Noor Mohammed

Modern management of acute non-variceal upper gastrointestinal bleeding

An acute upper gastrointestinal bleed (AUGIB) often represents a life-threatening event and is recognised universally as a common cause of emergency hospitalisation. Large observational studies have improved our understanding of the disease characteristics and its impact on mortality but despite significant advancement in endoscopic management, mortality remains high, particularly in elderly patients and those with multiple comorbidities. Skilled assessment, risk stratification and prompt resuscitation are essential parts of patient care, with endoscopy playing a key role in the definitive management. A successful outcome partly relies on the clinicians familiarity with current guidelines and recommendations, including the National Institute for Clinical Excellence guidelines published in 2012. Validated risk stratification scores, such as the Blatchford and Rockall score, facilitate early discharge of low-risk patients as well as help in identifying those needing early endoscopic intervention. Major advances in therapeutic endoscopy, including more recently, the development of non-toxic proprietary powders (Hemospray and EndoClot), have resulted in the development of effective treatments of bleeding lesions, reduction in rebleeding rates and the need for emergency surgery. The role of proton-pump inhibitor therapy prior to endoscopy and the level of optimum red cell transfusion in the setting of AUGIB remain fields that require further research.

Endoscopic biliary stenting in irretrievable common bile duct stones: stent exchange or expectant management—tertiary-centre experience and systematic review

Introduction Conventional endoscopic duct clearance may not be possible in up to 10%–15% of common bile duct stones (CBDS). Sphincterotomy and biliary drainage by endoprosthesis have for many years been the mainstay of management in irretrievable stones. Recent years have seen the advent of sphincteroplasty or cholangioscopically-guided electrohydraulic lithotripsy (EHL) permitting duct clearance in majority of cases. However, when bile duct clearance is not possible, options include long-term stenting followed by elective stent exchange (ESE) 6–12 monthly or permanent stent insertion (PSI) in selected cases, but it is not clear which management strategy among ESE and PSI is preferable. Methods and aims A retrospective review of all patients in Leeds Teaching Hospitals NHS Trust who underwent plastic stent insertion for biliary access for difficult CBDS from January 2006 to December 2011 was undertaken. Adult patients with irretrievable CBDS who had plastic stent insertions throughout the follow-up period were included. Patients who underwent PSI and ESE annually were retrospectively reviewed to determine the long-term outcomes. A detailed systematic review was also performed, examining the outcomes of CBDS managed with stents. Results During the study period, 674 patients underwent 1769 biliary-stent-related procedures; of which, 246 patients met our inclusion criteria. 201 patients had subsequent duct clearance. 45 patients were, therefore, included in the final analysis, 28 of whom underwent annual ESEs and 17 PSIs. Patients in the PSI group had higher American Society of Anesthesiologists (ASA) scores compared with the ESE group. In the PSI group, 9/17 patients presented acutely with blocked stents, 5 of whom presented within 12u2005months. 2/9 patients were severely ill and died within a fortnight following the repeat endoscopic retrograde cholangiopancreatography (ERCP). In the ESE group, 4/28 patients had duct clearance in subsequent ERCPs, 1/28 patient presented with a blocked stent, and no biliary-related deaths were observed. The mean numbers of ERCPs performed were 0.52 and 1.95 in the PSI and ESE groups, respectively. Conclusions Over 50% of patients treated with long-term stenting re-presented acutely with stent blockage, though many of these were before 12u2005months, meaning planned stent exchange would not have affected the outcome. Duct clearance using all possible modalities is the preferred option, but where not possible, management with biliary stenting either with elective exchange or permanent stenting remains a possibility for carefully selected patients, though maybe best suited to those with limited life expectancy.

Cholecysto-duodenal fistula as the source of upper gastrointestinal bleeding.

