Nerukav V. Radhakrishnan

Competency based medical education in gastrointestinal motility-the UK perspective

Dear Editors, We read the article by Yadlapati et al.1 with interest and strongly agree with the authors on the need to introduce competency based medical education (CBME) in gastrointestinal motility diagnostics. In North America, minimum standards in the GI fellowship core curriculum and the ANMS clinical training programme for select trainees have at least ensured that most fellows have the opportunity to observe and interpret motility studies during training.2,3 By contrast in the UK, where the core Gastroenterology training curriculum lacks minimum standards in GI motility, training opportunities appear to be virtually nonexistent and trainees have reported a worrying lack of basic knowledge such as the indications for commonly requested investigations.4 Consistent with the observations of the authors,1 data from a large national survey among GI clinicians and Physiologists in the UK and Ireland5 has identified deficiencies in knowledge,6 a marked variation in practice and quality in GI motility services, further highlighting the implications of the current lack of CBME. The UK survey of 313 respondents representing 98 motility labs has shown that GI clinician input in motility study reporting is infrequent and that therapeutic recommendations are provided by fewer than half of those who report studies.5 The most common reasons for not providing therapeutic recommendations included respondents not feeling ‘qualified’ or that there was ‘no subspecialty clinician’.5 Furthermore, only 4% of 163 nonspecialist GI clinicians surveyed are able to interpret motility study data themselves.5 Provision of therapeutic recommendations from diagnostic tests should be a standard of care and these data highlight an acute need for improved core training in motility investigations for Gastroenterologists and an alternative advanced subspecialty training pathway. In terms of ensuring competency, one successful example of CBME in Gastroenterology that we can learn from is the successful introduction of a national online webbased portfolio system for UK endoscopy training which uses workplace based assessments including standardized direct observation of procedural skills (DOPs).7 This system has also proven to be a resource in terms of understanding trainee learning curves for achieving competency.8 Interestingly, the UK Scientist Training Programme for GI physiologists already uses online assessment tools which include DOPs for GI motility procedures.9 Direct observation of procedural skills with internationally agreed standards could potentially be introduced alongside the novel webbased learning methods described by Yadlapati et al.1 in a portfolio system to deliver much needed CBME in this field. ACKNOWLEDGMENTS

Integrated low-intensity biofeedback therapy in fecal incontinence: evidence that "good" in-home anal sphincter exercise practice makes perfect.

Biofeedback therapy (BFT) is an established treatment for fecal incontinence (FI), with access often being restricted to tertiary centers due to resources and the perceived requirement for high‐intensity regimes. However, the optimal regime remains unknown. We evaluated outcomes from our low‐intensity integrated BFT program in a secondary care center.

Mesenteric ischaemic occurring in conjuction with acalculous cholecystitis: a case report

BackgroundThe incidence of mesenteric ischaemia is rising possibly due to increasing awareness and early diagnostic tools available. However it remains a challenging diagnosis especially in the elderly population.Case reportWe report an unusual case of acute mesenteric ischaemia in an elderly lady occurring in conjunction with acalculous cholecystitis. A 71 year old woman was referred to our hospital with abdominal pain, vomiting, diarrhoea and pyrexia. An initial ultrasound scan of the abdomen revealed acute acalculous cholecystitis.ConclusionShe failed to respond to medical treatment and further investigations revealed concurrent mesenteric ischaemia.

Biofeedback Therapy Improves Continence in Quiescent Inflammatory Bowel Disease Patients with Ano-Rectal Dysfunction

Introduction: Despite optimal disease control and absence of objective markers of mucosal inflammation, fecal incontinence (FI) secondary to anorectal dysfunction is common, difficult to treat and significantly reduces quality of life (QoL) in quiescent Inflammatory Bowel Disease (IBD). Whilst biofeedback therapy (BFT) is an established treatment for FI, its role in IBD patients with anorectal dysfunction has not been explored. Methods: Retrospectively we reviewed all IBD cases referred for ano-rectal manometry (ARM) and BFT at our institution between 2009-2014. For each patient, data confirming IBD quiescence (endoscopic, histology, radiography and biochemistry), IBD phenotypes, medication, surgical and obstetric histories, baseline FI frequency, QoL scores (rated 0-10) and results of anorectal investigations were recorded. Patients were classified as responders or non-responders to BFT based on symptoms at follow-up. Results: Nine quiescent IBD patients (6/9 crohn’s and 3/9 ulcerative colitis, median age 53, 7/9 females), with baseline median FI frequency 11.5/week and QoL score 6, had BFT following ARM. Manometrically, all had external anal sphincter weakness, 6/9 internal anal sphincter weakness, 2/9 with co-existing dyssynergic defecation and 8/9 had rectal hypersensitivity. Following a median 2 BFT sessions; 8/9 (89%) patients improved with reduced FI frequency (U=0.5, P=0.003) and 5/9 (56%) became fully continent. Conclusions: BFT appears to be just as effective for FI in IBD patients as it is in non-IBD populations and may have a role in restoring continence and QoL. This data highlights the importance of anorectal physiology studies in symptomatic patients once active inflammation is excluded.

PTU-121 Anorectal Dysfunction in Quiescent Inflammatory Bowel Disease: Is There A Role for Biofeedback Therapy?

