Stuart A. Riley

Studies of compliance with delayed‐release mesalazine therapy in patients with inflammatory bowel disease

Background: Non‐compliance with maintenance mesalazine therapy may be a risk factor for relapse in inflammatory bowel disease, but the prevalence and determinants of non‐compliance are unknown.

Are we meeting the standards set for endoscopy? Results of a large-scale prospective survey of endoscopic retrograde cholangio-pancreatograph practice

Objective: To examine endoscopic retrograde cholangio-pancreatography (ERCP) services and training in the UK. Design: Prospective multicentre survey. Setting: Five regions of England. Participants: Hospitals with an ERCP unit. Outcome measures: Adherence to published guidelines, technical success rates, complications and mortality. Results: Organisation questionnaires were returned by 76 of 81 (94%) units. Personal questionnaires were returned by 190 of 213 (89%) ERCP endoscopists and 74 of 91 (81%) ERCP trainees, of whom 45 (61%) reported participation in <50 ERCPs per annum. In all, 66 of 81 (81%) units collected prospective data on 5264 ERCPs, over a mean period of 195 days. Oximetry was used by all units, blood pressure monitoring by 47 of 66 (71%) and ECG monitoring by 37 of 66 (56%) units; 1484 of 4521 (33%) patients were given >5 mg of midalozam. Prothrombin time was recorded in 4539 of 5264 (86%) procedures. Antibiotics were given in 1021 of 1412 (72%) cases, where indicated. Patients’ American Society of Anesthesiology (ASA) scores were 3–5 in 670 of 5264 (12.7%) ERCPs, and 4932 of 5264 (94%) ERCPs were scheduled with therapeutic intent. In total, 140 of 182 (77%) trained endoscopists demonstrated a cannulation rate ⩾80%. The recorded cannulation rate among senior trainees (with an experience of >200 ERCPs) was 222/338 (66%). Completion of intended treatment was done in 3707 of 5264 (70.4%) ERCPs; 268 of 5264 (5.1%) procedures resulted in a complication. Procedure-related mortality was 21/5264 (0.4%). Mortality correlated with ASA score. Conclusion: Most ERCPs in the UK are performed on low-risk patients with therapeutic intent. Complication rates compare favourably with those reported internationally. However, quality suffers because there are too many trainees in too many low-volume ERCP centres.

Intestinal metaplasia at the squamocolumnar junction in patients attending for diagnostic gastroscopy

Background—The incidence of adenocarcinoma of the oesophagus and gastric cardia is increasing rapidly. Barrett’s oesophagus is the major risk factor. Intestinal metaplasia at the squamocolumnar junction in the absence of Barrett’s oesophagus is common but its relation to adenocarcinoma and gastro-oesophageal reflux disease is unclear. Aims—To study the prevalence and clinical, endoscopic, and histological associations of intestinal metaplasia at the squamocolumnar junction. Methods—Biopsy specimens were taken from 120 randomly selected patients undergoing routine diagnostic endoscopy. Eight biopsy specimens, taken from above and below the squamocolumnar junction, gastric fundus, and gastric antrum, were stained with haematoxylin/eosin, alcian blue/periodic acid-Schiff, and Gimenez, and graded independently by one pathologist. Results—Intestinal metaplasia at the squamocolumnar junction was found in 21 patients (18%). Metaplasia was associated with increasing age (p<0.01) and antral intestinal metaplasia (p=0.04). Logistic regression analysis revealed that age was the only independent predictor (p<0.01). There was no association with symptomatic, endoscopic, or histological markers of gastro-oesophageal reflux disease. Conclusions—Intestinal metaplasia at the squamocolumnar junction is a common finding. It is associated with increasing age but not gastro-oesophageal reflux disease.

Transient lower esophageal sphincter relaxations are no more frequent in patients with gastroesophageal reflux disease than in asymptomatic volunteers

OBJECTIVES:Studies of the relative frequency of transient lower esophageal sphincter relaxations (TLESRs) in patients with gastroesophageal reflux disease and asymptomatic controls have revealed conflicting data. We have therefore studied the frequency of TLESRs and the frequency and mechanisms of acid reflux episodes in patients with gastroesophageal reflux disease and age- and sex-matched asymptomatic controls using standardized criteria.METHODS:Ten patients with symptomatic gastroesophageal reflux disease (four male, aged 50 [30–59] yr) and 10 asymptomatic matched volunteers (four male, aged 50 [32–59] yr) were studied. Esophageal, lower esophageal sphincter, and gastric manometric and esophageal pH readings were recorded for 1 h before and 1 h after a 200-kcal, 150 ml long-chain triglyceride meal.RESULTS:TLESR frequency increased after the meal in both volunteers (median 0 [range = 0–3] to 3 [0–8] per hour, p < 0.01) and patients (1 [0–6] to 2.5 [0–9] per hour, p = 0.08). There was no significant difference in the frequency of TLESRs between volunteers and patients. TLESRs were more likely to be associated with acid reflux in patients (65% vs 37%, p = 0.03), whereas volunteers were more likely to reflux gas or liquid without acid (30% vs 3.0%, p = 0.01).CONCLUSIONS:TLESRs are no more frequent in patients with gastroesophageal reflux disease than age- and sex-matched asymptomatic volunteers. However, when TLESRs occur in patients, they are twice as likely to be associated with acid reflux.