A 44-year-old woman was admitted with recurrent hematemesis. She had a history of intermittent upper abdominal pain, which was investigated by computed tomography (CT) scan 1 year prior to the presentation (● Fig.1). She was taking aspirin for ischemic heart disease. On examination, her heart rate was 110bpm and she had postural hypotension. She was febrile (38.7°C) and had epigastric tenderness. Blood results were abnormal: white blood cells 17.0×103 cells/ μL, C-reactive protein 136mg/L, and alkaline phosphatase 515IU/L (normal range 70–300IU/L). Glasgow–Blatchford and Rockall scores were elevated at 11 and 8, respectively. Findings at gastrointestinal endoscopy and CT scan are shown in ● Fig.2 and● Fig.3. Biliary-enteric fistula (BEF) is a rare cause of upper gastrointestinal bleeding. Cholecysto-duodenal fistula (CDF) is the commonest type of BEF [1]. The common causes of CDF include gallstones, peptic ulcer disease, malignancy, and trauma/ surgery. Definitive management is cholecystectomy, resection of the fistula, and intraoperative cholangiography.Diagnosis is made by CT, endoscopic retrograde cholangiopancreatography, or laparoscopic cholecystectomy [2]. Proximal CDFs located in the posterior wall of the duodenal bulb are usually secondary to peptic ulcer disease whereas distal CDFs, which are located in the periampullary region, connect to the distal 2cm of the bile duct and are more commonly associated with biliary stones [3]. Our patient had symptoms of biliary colic and had gallbladder calculi on initial CT scan. She had recurrent hematemesis during episodes of cholangitis. She was treated conservatively with antibiotics and underwent successful elective open cholecystectomy with repair of the CDF. BEFs involving the duodenal bulb secondary to cholelithiasis are uncommon. CT allows visualization of the fistulas, air in the bile duct, and contraction of the gallbladder, and differentiates between cholecysto-enteric and choledocho-enteric fistulas [4]. We believe that this case highlights the importance of CT imaging in patients with upper gastrointestinal bleeding and unusual endoscopic findings. Fig.1 Coronal portal phase computed tomography image demonstrating low attenuation gallstones (arrow) in a normal gallbladder.

Colonic lesion characterization in inflammatory bowel disease: A systematic review and meta-analysis

AIM To perform a systematic review and meta-analysis for the diagnostic accuracy of in vivo lesion characterization in colonic inflammatory bowel disease (IBD), using optical imaging techniques, including virtual chromoendoscopy (VCE), dye-based chromoendoscopy (DBC), magnification endoscopy and confocal laser endomicroscopy (CLE). METHODS We searched Medline, Embase and the Cochrane library. We performed a bivariate meta-analysis to calculate the pooled estimate sensitivities, specificities, positive and negative likelihood ratios (+LHR, -LHR), diagnostic odds ratios (DOR), and area under the SROC curve (AUSROC) for each technology group. A subgroup analysis was performed to investigate differences in real-time non-magnified Kudo pit patterns (with VCE and DBC) and real-time CLE. RESULTS We included 22 studies [1491 patients; 4674 polyps, of which 539 (11.5%) were neoplastic]. Real-time CLE had a pooled sensitivity of 91% (95%CI: 66%-98%), specificity of 97% (95%CI: 94%-98%), and an AUSROC of 0.98 (95%CI: 0.97-0.99). Magnification endoscopy had a pooled sensitivity of 90% (95%CI: 77%-96%) and specificity of 87% (95%CI: 81%-91%). VCE had a pooled sensitivity of 86% (95%CI: 62%-95%) and specificity of 87% (95%CI: 72%-95%). DBC had a pooled sensitivity of 67% (95%CI: 44%-84%) and specificity of 86% (95%CI: 72%-94%). CONCLUSION Real-time CLE is a highly accurate technology for differentiating neoplastic from non-neoplastic lesions in patients with colonic IBD. However, most CLE studies were performed by single expert users within tertiary centres, potentially confounding these results.

Patient education interventions for optimizing bowel cleansing before colonoscopy: is the juice worth the squeeze?

