Mark Appleyard

Diagnosis and outcome of small bowel tumors found by capsule endoscopy: a three-center Australian experience.

OBJECTIVE:The objective of the study was to examine diagnosis and outcome in a series of patients with small bowel tumors detected by capsule endoscopy (CE) in three Australian centers.METHODS:Review of prospectively collected data from 416 CEs identified 27 tumors in 26 patients. Clinical parameters, tumor histology, and follow-up are reported.RESULTS:Twenty-seven tumors were identified in 26 patients (mean age 61 ± 13.7 yr). Indications for CE were obscure gastrointestinal (GI) bleeding (21), suspected tumor (3), abdominal pain (1), diarrhea (1). Prior radiology found a possible lesion in 8 of 23 (35%). Nine tumors were proven benign: hamartoma (4), cystic lymphangioma (1), primary amyloid (1), lipoma (1). Two lesions were non-neoplastic: heterotopic gastric mucosa and inflammatory fibroid polyp. Seventeen tumors were malignant: five adenocarcinomas, six carcinoids, two melanoma metastases, two gastrointestinal stromal tumors (GIST), one colon carcinoma metastasis, one non-Hodgkins lymphoma. Tumors were surgically resected in 23 patients. Resection was considered curative in 12 (52%). Mean duration of follow-up was 26 ± 13.7 months. Of the five patients with primary adenocarcinoma only one remains disease free. Three of the six with carcinoid tumors have had no recurrence up to 51 months postresection. Both patients with GIST are disease free. Anemia resolved after surgery in the patients with melanoma.CONCLUSIONS:Small bowel tumors are a significant finding at CE and are often missed by other methods of investigation. In many patients, detection of a tumor alters management and improves outcome. Even in malignant lesions, treatment is potentially curative in the absence of metastatic disease.

Decreased hospital stay and significant cost savings after routine use of prophylactic gastrostomy for high-risk patients with head and neck cancer receiving chemoradiotherapy at a tertiary cancer institution.

Evidence‐based nutritional and swallowing guidelines were developed to identify patients at high risk of developing malnutrition during chemoradiation for head and neck cancer. These guidelines recommended a prophylactic gastrostomy and were actively implemented at our institution in January 2007. This study assesses the effect of this policy change on patient outcomes.

Australian clinical practice guidelines for the diagnosis and management of Barrett's esophagus and early esophageal adenocarcinoma

Barretts esophagus (BE), a common condition, is the only known precursor to esophageal adenocarcinoma (EAC). There is uncertainty about the best way to manage BE as most people with BE never develop EAC and most patients diagnosed with EAC have no preceding diagnosis of BE. Moreover, there have been recent advances in knowledge and practice about the management of BE and early EAC. To aid clinical decision making in this rapidly moving field, Cancer Council Australia convened an expert working party to identify pertinent clinical questions. The questions covered a wide range of topics including endoscopic and histological definitions of BE and early EAC; prevalence, incidence, natural history, and risk factors for BE; and methods for managing BE and early EAC. The latter considered modification of lifestyle factors; screening and surveillance strategies; and medical, endoscopic, and surgical interventions. To answer each question, the working party systematically reviewed the literature and developed a set of recommendations through consensus. Evidence underpinning each recommendation was rated according to quality and applicability.

