Ja Campbell

Improving Outcomes of Chronic Pancreatitis: Is Isolated Pancreatic Exocrine Insufficiency an Early Marker to Identify Modifiable Risks?

Improving Outcomes of Chronic Pancreatitis: Is Isolated Pancreatic Exocrine Insufficiency an Early Marker to Identify Modifiable Risks?

Endoscopic ultrasound sedation in the United Kingdom: Is life without propofol tolerable?

There is compelling evidence to support the quality, cost effectiveness and safety profile of non-anesthesiologist-administered propofol for endoscopic ultrasound (EUS). However in the United Kingdom, it is recommended that the administration and monitoring of propofol sedation for endoscopic procedures should be the responsibility of a dedicated and appropriately trained anaesthetist only. The majority of United Kingdom EUS procedures are performed with opiate and benzodiazepine sedation rather than anaesthetist led propofol lists due to anaesthetist resource availability. We sought to prospectively determine the tolerability and safety of EUS with benzodiazepine and opiate sedation in single United Kingdom centre. Two hundred consecutive patients undergoing either EUS or oesophago-gastroduodenoscopy (OGD) with conscious sedation were prospectively recruited with a 1:1 enrolment ratio. Patients completed questionnaires pre and post procedure detailing anticipated and actual pain experienced on a 1-10 visual analogue scale. Demographics, procedure duration, sedation doses and willingness to repeat the procedure were also recorded. EUS procedures lasted significantly longer than OGDs (15 min vs 6 min, P < 0.0001), however, there was no difference in anticipated pain scores between the groups (EUS 3.37/10 vs OGD 3.47/10, P = 0.46). Pain scores indicated EUS was better tolerated than OGD (1.16/10 vs 1.88/10, P = 0.03) although higher doses of sedation were used for EUS procedures. There were no complications identified in either group. We feel our study demonstrates that the tolerability of EUS with opiate and benzodiazepine sedation is acceptable.

PTH-097 How Common Is Pancreatic Exocrine Insufficiency In Secondary Care Gastroenterology Clinics? A Dual Centre Study

Introduction Post-mortem studies suggest that chronic pancreatitis is present in 6–12% of the population, yet the diagnosis of chronic pancreatitis is infrequent. We hypothesised that previously undetected pancreatic exocrine insufficiency is seen in unselected patients referred to secondary care gastroenterology clinics. Methods A multicentre retrospective analysis of all gastroenterology patients tested for faecal elastase (FEL-1) between 2009–13 was performed. In Sheffield and Middlesbrough a FEL-1 <200 μg/g was defined as abnormal. Demographics, indication, co-morbidities and response to enzyme supplementation were recorded. Additionally, the findings of abdominal imaging were recorded. Prevalence of low FEL-1 was compared between the two centres (Fishers exact test). Binary logistic regression was used to determine if comorbidities could predict pancreatic insufficiency. Results 1887 patients (mean age 51.6, SD 16.91, 1144 females) were included. Sheffield’s group contained 1350 patients (mean age 49.1, SD 16.37, 857 females), and Middlesbrough’s 537 (mean age 57.9, SD 16.60, 287 female). The most common indication to test FEL-1 was diarrhoea (n = 1252), followed by abdominal pain (n = 378) and weight loss (n = 125). The overall prevalence of low FEL-1 was 11.4% (Sheffield 11.0% vs. Middlesbrough 22.9% p < 0.0001). 13.7% (n = 171/1252) of patients with diarrhoea as the predominant symptom had FEL-1 <200. Of those with abdominal pain and weight loss 12.4% (n = 47/378) and 27.2% (n = 35/125) had low FEL-1 respectively. 86.8% (n = 236) of patients with low FEL-1 had abdominal imaging, (MRI, CT or US). 50% of imaging was normal (n = 136), 33.1% (n = 90) demonstrated pancreatic pathology consistent with either chronic pancreatitis or malignancy. Binary logistical regression showed FEL-1 <200 was strongly associated with excess alcohol intake, diabetes mellitus, intrinsic pancreatic disease (malignant or non-malignant) and HIV infection (p < 0.0001). 79% (n = 128) of patients treated with pancreatic enzyme supplementation subjectively reported benefit from therapy. 12.3% (n = 20) had no benefit and in 8.6% (n = 14) it was not possible to assess benefit from medical records. Conclusion This is the largest study to report detection of exocrine pancreatic disease in unselected gastroenterology clinics. Exocrine pancreatic insufficiency is strongly associated with diabetes mellitus, intrinsic pancreatic disease, high alcohol intake and HIV. Creon provides symptomatic benefit for those with pancreatic insufficiency, but further work is needed to establish appropriate dosage of enzyme supplementation. Clinicians should have a low threshold for checking FEL-1. Disclosure of Interest None Declared.