Familial clustering of reflux symptoms

Objective:A number of case reports describe multiple family members with gastroesophageal reflux disease and Barretts esophagus. The wider importance of familial factors in gastroesophageal reflux disease has not been established. Therefore, we have studied the prevalence of reflux symptoms and medication use among relatives of patients with documented gastroesophageal reflux disease.Methods:A postal questionnaire study of the first degree relatives of six groups of matched patients. The groups comprised patients with 1) no dyspeptic symptoms; 2) reflux symptoms and a normal pH study; 3) reflux symptoms, an abnormal pH study, and a lower esophageal sphincter (LOS) pressure more than 10 mm Hg; 4) reflux symptoms, an abnormal pH study, and a LOS pressure less than 10 mm Hg; 5) Barretts esophagus; and 6) peptic stricture.Results:Four hundred eighteen subjects replied (78% response). Infrequent reflux symptoms were equally common in all groups of relatives. Frequent reflux symptoms, however, were more common among relatives of patients with an abnormal pH study and normal (26%, p= 0.007) or low LOS pressure (27%, p= 0.01) or Barretts esophagus (30%, p= 0.003), compared with relatives of nondyspeptic patients (9%). Frequent reflux symptoms were no more common among relatives of patients with a normal pH study (16%) or peptic stricture (18%). Reflux medication use showed a similar pattern.Conclusions:Familial clustering of reflux symptoms is seen in relatives of patients with reflux symptoms and increased esophageal acid exposure and in relatives of patients with Barretts esophagus.

Chromoscopy versus conventional endoscopy for the detection of polyps in the colon and rectum

BACKGROUNDnAlthough conventional colonoscopy is the most accurate test available for the investigation of the colorectum for polyps, data exist that raise concerns about its sensitivity. Chromoscopy (spraying dye onto the surface of the colon to make polyps more visible) may be one way of enhancing the ability of colonoscopy to detect polyps, particularly diminutive flat lesions, which otherwise may be difficult to detect.nnnOBJECTIVESnTo determine whether the use of chromoscopy enhances the detection of polyps and neoplasia during endoscopic examination of the colon and rectum.nnnSEARCH METHODSnWe searched the following databases: Cochrane Colorectal Cancer Group Specialised Register (October 2015), Cochrane Central Register of Controlled Trials (CENTRAL) (Cochrane Library; Issue 10, 2015), MEDLINE (January 1950 to October 2015), EMBASE (January 1974 to October 2015), and ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform (both November 2015). We also handsearched abstracts from relevant meetings from 1980 to 2015. Search terms included randomised trials containing combinations of the following: chromoscopy colonoscopy dye-spray chromo-endoscopy indigo-carmine magnifying endoscopy.nnnSELECTION CRITERIAnWe included all prospective randomised trials comparing chromoscopic with conventional endoscopic examination of the whole of the colon and rectum. We excluded studies of people with inflammatory bowel disease or polyposis syndromes and any studies that combined chromoscopy with additional interventions (cap assistance, water-perfused, etc.).nnnDATA COLLECTION AND ANALYSISnTwo review authors independently assessed the methodological quality of potentially eligible trials, and two review authors independently extracted data from the included trials. Outcome measures included the detection of polyps (neoplastic and non-neoplastic), the detection of diminutive lesions, the number of participants with multiple neoplastic lesions, and the extubation time.nnnMAIN RESULTSnWe included seven trials (2727 participants) in this update. Five trials were of sufficiently similar design to allow for pooled results. Two trials differed substantially in design and were included in a subgroup analysis. All the trials had some methodological drawbacks. However, combining the results showed a significant difference in favour of chromoscopy for all detection outcomes. In particular, chromoscopy was likely to yield significantly more people with at least one neoplastic lesion (odds ratio (OR) 1.53, 95% confidence interval (CI) 1.31 to 1.79; 7 trials; 2727 participants), and at least one diminutive neoplastic lesion (OR 1.51, 95% CI 1.19 to 1.92; 4 trials; 1757 participants). Significantly more people with three or more neoplastic lesions were also detected, but only when studies that used high-definition colonoscopy in the control group were excluded (OR 4.63, 95% CI 1.99 to 10.80; 2 trials; 519 participants). None of the included studies reported any adverse events related to the use of the contrast dye.nnnAUTHORS CONCLUSIONSnThere is strong evidence that chromoscopy enhances the detection of neoplasia in the colon and rectum. People with neoplastic polyps, particularly those with multiple polyps, are at increased risk of developing colorectal cancer. Such lesions, which presumably would be missed with conventional colonoscopy, could contribute to the interval cancer numbers on any surveillance programme.

