British Society Of Gastroenterology Guidelines Research Articles

708 Examining the Management of Acute Lower GI Bleeds in Order to Improve Policies and Reflect Safe and Updated Guidance

Abstract Introduction Acute lower gastrointestinal bleeding (LGIB) tends to occur in elderly patients with complex comorbidities. At North Middlesex University Hospital (NMUH), LGIB patients are primarily managed by the surgical department. We amended local policies by integrating aspects of new guidelines published by the British Society of Gastroenterology (BSG). Method Handover documentation between November 2019 and January 2020 established patients admitted with LGIB (n = 45). Further data regarding the management of these patients was collated from clinical software and compared to standards set from BSG guidelines. Results We found NMUH to be efficient in ruling out upper GI bleeds via 24-hour OGDs and had low surgical intervention rates (0.02%). 40% of patients were transfused with an admission haemoglobin above suggested NICE thresholds, accounting for cardiovascular comorbidities. 56% of patients were discharged without a documented anticoagulation plan. Over 50% of patients did not have BSG recommended inpatient investigations. Conclusions Updated Trust guidelines aim to uphold areas that NMUH were shown to excel in, while reiterating NICE transfusion thresholds and include guidance regarding anticoagulant and antiplatelet medications. The Oakland score and shock index have been integrated into local protocols and will aid clinicians in making safe decisions in the management of LGIB patients.

522 Audit of Acute Lower Gastrointestinal Bleed Management in a District General Hospital

Abstract Introduction Acute Lower Gastrointestinal Bleed (ALGIB) is a common emergency surgical referral. This project aims to audit current practice at a district general hospital against new British Society of Gastroenterology guidelines, which gives recommendations regarding assessment (Oakland score), investigation and management. Method A retrospective study was undertaken over one year (2019) of patients presenting to A&E or referred via GP with ALGIB. Patients were identified through the coding department. An online proforma was used for data collection, which was analysed with SPSS. Results 76 appropriate patients identified. Median length of hospital stay was 1 day. 10 patients (13.2%) scored ≤8 (probability of safe discharge 95%), 19 (11.8%) patients scored ≤9 (probability of safe discharge 93%) and 57 patients (75%) scored ≥10. 19 patients discharged the same day, of which 3 (15.8%) scored ≤8 and 8 (42.1%) scored ≤9. 23 patients admitted overnight, of which 5 (21.7%) scored ≤8 and 6 (26.1%) scored ≤9. Of 66 patients classified as ‘major’, 41 (62.1%) did not have a colonoscopy. Conclusions Introduction of a scoring mechanism and disseminating guidelines will enable GPs and A&E doctors to safely discharge ALGIB patients with appropriate outpatient investigations and reduce surgical admissions. There is currently poor compliance with inpatient investigations.

British Society of Gastroenterology guidelines on the management of irritable bowel syndrome

Irritable bowel syndrome (IBS) remains one of the most common gastrointestinal disorders seen by clinicians in both primary and secondary care. Since publication of the last British Society of Gastroenterology...

Risk stratification and geographical mapping of Brazilian inflammatory bowel disease patients during the COVID-19 outbreak: Results from a nationwide survey.

BACKGROUNDCoronavirus disease 2019 (COVID-19) pandemic is still evolving globally, and Brazil is currently one of the most affected countries. It is still debated whether patients with inflammatory bowel disease (IBD) are at a higher risk for developing COVID-19 or its complications.AIMTo assess geographical distribution of IBD patients at the highest risk and correlate these data with COVID-19 mortality rates in Brazil.METHODSThe Brazilian IBD Study Group (Grupo de Estudos da Doença Inflamatória Intestinal do Brasil) developed a web-based survey adapted from the British Society of Gastroenterology guidelines. The included categories were demographic data and inquiries related to risk factors for complications from COVID-19. Patients were categorized as highest, moderate or lowest individual risk. The Spearman correlation test was used to identify any association between highest risk and mortality rates for each state of the country.RESULTSA total of 3568 patients (65.3% females) were included. Most participants were from the southeastern and southern regions of Brazil, and 84.1% were using immunomodulators and/or biologics. Most patients (55.1%) were at moderate risk, 23.4% were at highest risk and 21.5% were at lowest risk of COVID-19 complications. No association between the proportion of IBD patients at highest risk for COVID-19 complications and higher mortality rates was identified in different Brazilian states (r = 0.146, P = 0.467).CONCLUSIONThis study indicates a distinct geographical distribution of IBD patients at highest risk for COVID-19 complications in different states of the country, which may reflect contrasting socioeconomic, educational and healthcare aspects. No association between high risk of IBD and COVID-related mortality rates was identified.