Practical guide to the management of chronic pancreatitis

Chronic pancreatitis (CP) is an irreversible fibroinflammatory disorder of the pancreas. It presents with relapsing, remitting upper abdominal pain accompanied by features of malabsorption due to pancreatic exocrine insufficiency and endocrine deficiency with the development of diabetes mellitus. The associated increased hospitalisation and high economic burden are related to CP often presenting at advanced stage with irreversible consequences. Diagnosing CP at an early stage is still challenging and therefore CP is believed to be under-reported. Our understanding of this disease has evolved over the last few years with attempts to redesign the definition of CP. Better recognition of the risk factors and conditions associated with CP can lead to an earlier diagnosis and coupled with a multidisciplinary approach to treatment, ultimately reduce complications. This article reviews the epidemiology, risk factors, diagnosis and management of CP.

Diagnostic yield of magnetically assisted capsule endoscopy versus gastroscopy in recurrent and refractory iron deficiency anemia

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 < 0.001). In upper GI examination (proximal to the second part of the duodenum, D2), MACE identified more total lesions than EGD (88 vs. 52; P < 0.001). There was also a difference if only IDA-associated lesions (esophagitis, altered/fresh blood, angioectasia, ulcers, and villous atrophy) were included (20 vs. 10; P = 0.04). Pathology distal to D2 was identified in 17 patients (34.7 %). Median scores (0 - 10 for none - extreme) for pain (0 vs. 2), discomfort (0 vs. 3), and distress (0 vs. 4) were lower for MACE than for EGD (P < 0.001). 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.

AODTH-009 Quantitative elastography is useful in the diagnosis of chronic pancreatitis

Introduction Endoscopic ultrasound (EUS) is widely used in the assessment of chronic pancreatitis (CP), however the Rosemont criteria that was initially developed has been criticised for being subjective and susceptible to intra-observer variability. Quantitative tissue stiffness measurement of the pancreas with EUS-elastography (EUS-E) is a potential non-subjective alternative to diagnose CP. It has been described as a tool for diagnosing CP in a single centre study with EUS-E readings/strain ratio of >2.25 found to have a diagnostic accuracy of >90%; but has not been validated. We aimed to assess if EUS elastography could accurately identify CP compared to EUS Rosemont scores. Method Patients referred for pancreatic EUS with suspicion of CP and those referred for EUS for unexplained upper abdominal pain were recruited prospectively. All patients had pancreatic computerised tomography (CT) or magnetic resonance cholangiopancreatography (MRCP) prior to EUS. Patients were also asked to return a stool sample for faecal elastase-1 (FEL-1) to assess for exocrine dysfunction. Two endoscopists conducted standard pancreatico-biliary EUS examinations using linear EUS endoscopes (UCT-260). Rosemont grades were recorded. EUS-E was performed to obtain strain ratios from the head, body and tail of pancreas, the mean of three ratios was included in analysis. Linear regression was used to determine if there was an association between strain ratios and number of features of CP. Student’s t test was used to determine if there was a difference in strain ratio in patients with low and normal FEL-1 and when comparing the strain ratios of the CP group and abdominal pain controls. Results 25 patients were recruited (9 CP group median age 51.2, range 24–82, 3 male and 16 abdominal pain group median age 53.7, range 36–70, 5 male). There was a statistically significant difference in average strain ratios when comparing the two groups (11.8 versus 2.1 p=0.017). Using a cut off of 2.25 we report sensitivity of 100% and specificity of 60% for diagnosis of CP (PPV 57.1%, NPV 100%). Higher strain ratios predicted finding a greater number of parenchymal features of CP on EUS suggestive of CP (R2=0.34 p=0.0046). The strain ratios of those with normal (>200 µg/g) and low (<200 µg/g) FEL-1 results were significantly different (2.11 versus 5.14 p=0.029). Conclusion EUS-E is a useful adjunct to existing tests to exclude a diagnosis of CP with unexplained abdominal symptoms. Further recruitment to this study will improve the reliability to enable routine use in clinical diagnostic practice. Reference . Iglesias-Garcia Jet al. Quantitative elastography associated with endoscopic ultrasound for the diagnosis of chronic pancreatitis. Endoscopy. 2013;45(10):781–8. Disclosure of Interest None Declared

PWE-156 What is The Prevalence of Chronic Pancreatitis at Post Mortem? A Novel Approach Using “Digital Autopsy”