Introduction Despite optimal disease control and the absence of objective evidence of mucosal inflammation, symptoms of faecal incontinence (FI), increased stool frequency, urgency and tenesmus secondary to anorectal dysfunction can significantly reduce quality of life (QoL) in Inflammatory Bowel Disease (IBD) patients. Biofeedback therapy (BFT) is an established treatment for FI but its role in IBD patients with Anorectal dysfunction has not been explored. Methods In a retrospective study, we reviewed all patients with IBD referred for Anorectal Manometry (ARM) studies and BFT at our institution between 2009–2014 for FI.1 Data confirming IBD quiescence was recorded with endoscopy, histology, radiography and biochemistry from all subjects. Additionally, IBD phenotypes and therapies, surgical and obstetric histories, baseline FI frequency, QoL scores (rated 0–10), ARM data and Endoanal Ultrasonography results (when available) were recorded. Patients were classified as responders or non-responders to BFT based on symptoms at follow-up. Results Nine IBD patients (median age 53, 7/9 female), with quiescent IBD (6/9 Crohn’s Disease (CD) and 3/9 Ulcerative Colitis (UC)), median baseline FI frequency 11.5/week and QoL score 6, completed in our Gastroenterologist-led BFT programme. In the CD cohort; 1/6 had previous anal fistula repair, 2/6 previous right hemicolectomy with ileal resection and 3/6 crohns colitis. In the UC group; 2/3 patients had proctitis/proctosigmoiditis and the other patient had ileo-anal pouch post-panproctocolectomy. Based on ARM findings; All patients had external sphincter weakness 9/9, whilst 6/9 had internal anal sphincter weakness and 2/9 met criteria for co-existing dyssynergic defecation. Following a mean of 3 BFT sessions; 8/9 (89%) patients reported improvement in FI symptoms with statistically significant improvement in FI frequency compared to baseline (Mann-Whitney U = 0.5, P = 0.003) and 5/9 (56%) reporting no FI episodes. Conclusion Our data in a heterogenous cohort of IBD patients with moderate QoL scores and FI despite disease quiescence, highlights the importance of considering referral for ARM studies after excluding active inflammation. BFT appears to be as effective in IBD patients as it is in non-IBD patients with FI and may have a role in improving QoL in these patients. Reference 1 Vasant D, Solanki K, Sharma R, et al. Ptu-180 predicting outcomes of biofeedback therapy for faecal incontinence – where ‘good’ practice makes perfect. Gut 2015;64:A142. Disclosure of Interest None Declared

PTU-180 Predicting outcomes of biofeedback therapy for faecal incontinence – where ‘good’ practice makes perfect

Introduction Biofeedback therapy is known to be effective in Faecal Incontinence (FI) with reported success rates of around 70%. However, virtually all available data is from tertiary centres. We aimed to evaluate our biofeedback programme based on the Iowa protocol1within the constraints of a District General Hospital (DGH) and determine predictive factors for successful outcomes. Method We retrospectively reviewed 199 FI patients (mean age 62 ± 1 years, 72% female) enrolled in our Gastroenterologist-led biofeedback programme between 2009–2014. Baseline symptoms, QOL scores, co-morbidities and investigations including lower GI endoscopy (91%) were noted in addition to anorectal manometry findings. Anorectal sphincter technique was graded (good, fair or poor) at each session. Based on symptoms during the last session, patients were classified as responders (complete or partial) or non-responders. The 2 groups were compared statistically for factors including; demographics, symptoms, pelvic dyssynergia, manometry data, sphincter exercises technique/practice and the number and frequency of biofeedback sessions. Data are expressed as the mean (± SEM) unless stated otherwise. P values ≤0.05 were deemed statistically significant. Results All 199 patients had auditable outcome measures despite 5% having ongoing therapy and 23% drop out. Patients attended a mean 4 (± 0.1) biofeedback sessions with an interval of 69 (±3) days between visits. Neurotrac stimulator was used adjunctively in 12% of cases. Overall, 148/199 (74%) responded (complete n = 100, partial n = 48) with marked reduction in FI frequency (median before 7/week vs. post-treatment 0.25/week, U = 20,425, P < 0.0001). Whilst male gender was associated with poorer outcome (Chi2= 5.4, P = 0.02), documented ‘good’ sphincter exercise technique (Chi2= 9.3, P = 0.002) and longer weekly durations of sphincter exercises at home (df = 66.3, P = 0.01) were associated with favourable outcomes. By contrast, age, symptoms, QOL, physical/sexual abuse, depression, lateral sphincterotomy, resting and squeeze pressures, rectal sensitivity, dyssynergia, number and frequency of biofeedback sessions were not associated with outcomes. Conclusion To the best of our knowledge this is the largest series from a DGH in the UK. Despite less intensive follow-up schedules we were able to achieve comparable outcomes to studies reported elsewhere with bi-weekly induction followed by periodic reinforcements suggesting our physician-led approach may be just as effective. Our data reinforces the importance of sphincter exercise technique, training and patient self-practice at home, which along with female gender appear to be predictive factors in successful outcomes. Disclosure of interest None Declared. Reference Ozturk, et al .APT2004;20(6):667–74