Regi George

Mo1302 Incidental Diagnosis of Inflammatory Bowel Disease in a British Bowel Cancer Screening Cohort: A Multi-Centre Study

Introduction The UK Bowel Cancer Screening Programme (BCSP) was launched in 2006 and rolled out in successive waves covering the entire population of England and Wales. It screens individuals aged 60–69 years with a Faecal Occult Blood test (FOBt) followed by a screening colonoscopy if FOBt positive. Our study aimed to quantify the incidental diagnosis of Inflammatory Bowel Disease (IBD) through BCSP and patient outcome in this cohort. Methods We conducted a retrospective review of BCSP outcomes at our centres from launch in February 2007 until September 2011. Screening data included the number of patients invited, number screened (FOBt outcome “normal” or “abnormal”) and number of colonoscopies performed. In those with newly diagnosed IBD at colonoscopy confirmed on histology, clinical data including demographics, disease characteristics, treatment and outcome were obtained from case note and electronic patient record review. Results Of 378 424 patients invited, 172 244 were screened, representing an uptake of 45.52% and FOBt positivity of 2.71%. Colonoscopy was performed in 4195 patients (female 1761). Polyps were detected in 1870 (40.14%), cancer in 279 (5.99%) and 1216 (26.10%) had a normal examination. 83 patients had endoscopic appearance suggestive of IBD, confirmed at histology in 44. Seven patients were excluded as the diagnosis of colitis preceded the screening examination on case note review. Eleven of 37 incidental cases were female. Median age at diagnosis was 64. Twelve patients had Crohn9s disease (CD), 22 ulcerative colitis (UC) and three had IBD-type unclassified (IBDU). 31 patients had follow-up data available with a mean follow-up period of 24.4 months. Fifteen patients (48.4%) were asymptomatic at diagnosis. Mean values for CRP were 11.8, Hb 13.8, Platelets 278.5, and Albumin 42.9. Treatment included steroids (8), 5-ASA (25), immunomodulators (azathioprine 5; methotrexate 1) and anti-TNF (infliximab 2; adalimumab 1). None required surgery. Those requiring immunomodulators and/or anti-TNF therapy (male 4; female 1) had asymptomatic extensive UC, symptomatic left sided UC, symptomatic left-sided IBDU, symptomatic Crohn9s colitis and symptomatic stricturing terminal ileal CD at diagnosis. Conclusion An incidental diagnosis of IBD is not uncommon and with the advent of bowel cancer screening this number is set to increase. These patients may present an important model for study of early disease with novel insights and evolving treatment paradigms. Competing interests None declared.

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.

PTH-091 Incidental Diagnosis of Inflammatory Bowel Disease Through The Bowel Cancer Screening Programme: A 7 Year Experience

Introduction The UK Bowel Cancer Screening Programme (BCSP) launched in 2006, currently screens individuals aged 60–74 years through a Faecal Occult Blood test (FOBt). If positive patients are invited for colonoscopy. We reported in 2012 the first ever experience of incidental diagnosis of IBD through a screening cohort and now present a 7 year experience. Methods We conducted a retrospective assessment of BCSP outcomes at our centre between April 2008 (launch) and December 2015. Assessment included the number of patients invited for screening, number successfully screened (inclusive of “normal” and “abnormal” FOBt) and the number of index colonoscopies. In those with confirmed IBD diagnosis, clinical outcomes, symptoms at diagnosis, disease distribution and behaviour and treatments undertaken were recorded through patient record and case note reviews. Results Of 358,716 invited individuals 180,075 were adequately screened (uptake 50.2%) with FOBt positivity of 1.83%. Of 3598 index colonoscopies undertaken, an incidental diagnosis of IBD was made in 37 (12 female) patients. Ulcerative Colitis (UC) was diagnosed in in 22 (59.4%) patients and Crohn’s (CD) in 10 (27.0%). A further 5 (13.5%) patients were diagnosed with IBD-type unclassified (IBDU) of which 2 were reclassified as UC through follow up. In those diagnosed with UC initially 9 (41.0%) had proctitis, 8 (36.4%) left sided disease and 5 (22.7%) had extensive disease. The majority of CD patients (80%) had an isolated colonic distribution and behaviour was non-stricturing and non-penetrating (70%) or stricturing (30%). Follow up data was available for 25 (67.6%) patients over a median of 40.5 months (range 3–87) of which 14 patients were asymptomatic at diagnosis. Eleven (78.6%) became symptomatic and 2 (8.3%) demonstrated phenotypic progression during follow up. Treatment included 5 ASA (23), steroids (14), Immunomodulation (Azathioprine – 7: Methotrexate – 1) and Anti-TNF (Infliximab -2; Adalimumab – 1). Median time to immunomodulation was 29.0 months and to anti-TNF treatment was 28.0 months. Five patients died: 3 from unrelated causes, 1 from an unknown cause and 1 seven days after subtotal colectomy (undertaken 54 months after diagnosis with symptomatic IBDU). Conclusion An incidental diagnosis of IBD at screening is not uncommon, with an incidence of 1.0% in our cohort . A proportion of patients demonstrate significant disease progression requiring immunomodulation, biologic therapy or surgery. IBD detection from screening provides a unique model to study early disease in ‘elderly’ (and potentially asymptomatic) patients. Disclosure of Interest None Declared