Introduction The prevalence of exocrine insufficiency in patients with IBS type symptoms does not correlate with post mortem prevalence of chronic pancreatitis (CP) suggesting a failure of early diagnosis. Historical dissection post mortem studies estimate the incidence of chronic pancreatitis to be around 6–12%. “Digital autopsy” computerised tomography (CT) is a non-invasive alternative to conventional post mortem examination. We aimed to evaluate the prevalence of radiological changes of CP with this technique. Methods Consecutive non-contrast post mortem CT scans were reviewed. Simple demographic information was collected (sex, age at death) as well as interval between death and scan. The presence of pancreatic calcification and/or atrophy was noted as radiological indicators of chronic pancreatitis. Main pancreatic duct anatomy was reviewed but smaller ductal changes were not assessed due to lack of intravenous contrast. Results 124 scans were included for assessment (mean age 67.6 years, SD 18.6, 63.8% male). 9 scans were excluded due to inadequate pancreatic views (6 due to decomposition, 3 due to intra-abdominal fluid, lymphadenopathy or artefact). Scans were performed 0–14 days post mortem (median 2 days). 36/115 (32.1%) of those scanned had features of chronic pancreatitis. 20/115 (17.9%) had calcification, 26 (23.2%) had atrophy and 2 (1.8%) main pancreatic duct dilatation. There is a significant difference between average ages of those with (78 years) and without (62 years) radiological evidence of chronic pancreatitis (p < 0.0001) Conclusion This is the first study to report the prevalence of chronic pancreatitis using post mortem CT. The prevalence seems to be higher when compared to conventional autopsy reporting. This could suggest an under diagnosis of early CP in clinical practice. Disclosure of Interest None Declared

PWE-155 Should Patients with Human Immunodeficiency Virus and Gastrointestinal Symptoms be Routinely Tested for Pancreatic Exocrine Insufficiency?

Introduction Diarrhoea and gastrointestinal (GI) symptoms are common symptom in patients with human immunodeficiency virus (HIV). Malabsorption secondary to pancreatic exocrine insufficiency (PEI) has been reported in patients with HIV. Treatment with pancreatic enzyme replacement therapy (PERT) improves symptoms and reduces complications of PEI (malnutrition and osteoporosis). We aimed to calculate the prevalence of PEI in patients with HIV referred to gastroenterology secondary care clinics for persistent GI symptoms. Methods All patients tested for PEI between 2010 and 2014 were identified. Presenting symptoms and presence of HIV were noted. Faecal elastase (FEL-1) was used to assess pancreatic function with FEL-1 <200μg/g defined as abnormal. Co-morbidities, response to PERT and abdominal imaging results were noted. Prevalence of PEI was compared in patients with and without HIV. Patients treated with PERT were identified on follow up and a positive symptom response noted. Results 84 patents were identified during the period. 21 were identified with HIV (mean age 47.5, SD 9.8, 85.7% male). 12/21 (57.1%) HIV patients with GI symptoms had low FEL-1 compared to 8/63 (12.7%) patients with GI symptoms without HIV (p =< 0.0001). The most common presenting GI symptom in patients tested for FEL-1 was diarrhoea, (85.7% in both groups) other symptoms included abdominal pain (HIV 9.5%, non HIV 19.0%), weight loss (HIV 0%, control 9.5%) and bloating (HIV 4.8%, control 6.3%). 10/12 (83.3%) HIV patients with low FEL-1 had abdominal imaging. Pancreatic abnormalities were detected in 2/10 cases (20%). 7/8 (87.5%) controls with low FEL-1 had imaging, 3/7 (42.9%) had pancreatic abnormalities. In both groups pancreatic calcification and atrophy were detected. No malignancy was identified. 9/12 (72.5%) HIV patients and 5/8 (62.5%) controls were treated with PERT. 9/9 (100%) HIV patients reported symptomatic improvement; 4/5 (80%) controls derived benefit. Doses prescribed varied from 60,000–140,000 units/day across both groups. Conclusion Given its significantly high yield and response to treatment FEL-1 should be performed to check for PEI in patients with HIV presenting with gastrointestinal symptoms or weight loss. Disclosure of Interest None Declared

PTU-150 Simplified Barrett’s Radiofrequency Ablation Technique in The Elderly. Consideration Should Be Given to Balancing The Increased Risks with Benefits