Non-physician endoscopists: A systematic review

AIM To examine the available evidence on safety, competency and cost-effectiveness of nursing staff providing gastrointestinal (GI) endoscopy services. METHODS The literature was searched for publications reporting nurse endoscopy using several databases and specific search terms. Studies were screened against eligibility criteria and for relevance. Initial searches yielded 74 eligible and relevant articles; 26 of these studies were primary research articles using original datasets relating to the ability of non-physician endoscopists. These publications included a total of 28883 procedures performed by non-physician endoscopists. RESULTS The number of publications in the field of non-specialist gastrointestinal endoscopy reached a peak between 1999 and 2001 and has decreased thereafter. 17/26 studies related to flexible sigmoidoscopies, 5 to upper GI endoscopy and 6 to colonoscopy. All studies were from metropolitan centres with nurses working under strict supervision and guidance by specialist gastroenterologists. Geographic distribution of publications showed the majority of research was conducted in the United States (43%), the United Kingdom (39%) and the Netherlands (7%). Most studies conclude that after appropriate training nurse endoscopists safely perform procedures. However, in relation to endoscopic competency, safety or patient satisfaction, all studies had major methodological limitations. Patients were often not randomized (21/26 studies) and not appropriately controlled. In relation to cost-efficiency, nurse endoscopists were less cost-effective per procedure at year 1 when compared to services provided by physicians, due largely to the increased need for subsequent endoscopies, specialist follow-up and primary care consultations. CONCLUSION Contrary to general beliefs, endoscopic services provided by nurse endoscopists are not more cost effective compared to standard service models and evidence suggests the opposite. Overall significant shortcomings and biases limit the validity and generalizability of studies that have explored safety and quality of services delivered by non-medical endoscopists.

Evidence-based guideline for the written radiology report: Methods, recommendations and implementation challenges

The written radiology report is the dominant method by which radiologists communicate the results of diagnostic and interventional imaging procedures. It has an important impact on decisions about further investigation and management. Its form and content can be influential in reducing harm to patients and mitigating risk for practitioners but varies markedly with little standardisation in practice. Until now, the Royal Australian and New Zealand College of Radiologists has not had a guideline for the written report. International guidelines on this subject are not evidence based and lack description of development methods. The current guideline seeks to improve the quality of the written report by providing evidence‐based recommendations for good practice. The following attributes of the report are addressed by recommendations: Content Clinical information available to the radiologist at the time the report was created Technical details of the procedure Examination quality and limitations Findings (both normal and abnormal) Comparison with previous studies Pathophysiological diagnosis Differential diagnoses Clinical correlation and/or answer to the clinical question Recommendations, particularly for further imaging and other investigations Conclusion/opinion/impression Format Length Format Language Confidence and certainty Clarity Readability Accuracy Communication of discrepancies between an original verbal or written report and the final report Proofreading/editing of own and trainee reports

A systematic analysis of complication rates of colonoscopy in an Australian teaching hospital