Prevalence of Barrett’s esophagus and performance of societal screening guidelines in an unreferred primary care population of U.S. veterans

Less than 10% of patients diagnosed with esophageal adenocarcinoma have a pre-existing Barrett's esophagus (BE) diagnosis, possibly because of suboptimal performance of guidelines. We examined the prevalence of BE in a previously unscreened primary care population and the potential yield of practice BE screening guidelines. This was a retrospective analysis of a prospective cross-sectional study of consecutively recruited unreferred patients from primary care clinics who underwent study upper endoscopy. We examined the performance of BE screening guidelines of the European Society of Gastrointestinal Endoscopy (ESGE), British Society of Gastroenterology (BSG), American Society for Gastrointestinal Endoscopy (ASGE), American College of Gastroenterology (ACG), American Gastroenterological Association (AGA), and our own modification of guidelines. We identified 44 BE cases and 469 control subjects (prevalence, 8.6%). Among 371 patients without GERD symptoms, 25 (6.7%) had BE. The AGA guidelines requiring≥2 BE risk factors had sensitivity of 100% and specificity of only .2%, whereas ACG, ASGE, ESGE, and BSG guidelines (all requiring GERD first) had low sensitivities (38.6%-43.2%), specificities ranging from 67.4% to 76.5%, and area under the receiver operating curve (AUROC) of .50 to .60. Our 2-pronged approach depending on presence or absence of GERD symptoms but with other risk factors achieved sensitivity of 81.8%, specificity of 51.2%, and AUROC of .66. Over half of BE cases were without frequent GERD symptoms, but virtually all had at least 1 known BE risk factor. Practice guidelines requiring GERD symptoms have low sensitivity, whereas those not requiring GERD have low specificity. We have proposed a screening guideline with better use of known risk factors.

Adaptations to the British Society of Gastroenterology guidelines on the management of acute severe UC in the context of the COVID-19 pandemic: a RAND appropriateness panel

ObjectiveManagement of acute severe UC (ASUC) during the novel COVID-19 pandemic presents significant dilemmas. We aimed to provide COVID-19-specific guidance using current British Society of Gastroenterology (BSG) guidelines as a...

Editorial introductions

Current Opinion in Gastroenterology was launched in 1985. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of gastroenterology is divided into 12 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Section Editors for this issue. SECTION EDITORS Don C. RockeyDon C. RockeyDr Don C. Rockey completed internship, residency, chief residency, and fellowship at the University of California, San Francisco, USA. He is currently Chairman of the Department of Medicine, the Medical University, Charleston, USA. He has active, basic and clinical research interests in liver disease. His basic research focuses on understanding the molecular basis of fibrosis and portal hypertension. His laboratory initially demonstrated that a key player, the hepatic stellate cell, exhibits a contractile phenotype. Further, following liver injury, stellate cells exhibit exaggerated contractility, constrict liver sinusoids, and contribute to increased intrahepatic vascular resistance typical of portal hypertension. Dr Rockey also has an active clinical research program, focused on clinical management problems in chronic liver diseases including complications of portal hypertension, drug induced liver injury, and gastrointestinal bleeding. Dr Rockey and his colleagues have published nearly 300 peer reviewed original scientific papers related to his research and over 100 editorials, reviews, and book chapters. He has served as a mentor for over 120 trainees, including students, residents, fellows, and junior faculty members - the vast majority of whom are pursuing careers in academic medicine. He has had a number of editorial responsibilities, including as Associate Editor for Hepatology, Liver International, and the Journal of Investigative Medicine, and has served on various NIH and other study sections, and editorial boards. Reena SidhuReena SidhuProf Reena Sidhu is a Consultant Gastroenterologist and an Honorary Professor with the University of Sheffield, UK. Her main area of interest is the small bowel and she completed a clinical MD with the University of Sheffield on modern modalities of investigation of the small bowel. She is currently the lead for the tertiary double balloon enteroscopy service at Sheffield Teaching Hospitals and co-runs one of the biggest Capsule Endoscopy services in Europe. Both of these services are established regional services which have won national awards. She runs an international capsule endoscopy course for doctors. She carries out clinical research related to the small bowel and continues to publish actively in this field. She has research fellows under her banner. She is regularly invited to speak at national and international meetings. As part of her work with the United Kingdom Small bowel Users group, she is setting up training standards for device assisted enteroscopy. She is also leading a curriculum for device Assited Enteroscopy as part of her role in the ESGE curricula group. She has also been involved in formalising accreditation for capsule endoscopy in the UK. She was awarded the Hopkins Endoscopy Prize by the BSG in 2012, the first female gastroenterologist to have ever won this. She is the first author of the British Society of Gastroenterology guidelines on capsule endoscopy and enteroscopy, published in 2008 and is also a co-author on the 2015 ESGE guidelines on small bowel endoscopy. She is also the BSG Education Web Editor. She has a young family and enjoys listening to music, cinema and collecting modern art.