Introduction Barrett’s oesophagus (BO) is a major risk factor for the development of oesophageal adenocarcinoma. Radiofrequency ablation (RFA) is an established treatment option in high risk patients with high grade dysplasia (HGD). Recent simplified methods have also been shown to have equivocal treatment success with shorter treatment times. New recommendations to treat patients with low grade dysplasia have been established which will increase numbers of eligible patients. Reduction in procedure duration is attractive to accommodate the increasing referrals, and reduce sedation requirements, especially in the elderly. We aimed to assess the complications and success of simplified RFA technique in consecutive patients undergoing treatment for Barrett’s oesophagus. Methods All patients discharged from simplified RFA treatment course for BO over a 2 year period were identified. Circumferential RFA (c-RFA) or Focal Ultra RFA (u-RFA) was performed with a simplified double application of RFA (12 J/cm) - the device was not removed or cleaned. Simplified Focal RFA (f-RFA) with smaller devices was performed with a (3×15 J/cm no clean) regimen. Strict RFA medication protocol and repeat 3 month follow up was performed for each patient. Patient demographics, success of treatment, withdrawal from treatment and complications were noted. Outcomes were compared in age groups under and over 75 (Fisher’s exact test) to assess if there was a difference in complication rate. Results 36 patients discharged from simplified RFA treatment were identified (11 female; median age 71: range 46–80). 76 treatments were performed in total (22 c-RFA 11 u-RFA and 43 f-RFA). Complete eradication of Barrett’s mucosa was successful in 83.3% (30/36) patients. Median number of treatments was 2 (range 1–6). 1 patient with an incomplete response after 4 treatments was treated twice with a non simplified RFA method but after no further response the patient was discharged from RFA programme. 4/36 patients (11.1%) reported complications which resulted in discharging from programme. Reasons were: prolonged atrial-fibrillation with haemodynamic compromise (2 nd treatment u-RFA); significant oesophageal stricture (c-FRA); hypotensive fall with 7 day admission (u-RFA); prolonged post procedure pain (f-RFA). All complications lead to withdrawal from the RFA programme. 30.7% of patients aged over 75 experienced complications compared to 0% in patients under 75 (p = 0.0121). Conclusion A simplified oesophageal RFA regime is effective to remove BO, however its use in the elderly may be linked with increased complications leading to program withdrawal. Disclosure of Interest None Declared

PWE-208 How common is pancreatic exocrine insufficiency in primary care?

Introduction The prevalence of chronic pancreatitis in post mortem studies is between 6–12%. We previously studied over 1800 all-comers to secondary care gastroenterology and found 14.4% had low faecal elastase-1 (FEL-1) suggestive of exocrine pancreatic insufficiency (EPI). We sought to investigate if there were similar rates in primary care. Method A retrospective analysis of primary care patients tested for EPI between 2009–13 was performed. FEL-1 <200 was considered abnormal. Demographics, indication, co-morbidities and response to Creon were noted. Patients were excluded if the test originated in secondary care. Pancreatic imaging results were noted. Logistic regression helped determine if co morbidity or symptom could predict EPI. Comparisons were made with the secondary care cohort. Results 168 primary care patients and 1887 ssecondary care patients were identified. The mean age in primary care was 59.74 (SD 16.26, 98 female) cf secondary care mean age 51.60 (SD 16.91, 1144 female) p < 0.0001. The most frequent indications to test in primary care were diarrhoea (60.1% 101/168), weight loss (14.9% 25/168) and abdominal pain (13.1% 22/168). In secondary care the most common indications were diarrhoea (68.4% 1252/1887), abdominal pain (20.0% 378/1887) and weight loss (6.6% 125/1887). The overall prevalence of EPI in primary care was 20.2% (FEL-1 <200) and 11.9% (FEL <100). In secondary care the overall prevalence of EPI was 14.4% (FEL-1 <200) and 8.6% (FEL-1 <100). In primary care patients with weight loss, abdominal pain and diarrhoea the rates of FEL-1 <200 were 28.0% (7/25), 18.2% (4/22) and 16.8% (17/101) respectively. 79.4% (27/34) of primary care patients with FEL-1 <200 had abdominal imaging (CT/MRI/USS); pancreatic pathology was detected in 59.6% (16/27). 86.8% of secondary care patients with FEL-1 <200 had imaging; 38.1% (90/236) had pathology (p = 0.04). Weight loss and steatorrhoea were significantly associated with FEL-1 <200 using binary logistic regression (p < 0.05). Diabetes mellitus, coeliac disease and excess alcohol consumption were strongly associated with pancreatic insufficiency (p < 0.05). 76.5% (26/34) patients had documented pancreatic enzyme supplementation, of which 80.7% (21/26) reported symptomatic relief. 7.7% reported no benefit and 11.5% were unable to tell. Conclusion This is the first primary care study reporting a prevalence of exocrine pancreatic insufficiency (20.2%). Primary care physicians are correctly identifying patients for testing presenting with weight loss and steatorrhoea, as well as considering the associations of diabetes, coeliac disease and excess alcohol. Imaging and symptomatic benefit (from Creon) supports their diagnosis in almost 60% and 80% respectively. Disclosure of interest None Declared.