Worldwide, colorectal cancer (CRC) is the third most common cancer and the fourth most common cause of cancer deaths 1. Although treatments for CRC have advanced over the past decade, they have translated into only a modest benefit for patients who have advanced and metastatic CRC, and with significantly increased treatment costs 2. The aim of national screening programs is to reduce the burden of CRC in the population. Screening for CRC with colonoscopy has been shown to be cost-effective in detecting and removing adenomas, which are the clinical precursors of CRC, and several large studies have demonstrated that high quality colonoscopy can improve outcomes with a substantial reduction in CRC rates 3 4. However, the detection of precursor lesions and early CRC depends on a number of factors, including adequate bowel preparation, and studies have shown that inadequate bowel cleansing increases the risk that flat adenomas and other high risk lesions will remain undetected 5 6. n nThe reasons for not adhering to bowel-cleansing instructions before colonoscopy are likely to be multifactorial; both patient-related factors (e.u200ag., limited mobility, language barriers, illiteracy) and factors related to the bowel-cleansing agent itself (e.u200ag., unpalatability, the large volume that must be consumed, side effects such as nausea and headache) are worth considering. Patient educational interventions are thought to result in an improved quality of bowel preparation, and in practice they should result in increased rates of adenoma detection. n nIn this month’s issue, a meta-analysis by Chang et al. summarizes the outcomes of patients who receive educational intervention compared with the outcomes of those who receive no intervention in regard to the quality of bowel preparation and the polyp detection rate. Nine randomized controlled trials (RCTs) enrolling 2885 patients were included in the meta-analysis. The educational interventions used were pamphlets, booklets, videos, questionnaires, and visual aids in seven studies, and mobile phone messages and telephone consultations in the remaining two studies. The authors reported an overall significant improvement in the quality of bowel preparation in patients who received educational intervention compared with those who did not, irrespective of whether the intervention was conducted directly by health professionals (RRu200a=u200a1.19; 95u200a%CI 1.08u200a–u200a1.32) or consisted of self-directed learning with provided materials (RRu200a=u200a1.22; 95u200a%CI 1.05u200a–u200a1.42). Perhaps disappointingly, the improvement in the quality of bowel preparation did not translate into a significant improvement in the polyp detection rate, although only three of the nine studies reported this particular outcome, and as the authors state, the data were insufficient to allow any meaningful conclusions for this outcome to be drawn. Furthermore, the polyp detection rate is likely to depend on other factors not assessed in these studies, such as withdrawal time and colonoscopist experience. A limitation of this meta-analysis was that the scales used to assess the quality of bowel preparation, the types of bowel purgative, and the timing of administration (single vs. split dose) differed among the included studies, resulting in significant heterogeneity. n nEducational intervention to ensure adequate bowel cleansing before colonoscopy is likely to be most beneficial in a small but significant subset of “high risk” patients, and identifying these patients and tailoring the intervention to their individual needs remains the challenge. One size does not fit all! The use of electronic media, such as smartphone applications and interactive online educational material, is attractive. However, simple interventions, such as face-to-face consultations to overcome language and educational barriers in high risk patients, may be just as important.

Giant gastric ulcers: Malignancy yield and predictors from a 10-year retrospective single centre cohort:

Background and study aims Gastric cancer is known to reside in some gastric ulcers but what predicts this association is still unclear. Historically it has been thought that the increasing size of gastric ulcers may be a predictor for harbouring malignancy. Giant gastric ulcers are arbitrarily defined as ≥3u2009cm. The aim of this retrospective study was to examine patients with giant gastric ulcers within a single tertiary centre over a 10-year period. Our primary outcomes included the malignancy yield in giant gastric ulcers and to determine if any demographic, clinical or endoscopic predictors for malignancy exist. Secondary outcomes included the 30-day and 12-month mortality. Method Patients with giant gastric ulcers ≥3u2009cm presenting from September 2005 to December 2015 were included in the study. Malignancy yield was obtained by looking at histology reports. Predictors for malignancy were tested using binary logistic regression, after demographic, clinical and endoscopic variables were tested using univariate analysis and for collinearity. Results A cohort of 111 patients was included for the final analysis. Forty-two giant gastric ulcers were malignant, equating to a yield of 37.8% (95% CI 28.8–46.8). Binary logistic regression revealed predictors for malignancy included: ulcer location being within the fundus, cardia or incisura (odds ratio (OR) 4.417; 95% CI 1.10–17.76; Pu2009=u20090.036); younger age of patient (OR 0.202; 95% CI 0.06–0.71; Pu2009=u20090.013); and endoscopic ‘non-suspicion’ (OR 0.138; 95% CI 0.049–0.39; Pu2009<u20090.001). Patients 12-month mortality for giant gastric ulcer was 61.9% (26/42) for malignant and 21.9% (11/73) for benign histology. Conclusion We have shown a high malignancy yield of 37.8% (95% CI 28.8–46.8) and a 12-month mortality of 61.9% for malignant giant gastric ulcers and 21.9% for benign giant gastric ulcers. Predictors for malignancy in patients with giant gastric ulcers include ulcer location, patients age and endoscopists ‘suspicion’ during endoscopy.