Diminutive” colonic polyps are by defi nition polyps that are 5 mm or less in size. Previous studies suggest that such polyps are of low risk for malignancy. However, improvements in optical imaging and image resolution (High Defi nition Endoscopy) coupled with increased operator awareness have resulted in a higher detection rate at colonoscopy. Past studies suggest that high grade dysplasia may occur up to a rate of 4% in these polyps. Methods Patients referred to a single Tertiary Institution for screening colonoscopy after detection of a positive FHH. All patients referred between 2009 and 2010 were included in this retrospective study. The patients were referred either through the National Bowel Cancer Screening Program or through GP initiated screening. Polyps were measured after the tissue was placed in formalin (histological size). For each colonoscopy the predetermined aim was to resect all polyps and to submit them to histological assessment. Results A total of 307 patients were investigated. NBCSP referred (41%) and GP initiated FOBT (59%). Male : Female (1.1:1). 148 (48%) patients showed a total of 258 polyps. 62% of polyps were size <5 mm, 22% were 5–9 mm and 16% were 10 mm or greater. The histological features of the polyps <5 mm were 56% tubular adenomas (TA), 7.5% were TVA and 0.6% were VA. Only 30% of polyps <5 mm were hyperplastic in nature. One TA showed high grade dysplasia (0.6%). No carcinoma was found in polyps <5 mm. A total of 11 (3.6%) carcinomas were identifi ed, 2/11 were in polyps >10 mm size and one in the 5–9 mm size. We also identifi ed the position of the polyp (<5 mm) according to left and right colonic classifi cation. 51% were left sided, 14%were right sided, location not specifi ed in 35%. Conclusion: In patients who are positive for FHH the incidence of diminutive polyps is considerable and importantly there is a signifi cant proportion of adenomatous polyps. Based on these fi ndings we believe that diminutive polyps should be resected and that they be followed up appropriately. Differences in bowel preparation for colonoscopy between ethnic groups S SETHI Bankstown Day Surgery, Sydney Introduction Suboptimal bowel preparation can result in missed lesions, aborted procedures and increases in cost and complication rates. The quality of bowel preparation can vary among patients depending on factors such as age, time of the day when colonoscopy is performed, literacy and inpatient status. There is a paucity of literature about the difference between ethnic groups in the quality of bowel preparation. Differences in literacy, diet and cultural factors may affect bowel preparation. The aim of this study was to determine whether the quality of bowel preparation differs among racial groups. Methods This was a retrospective study looking at 100 patients each undergoing colonoscopy from East Asia (China/Japan/South Korea/ Vietnam/Thailand), the Indian subcontinent (India/Bangladesh/Pakistan), United Kingdom, Southern Europe (Italy/Greece) and Arabic origin patients. Patients were contacted by telephone and classifi ed into an ethnic group. Patient related data was extracted from case notes. All patients were instructed to follow a standardized protocol of bowel preparation involving a low residue diet for 2 days and prep kit C the evening before the procedure. The quality of bowel preparation was graded by the endoscopist during the procedure and classifi ed as excellent, good, average or poor. These were then classifi ed as being either satisfactory (excellent/good) or unsatisfactory (average/poor). All were outpatients in a community day surgery setting and were performed in the morning. Results The groups did not differ signifi cantly in terms of age/sex. SATISFACTORY UNSATISFACTORY UNITED KINGDOM 87% 13% SOUTHERN EUROPE 84% 16% INDIAN SUBCONTINENT 76% 24% ASIAN 83% 17% ARABIC 81% 19% The Indian group had signifi cantly poorer bowel preparation as compared to the United Kingdom Group (p 0.002). There was no statistically signifi cant difference between the other groups. Discussion The poor bowel preparation of the Indian group may be due to factors such as poor English language profi ciency, diet and socioeconomic status. Hence, the Indian group may benefi t from more precise instructions and a more rigorous bowel preparation regime. Future studies should be performed to identify how ethnic factors affect bowel preparation. Journal of Gastroenterology and Hepatology (2011) 26 (Suppl. 4)

Future Perspectives of Small Bowel Capsule Endoscopy

Since the advent of the first swallowable capsule designed to measure internal parameters from the small bowel 50 years ago, enormous advances in the ability to visualize the entire small bowel mucosa using a similar concept of a small swallowable capsule have been made. The incorporation of novel uses of light and other senses will lead to an expanded role for diagnostic capsules, as will the application of nanotechnologies to usher in new therapeutic indications for capsule endoscopy.

Role of double balloon enteroscopy in obscure gastrointestinal bleeding.

EoE and CD by chance is considerably higher (1:10 000). This may, in part, explain the unexpected frequency of patients with both conditions in the case series by Ooi et al. In children, EoE and CD are both food protein-induced and T lymphocyte-mediated diseases. However, from a pathophysiological perspective, there are striking differences between them. CD is thought to be a Th1-mediated and HLA DQ2/DQ8-restricted disorder which aligns with autoimmunity. By contrast, EoE has been shown to be a Th2-mediated disorder, which is closely associated with immunoglobulin E (IgE)and non-IgE-mediated food allergy, as well as eczema, asthma, and inhalant sensitization. Eosinophils are not considered a histological feature in patients with CD, while the presence of large numbers of mucosal eosinophils in the upper and lower esophagus is diagnostic for EoE. In addition, both conditions occur in strictly separated compartments of the gastrointestinal tract: in EoE, abnormalities are limited to the esophagus, while CD affects the small intestine and is not associated with esophageal changes. Based on these differences in pathophysiology and affected gastrointestinal compartments, a causal relationship between EoE and CD appears unlikely. One of the main conditions presenting in early childhood with small intestinal villous atrophy is cow’s milk protein-induced enteropathy. Clinically, this condition may be difficult to distinguish from CD. Given the considerable overlap in symptoms and histological features between CD and cow’s milk protein-induced enteropathy, the unequivocal resolution of symptoms after strict wheat elimination remains part of the core diagnostic criteria for CD in children. If causally related, EoE may also respond to dietary gluten restriction. A recent Italian study suggested at least a partial treatment response after a gluten-free diet in patients with EoE and concomitant CD. However, this case series was uncontrolled and retrospective, so it is possible that seasonal or spontaneous fluctuation in mucosal eosinophil numbers accounted for the apparent improvement on a gluten-free diet. Other case series have found no consistent treatment response to a gluten-free diet in EoE. In summary, although there are fundamental differences in the pathophysiological mechanisms involved in EoE and CD, the observations of Ooi et al. confirm that these conditions may coexist in some children. Both diseases are relatively common, and their coexistence, whether by chance or other yet undiscovered linkage, is more frequent than anticipated. EoE and CD can only be diagnosed by upper gastrointestinal endoscopy and biopsy from the esophagus and duodenum. Provided that these biopsies are routinely obtained, both diagnoses should be reliably recognized. As the natural history of EoE is largely unknown, it is uncertain what proportion of patients with histological EoE is at risk of developing esophageal strictures or dysphagia in the long term. In addition, there is debate whether treatment of EoE should aim for histological resolution or symptomatic control only. Longitudinal studies on the natural history of untreated EoE are called for to help resolve these new therapeutic dilemmas.