Once versus divided daily dosing with delayed-release mesalazine : a study of tissue drug concentrations and standard pharmacokinetic parameters

Delayed‐release mesalazine is traditionally taken as three divided doses. However, it is well‐recognized that dosing frequency has a significant impact on compliance and that once daily dosing is preferable.

Factors associated with abdominal discomfort during colonoscopy: a prospective analysis.

Objectives Colonoscopy can be uncomfortable. To increase safety, there is a trend, in the UK, towards reduced sedative use. We aimed to determine factors predictive of discomfort during colonoscopy. Methods Prospectively recruited patients were asked to grade anticipated discomfort on a Numeric Rating Scale ranging from 0 to 10. Discomfort scores were recorded every 2u2009min during the procedure and during peaks of discomfort. An overall discomfort score was recorded. Results One hundred and nine patients [44 male, 65 female; median 61.5 (21–80) years] were recruited. One hundred and three procedures were completed. Forty-five patients received midazolam [median 2 (1.5–5)u2009mg]. Mean overall Numeric Rating Scale score was 4.7 (men 4.0; women 5.2; P<0.01) and median peak score 7. Discomfort was usually greatest at the beginning of the procedure, while in the sigmoid colon. Discomfort scores were higher in patients with irritable bowel syndrome (Pu2009=u20090.03); diverticular disease (P<0.01); midazolam (Pu2009=u20090.02), buscopan (P<0.001) or nitrous oxide (P<0.001) use; endoscope tracker use (Pu2009=u20090.01); incomplete procedures (P<0.001) or a preceding gastroscopy (Pu2009=u20090.02), but were not correlated with discomfort during venous cannulation or digital rectal examination. Multivariate analysis showed that female sex, high anxiety, anticipation of high discomfort, longer intubation time and higher endoscopists grade of procedural difficulty were independent factors significantly related to overall discomfort scores. Recollected discomfort scores 2–3 months later were lower (P<0.01). Low-dose midazolam had no appreciable amnesic effect. Conclusion Factors indicative of difficult colonoscopy, and preceding gastroscopy, are associated with greater discomfort, as are the presence of female sex, irritable bowel, anxiety and anticipated discomfort. Low-dose midazolam neither relieves discomfort nor makes patients forget it. Selected patients may benefit from increased analgesia.

Development and validation of a novel method for assessing competency in polypectomy: direct observation of polypectomy skills

BACKGROUNDnDespite its ubiquitous use over the past 4 decades, there is no structured, formal method with which to assess polypectomy.nnnOBJECTIVEnTo develop and validate a new method with which to assess competency in polypectomy.nnnDESIGNnPolypectomy underwent task deconstruction, and a structured checklist and global assessment scale were developed (direct observation of polypectomy skills [DOPyS]). Sixty bowel cancer screening polypectomy videos were randomly chosen for analysis and were scored independently by 7 expert assessors by using DOPyS. Each parameter and the global rating were scored from 1 to 4 (scores ≥3 = competency). The scores were analyzed by using generalizability theory (G theory).nnnSETTINGnMulticenter.nnnRESULTSnFifty-nine of the 60 videos were assessable and scored. The majority of the assessors agreed across the pass/fail divide for the global assessment scale in 58 of 59 (98%) polyps. For G-theory analysis, 47 of the 60 videos were analyzed. G-theory analysis suggested that DOPyS is a reliable assessment tool, provided that it is used by 2 assessors to score 5 polypectomy videos all performed by 1 endoscopist. DOPyS scores obtained in this format would reflect the endoscopists competence.nnnLIMITATIONSnSmall sample and polyp size.nnnCONCLUSIONSnThis study is the first attempt to develop and validate a tool designed specifically for the assessment of technical skills in performing polypectomy. G-theory analysis suggests that DOPyS could reliably reflect an endoscopists competence in performing polypectomy provided a requisite number of assessors and cases were used.

The effect of cholecystokinin antagonism on postprandial lower oesophageal sphincter function in asymptomatic volunteers and patients with reflux disease

Postprandial acid reflux is thought to be mediated by the increase in transient lower oesophageal sphincter relaxations (TLOSR) frequency and fall in lower oesophageal sphincter (LOS) pressure seen after ingestion of a meal. Studies in animals and healthy volunteers suggest that cholecystokinin (CCK) may play a role.