Risk stratification of colorectal polyps for predicting residual or recurring adenoma using the Size/Morphology/Site/Access score:

Background and Aims Endoscopic mucosal resection is an effective and safe procedure to manage large non-pedunculated colonic polyps for which residual/recurrent adenoma is the main drawback. Size/Morphology/Site/Access score determines polypectomy difficulty. We aimed to describe residual/recurrent adenoma rate according to Size/Morphology/Site/Access and to select the ize/Morphology/Site/Access cut-off to predict low residual/recurrent adenoma. Methods This was a retrospective cohort study of endoscopic mucosal resection for large non-pedunculated colonic polyps performed in a tertiary centre. Results Three hundred and sixteen procedures were included. The mean size of lesions was 34.5u2009±u200917.1u2009mm, 59.5% were sessile, 60.4% were in the right colon and in 17.7% (nu2009=u200956) the access was difficult. Of the lesions, 83.6% were Size/Morphology/Site/Access 3–4. Residual/recurrent adenoma at first and second follow-up was significantly lower in Size/Morphology/Site/Access 2 (1.9% and 0.0%, respectively) when compared to Size/Morphology/Site/Access 3 (18.2%, pu2009=u20090.004 and 6.7%, pu2009=u20090.049) and Size/Morphology/Site/Access 4 (30.8%, pu2009<u20090.001 and 22.7%, pu2009=u20090.030). The negative predictive value of Size/Morphology/Site/Access 2 for residual/recurrent adenoma at second follow-up was 86.1%. On multivariate analyses, Size/Morphology/Site/Access 3–4 predicted residual/recurrent adenoma at first (odds ratio 11.96, 95% confidence interval 1.57–91.13) and second follow-up (odds ratio 2.47, 95% confidence interval 1.51–4.22) and had higher cumulative incidence of residual/recurrent adenoma compared to Size/Morphology/Site/Access 2 (pu2009≤u20090.003). Conclusion Use of the Size/Morphology/Site/Access score allows cases to be identified with a low risk of residual/recurrent adenoma.

PWE-035 HDCE using 0.03% versus 0.2% indigocarmine for detecting dysplasia in IBD colitis surveillance. RCT interim-analysis

Introduction Patients with ulcerative colitis (UC) and Crohn’s colitis are known to have an increased risk of colorectal cancer compared with that of the background population. The recent SCENIC consensus statement endorses high definition chromoendoscopy (HDCE) with targeted biopsies for dysplasia detection but required more evidence regarding optimal dye concentrations and mode of delivery. No trials have previously studied this. Our aim was to compare 0.2% indigo carmine (IC) using a spray catheter with that of 0.03% IC via a foot pump, for dysplasia detection in patients undergoing surveillance in IBD colitis. Method A parallel group randomised controlled trial (ClinicalTrials.gov ID: NCT03250780) in which patients undergoing surveillance endoscopy for IBD colitis were randomised into either HDCE using 0.2% IC using a spray catheter or HDCE using 0.03% IC via a foot pump. HD scopes (Olympus CF-HQ290L) and processors (Elite CV 290) were used. Two expert GI histopathologists confirmed presence of dysplasia. Time of withdrawal and ampoules of IC were also recorded. Results There were 75 patients in each arm (total n=150). Baseline characteristics including colitis phenotype, disease duration, BSG risk category, number of biopsies, concomitant PSC and previous dysplasia were similar in both arms. Dysplasia within the colitic area was found in 12 patients (16.0%) in the 0.2% IC group and 13 patients (17.3%) within the 0.03% IC group, p=0.666 (table 1). Withdrawal was significantly (p<0.001) quicker in the 0.03% IC group (16.36±5.92, 95%u2009CI 14.9–17.7) than in the 0.2% IC group (21.23±6.69, 95%u2009CI 19.7–22.8). The 0.03% IC group used significantly less IC ampoules (2, IQR 2–3) compared with 0.2% IC group (5, IQR 4–5.25), p<0.001. Dysplasia on random biopsies only, was found in 3.3% (n=5) of the cohort. Univariate analysis for dysplasia on random biopsies showed association with BSG high-risk category group (p<0.001), concomitant PSC (p=0.033) and having previous dysplasia (p<0.001). Conclusion There is no significant difference in dysplasia detection between 0.2% and 0.03% IC concentration. 0.03% IC seems to be on average 5u2009min quicker and uses less ampoules of IC. There maybe still a place for random biopsies in patients defined by the BSG as high-risk.Abstract PWE-035 Table 1 0.2 % (n= 75) 0.03 % (n= 75) P value Per patient analysis Number of patients with dysplasia detected within colitic area 12 13 .666 Number of patients with dysplastic lesions detected within colitic segment 10 (13.3%) 10 (13.3%) .265 Number of patients with dysplasia detected on random biopsies 3 6 .494 Per lesion analysis Total number of dysplastic lesions within colitic segment detected 12 13 .943 Mean withdrawal time 21.23±6.69 16.36±5.92 < 0.001