Sa1896 Incidental Diagnosis of Inflammatory Bowel Disease in a British Bowel Cancer Screening Cohort: 6-Year Clinical Outcome Follow-Up of the First Reported Cohort

Introduction The UK Bowel Cancer Screening programme (BCSP) was launched in 2006 in England and Wales, screening individuals aged 60–69 years with a Faecal Occult Blood test (FOBt) followed by a screening colonoscopy if FOBt positive. We reported the first ever experience of incidental diagnosis of Inflammatory bowel disease (IBD) through screening in 2012. We present a 6 year follow-up of this cohort. Methods We conducted a retrospective case record review of clinical outcomes until 31 st December 2015 for patients diagnosed with IBD from the BCSP from April 2008 until September 2011. We reviewed their symptoms at diagnosis, treatment course and compared stage of disease at initial presentation to that at last follow-up. Results Between April 2008 and September 2011, 136,811 patients were invited to the BCSP and 67,485 were screened with a 49.33% uptake and FOBt positivity of 2.02%. Colonoscopy was performed in 1401 patients and 13 patients (3 female) were diagnosed with IBD. Of these, 6 patients had Ulcerative colitis (UC), 5 had Crohn’s disease (CD), 2 had IBD-unclassified (IBDU). One IBDU patient was subsequently re-classified as UC during follow-up. At diagnosis 7 (53.8%) patients were asymptomatic. An asymptomatic patient died of an unrelated cause, with follow-up data available for 12 patients. Median follow-up time was 80 months (range 39–87 months). Using the Montreal classification the distribution for UC included E1 (2), E2 (2) and E3 (2) and in CD showed L2 (7). Four CD patients had B1 disease and 1 had B2. Disease progressed in 2 patients and all 6 (100%) asymptomatic patients developed symptoms during follow-up. Treatment included steroids (10), 5 ASA (12), Azathioprine (6); Methotrexate (1) and Anti-TNF (Infliximab (2); Adalimumab (1)). Median time to immunomodulator was 29.5 months and to anti-TNF, 28.0 months. Mean CRP at diagnosis for those who progressed to Immunomodulator was 10.4 compared to 5.5 in those that didn’t and 15.5 in those that required biologics. A patient with symptomatic IBDU underwent subtotal colectomy 54 months after diagnosis but died 7 days post-operatively. Another patient died at 39 months from an unrelated cause. Conclusion Incidental diagnosis of IBD presents an important model for the study of early disease. A proportion of initially asymptomatic patients demonstrate disease progression with a rapid requirement for treatment escalation. Disclosure of Interest None Declared

Posterior Reversible Encephalopathy Syndrome and Fatal Cryptococcal Meningitis After Immunosuppression in a Patient With Elderly Onset Inflammatory Bowel Disease

Advanced age and associated comorbidities are-recognized predictors of life-threatening adverse outcomes, such as opportunistic infection following immunosuppressive therapy. We describe the case of an elderly patient with stricturing colonic Crohn’s disease and significant clinical comorbidities, initially controlled with corticosteroid induction followed by infliximab, whose course was complicated by fatal disseminated cryptococcal infection and posterior reversible encephalopathy syndrome. Our patient’s case highlights rare, but serious, complications of immunosuppression. In applying modern treatment paradigms to the elderly, the clinician must consider the potential for more pronounced adverse effects in this potentially vulnerable group, maximizing benefit and minimizing harm.

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