The Use of Acetic Acid in Magnification Colonoscopy

The Use of Acetic Acid in Magnification Colonoscopy Kazutomo Togashi, David G. Hewett, David A. Whitaker, Georgia E. Hume, Leo Francis, Mark N. Appleyard Background: Staining dyes can provide a clear image in magnification colonoscopy, but not instantly. Indigocarmine (IC) shows contrast effect instantly, but this effect is not as reliable as the staining dyes. Acetic acid (AA) is cheap, easily available and safe. AA has been used in the evaluation of cervical and oesophageal mucosa, but its use has not been evaluated in magnification colonoscopy. The aim of this study was to evaluate the role of AA dye spray during magnification colonoscopy alone and in combination with IC dye. Methods: In one institution, 46 patients (F22, M24; age 56617) entered into a prospective study of magnification colonoscopy, performed by a single endoscopist. The 46 consecutive patients were divided alternately into 2 groups; A (n=23) andB (n=23). InGroup A, 1.5%AAwas initially sprayed on to all detected lesions, followed by spray with 0.2% IC. In Group B, the order was reversed, with IC preceding AA. Pit pattern image was assessed in real time after the spraying of each consecutive dye. Pit patterns were evaluated based upon Kudo’s classification. The time required to obtain a clear image after the first dye spray wasmeasured. The effect of the second dye was evaluated based upon whether the pit pattern image following additional dye spray was clearer than that after the first dye alone. Results: 37 adenomas (AD), 36 hyperplastic polyps (HP), 5 normalmucosa, 4 inflammatory polyps and 1 serrated adenoma were detected. The 73 lesions comprised of AD and HP alone were subjected to further analysis. In group A, 20 AD and 23 HP were detected, and accuracies after AA spray were 95% with AD and 96% with HP. After subsequent IC spray, 37% showed enhanced images, and accuracies increased to 100% in AD and 97% in HP. In group B, 17 AD and 13 HP were detected, and accuracies after IC spray were 76% with AD and 92% with HP. After subsequent AA spray, images were enhanced in 70%with increases in accuracy to 94% in AD and 100% in HP. In both groups, the mean time required to obtain an initial clear image was 14 seconds. Conclusion: The use of AA spray instantly improves pit pattern image during magnification chromo-colonoscopy and improves the accuracy of histological prediction of colorectal polyps. This method could be easily applied to routine magnification colonoscopy. **267 Prevalence and Characteristics of Flat and Depressed Colorectal Neoplasms in a Western Population: A Prospective Study by a Japanese Trained Endoscopist Noriko Suzuki, Nicola C. Palmer, Brian P. Saunders Background: Flat and depressed colorectal neoplasms have been widely investigated in Japan and recently inWestern countries with incidence rate of 6.8%48.5%. This wide variation reflects differences in population characteristics or colonoscopic technique. The aim of this study was to determine the prevalence of flat neoplasms in a UK population by a colonoscopist trained in Japan. Methods: A prospective analysis of 1000 consecutive colonoscopies was performed. Macroscopically the lesions were classified according to the classification described by Japanese Society for Cancer of the Colon and Rectum and histological diagnosis was made based on WHO system. Result: Total colonoscopy (adjusted) was achieved in 98% of patients. Indications for colonoscopy were: neoplasia surveillance (211), change in bowel habit (179), bleeding (160), assessment of IBD (141), family history of colorectal neoplasms (106), anaemia (86), and others (117). In total 1075 polyps were found in 412 patients, which includes 25 cases of advanced cancer. 758 polyps were histologically proven to be neoplastic. Of these, 617 were classified as polypoid (81%) and 141 flat (IIa, IIb, IIc)(19%). A higher incidence of advanced pathology (severe dysplasia or Dukes’A adenocarcinoma) was observed in flat and depressed neoplasms (0% in IIa, 14% in IIb,IIc) than in polypoid ones (2%). Conclusion: A Japanese trained endoscopist found flat neoplasms represented 19 % of all adenomas (flat/ depressed 3% in a western population. Flat elevated (IIa) and polypoid lesions appeared to have similar characteristics, while flat (IIb) or depressed lesions (IIc) contain more advanced pathology. Flat and depressed neoplasms are rare finding but exist in a Western population.

