patients selected for IC resection. The implementation of the protocol requires close liaison between gastroenterologists, colorectal surgeons and dieticians. The protocol does not delay emergency surgery. Disclosure of interest None Declared.

PTU-044 Tertiary Centre Experience Of 360 Degree Side-viewing Video Capsule Endoscopy

Introduction Since it’s development in 1999, video capsule endoscopy (VCE) has become the investigation of choice for examining the small bowel. Recently, a novel panoramic 360 degree side-viewing VCE (Capsovision, Medical Innovations, USA) was launched. It differs from previous capsules in that no data recorder or sensors are required. The images are stored on the capsule itself, which when passed, must be retrieved and sent to the endoscopy reader for analysis. We report our initial experience of this novel VCE. Methods We retrospectively analysed the first 51 side-viewing VCE over a 6-month period at our institution. All patients had a clear liquid diet as preparation the day before. Results 51 patients (26 males) underwent examination with the side-viewing VCE. 39 (76.4%) examinations were completed and 12 were incomplete. This included 4 which were lost due to being flushed away. Over the same time period, forward-viewing VCE complete results were available in 83.2% patients. 1 of the incomplete examinations was due to a NSAID-induced stricture, subsequently diagnosed with a forward-viewing VCE. 31 patients had good bowel preparation, 11 satisfactory preparation and 6 were reported as having poor bowel preparation. The duodenal ampulla was reliably identified in 3/47 (6.4%) examinations. Pathology was identified in 11/47 (23.4%) examinations. Conclusion Side-viewing VCE was well tolerated and completed examination results were available for 76.4% of patients examined. Our findings did not correlate with previous reported results (71%) regarding the identification rate of the duodenal papilla as a small bowel landmark with side-viewing VCE. Advantages of the side-viewing VCE are not needing the patient to wear a recorder, with the data being stored in the capsule itself. This enables multiple patients to be examined on the same day and the number of examinations is not limited by available data recorders. Patients can also take the capsule home and take the capsule at any time which can be useful in the investigation of obscure GI bleeding. Side-viewing VCE is comparable to forward viewing VCE with respect to cost and accuracy. Disclosure of Interest None Declared.

PTH-112 A Single Centre Experience Of Treatment Of Refractory Celiac Disease Type 2

Introduction Refractory celiac disease (RCD) is a persistent malabsorption and villous atrophy despite adhering to a strict gluten-free diet (GFD) for at least 6–12 months in the absence of other cause 1. It is a rare complication of celiac disease (CD). RCD is classified based on the T-cells in the intraepithelial lymphocyte (IEL) morphology into type 1 with normal IEL and type 2 with aberrant IEL. RCD1 is managed with strict nutritional and pharmacological management. RCD2 can be complicated by ulcerative jejunitis or enteropathy associated lymphoma (EATL), the latter having a 5-year mortality of 8–20%. It is therefore necessary to investigate and manage RCD2 which has a less predicted response and has a poor prognosis due to the associated complications. Treatment options vary due to the low incidence of RCD2 and hence the small numbers of randomised control trials. We present a single centre’s experience in the treatment of RCD2. Methods We performed a single centre retrospective study of all cases of RCD2 using the celiac database in a single centre between 2000 and 2013. Case notes, biological and histological data were reviewed for patients with a diagnosis of RCD2 diagnosed between 2000 and 2013. All patients were treated with prednisolone, 20 mg, and azathioprine, 2 mg/kg/day with repeat small bowel biopsy and T cell receptor analysis by PCR at 4 monthly intervals. Results Fourteen out of twenty patients with RCD2 were successfully treated with prednisolone and azathioprine to become either type 1 refractory celiac disease, in 12 patients, or celiac disease, in 2 patients, with a better 5-year survival. None of the type 2 refractory patients developed lymphoma on this treatment. Conclusion Prednisolone combined with azathioprine can be used successfully to treat RCD2. Our experience shows it is a safe and successful approach to improve prognosis. We successfully treated 7 out of 10 patients with RCD2 with this regimen. Reference 1 Alberto Rubio-Tapia, Joseph A Murray. Classification and Management of Refractory Celiac Disease. Gut 2010 April; 59(4):547–557 Disclosure of Interest None Declared.