PTH-017 Optical characterisation of lesions in ibd colitis: a systematic review and meta-analysis

Introduction Optical imaging is increasingly advocated for characterisation of polyps during colonoscopy. Accuracy of these techniques during surveillance colonoscopy in colonic inflammatory bowel disease (IBD-C) is unclear, with variable results reported. We performed a systematic review and meta-analysis of the diagnostic accuracy of optical imaging techniques including dye-based chromoendoscopy (DCE), virtual chromoendoscopy (VCE), magnification endoscopy and confocal laser endomicroscopy (CLE). Method We searched Medline and Embase for relevant papers. Full articles or abstracts were eligible when characterisation performance of DCE, VCE (narrow-band imaging [NBI], i-scan, Fujinon intelligent chromoendoscopy [FICE]), magnification endoscopy and CLE had been compared with histopathology, as the reference standard. Enough information had to be required to obtain 2 × 2u2009contingency table. Pooled analysis was done using random-effects model. Sub-group analysis was performed at real-time (RT) Kudo pit pattern based and real-time (RT) CLE for characterisation of visible lesions. Heterogeneity was assessed using X2 and I2 statistics. Results Our search stratergy identified 172 studies of which 20 met the inclusion criteria. Pooled results are outlined in the table. Conclusion Real-time CLE and magnification endoscopy had best performance characteristics. However there is a lot of herterogeneity in the results. Most CLE and magnification studies were single centre, single expert user which could explain the results. CLE studies were also affected by attrition bias with some studies reporting non-interpretable images in a significant proportion. Disclosure of Interest None Declared

PTH-045a The Accuracy of Wavstat Version 4 Optical Biopsy Forceps in Characterising Colorectal Polyps Less 10 MM: A Prospective Blinded Study: Abstract PTH-045a Table 1

Introduction WavSTAT version 4 is an optical biopsy system designed for prediction of histology based on laser induced autofluorescence spectroscopy. The primary aim of this study was to demonstrate the accuracy of WavSTAT4 in characterising colorectal polyps <10 mm. The secondary aim was to compare the real time diagnostic performance of WavSTAT4 with NBI and a combination of endoscopic and WavSTAT assessments.Abstract PTH-045a Table 1 Diagnostic performance of WavSTAT4, Endosocpic assessment and combined alogithmic assessment for characterisation of colorectal poylps < 10 mm and prediction of surveillance intervals WavSTAT alone WLE+NBI assessment Combination of WavSTAT + endoscopic assessment (algorithmic approach) Sensitivity 97.6% 85.0% 95.8% Specificity 46.9% 77.2% 78% NPV 96.8% 91% 98.5% PPV 54.7% 66% 89.3% Surveillance interval (% of patients coded correctly) 81.2% 97% 100% Surveillance interval (% of patients called earlier) 18.8% 3% 0% Methods Adult patients referred for lower gastrointestinal endoscopy were included in the study. Patients with inflammatory bowel disease or colorectal cancer were excluded. Polyps sized <10 mm were assessed in real time by high definition white light, NBI and WavSTAT4 optical biopsy forceps. Histopathological specimens were read separately by two expert GI pathologists blinded to the results of the NBI and WavSTAT assessments. Results 156 polyps were found in 70 patients (Males-44, females-27, average age 65). After applying exclusion criteria a total of 126 polyps <10 mm were included in the analysis. Wavstat4 had a NPV of 96.8% but lacked specificity. Endoscopic assessment had a NPV of 91% and was more specific. Since the specificity of WavSTAT was poor mainly for hyperplastic recto-sigmoid polyps we evaluated an algorithmic approach where we classified the polyps according to the WavSTAT4 result when proximal to the recto-sigmoid junction. We classed them according to the endoscopic classification if WavSTAT4 predicted an adenomatous polyp in the recto-sigmoid area. This combined algorithmic approach met the PIVI thresholds and had a NPV of 95.8% and predicted 100% of surveillance intervals correctly. Conclusion WavSTAT version 4 has a high NPV for characterising colorectal polyps less than 10 mm in size but only predicts surveillance intervals correctly in 81.2% of patients. . An algorithmic approach combining Wavstat4 and endoscopic assessment had a high NPV with accurate prediction of surveillance intervals. Disclosure of Interest None Declared