The incidence of 30-day adverse events after colonoscopy in an IBD population

Background: Perianal fistulae are a common complication of Crohns disease (CD), affecting up to 23% of patients during their lifetime. Fistulae are associated with significant symptoms and lead to poor quality of life. Clinical trials have shown anti-tumour necrosis alpha antibodies (infliximab or adalimumab, and anti-TNF-α) can improve the medical outcomes of perianal fistulae. Aims: We aimed to describe the real-world experience of patients who are prescribed anti-TNF-α for CD with perianal fistulae at a quaternary referral centre. Using a prospectively maintained database, we selected patients who were prescribed anti-TNF-α for perianal fistulae associated with CD. We utilised the electronic medical record to retrospectively review the charts and recorded demographics, Vienna classification, number of fistulae and symptoms (pain and discharge), complexity of fistulae, use of medications and the number of examinations under anaesthetic (EUA). These clinical details were recorded every 6 months until end of follow up. Results: Forty-one patients met inclusion criteria, with median follow up of 16.5 months (range 1–57months). The median age was 32 years (range 20–60), 19 were male. The median number of fistulae at baseline was 1 (range 1–3), and 23 (56%) patients had transphincteric fistulae at baseline. Twenty-two patients were prescribed infliximab (54%), and 19 (46%) were prescribed adalimumab. Twenty-nine patients (71%) were prescribed thiopurines, and 26 (63%) were prescribed antibiotics at any time during their follow up. Thirty patients had an EUA (73%) during follow up with a median of 2 EUAs per patient. Nineteen (46%) patients were prescribed an anti-TNF-α, thiopurines and antibiotics during their follow up (triple therapy), of which 15 (36.7%) also had an EUA (quadruple therapy). At end of follow up, 46% of patients were asymptomatic (absence of pain or discharge), and 5% had complete healing (documentation of their tracts being closed). The mean number of fistulae seen at baseline was 1.48; for patients where follow up was obtained beyond 24months, the mean number of fistulae was 1.06. The number of symptomatic patients declined with increasing duration of anti-TNF-α therapy (60.4% of visits seen in 1st 6 months, 40.8% at 24months). The composite end point of healing/symptom resolution was not associated with any clinical parameter on univariate analysis. Summary: This review of CD patients with perianal fistulae, who were prescribed an anti-TNF-α at a quaternary referral institution, shows that prolonged therapy with anti-TNF-α improves symptoms, but complete healing was rare. Multimodality treatment was only used in one third of patients, raising the possibility that increased use of combined therapy may improve outcomes.