P010 FIRST SURVEILLANCE COLONOSCOPY FOR INFLAMMATORY BOWEL DISEASE – ARE WE GETTING IT RIGHT FROM THE START?

Abstract Background Surveillance for colorectal cancer (CRC) is necessary in patients with inflammatory bowel disease (IBD). Patients with ulcerative colitis (UC) have a similar CRC risk to those with Crohn’s colitis (CC). British Society of Gastroenterology (BSG) guidelines from 2010 outlined recommendations for screening including surveillance intervals and pancolonic dye spraying with targeted biopsies. We aimed to identify reasons why the first surveillance colonoscopy is not being performed as advised, including the role of poor bowel preparation and disease activity. Methods Retrospective study of all IBD colonoscopies over a 7 year period (2011–2018) across two sites at a tertiary London based hospital trust. 214 patients were identified and exclusion criterion was applied (not first surveillance/diagnosis prior to year 2000/PSC/inadequate data). 93 patients were included for analysis. Results 26 (28.0%) surveillance colonoscopies were performed prior to 10 years of diagnosis (ie. before BSG guideline recommendation). 22 (23.7%) surveillance colonoscopies performed after the recommended interval. Dye spray was performed in only 2 patients (2%). Reasons cited for not dying were only given in 4 (4.3%) cases, and included poor bowel prep or active disease. No reason was given in 87 (93%) cases. Targeted biopsies were performed in 24 (25.8%) patients, with random biopsies in 56 (60.2%) patients. Conclusion The first IBD surveillance colonoscopy is only being performed at the correct time interval in approximately 50% of cases with over a quarter being performed too soon and almost a quarter being performed too late. Pan-colonic dye spray is used in only 2% and targeted biopsies are taken in only 1 in 4 patients. Poor bowel preparation and disease activity do not appear to be limiting factors in the use of dye spray. We conclude that appropriate initial colitis surveillance is not being performed in the majority despite published guidelines. Organisational factors such as sufficient time allocated to dye spray colonoscopy, along with endoscopist skill, may be contributing factors.

How to Manage a Patient With Gastric Intestinal Metaplasia: An International Perspective

How to Manage a Patient With Gastric Intestinal Metaplasia: An International Perspective

1066 Effectiveness of a Nurse-Led Fibroscan Service Towards Enhanced Care in Liver Disease

INTRODUCTION: Fibroscan as a convenient, non invasive tool for classification of Liver Stiffness (KPA) and fat component (CAP) has gained popularity in the hospital as well as community health services .With burden of liver disease significantly affecting the NHS in terms of finances as well as mortality, an accurate measure of the liver parenchyma assists in delivery of safe enhanced care.We present our nurse led fibroscan service in comparison to conventional modalities in the management of liver disease. METHODS: 273 patients were referred to the Nurse led Fibroscan service from July 2017-18.The Fibroscan readings were then compared to the USS, biochemistry and liver biopsy results. British Society of Gastroenterology(BSG) guidelines were then used to manage these subjects. RESULTS: Out of 273 patients referred 30 were excluded due to difficult procedures. Out of 243 screened, 52.68% were female.An average age of 53.9 years was seen (Median 55,IQR 19).The Fibroscan results were classified based on KPA and CAP for different etiology.Mean ALT of 49.22 was seen. Fibroscan results showed , Normal 9.87% ,Fatty Liver = 50.2%,Fibrosis = 22.2%and Cirrhosis 17.69% and compared to USS. Of the 48 subjects with Normal USS, 22 showed fatty liver, 9 had fibrosis and 2 had cirrhosis on fibroscan showing a 68.75% variance in diagnosis indicating a worsening stage of liver disease. Of the 123 that had fatty liver on USS,81 had the same diagnosis on fibroscan too.There was variance in 34.14% with 3 showing a better diagnosis having Normal fibroscan and 23 and 16 subjects showing fibrosis and cirrhosis respectively, indicating a worsening diagnosis. As Per BSG guidelines, fatty liver disease and ALT of below 50 can be discharged back to the care fo GP. 51.2% of these patients were similarly discharged to the GP. 70 subjects had Cirrhosis on USS 45 had a better diagnosis indicating the variance to be 50%. The total variance in diagnosis was noted in 122 (50.2%) from USS to fibroscan, with 41% (n = 50)having a better stage and 72 (59%) showing worse stage of disease. 44 of these subjects underwent liver biopsies which correlated to the above findings in similar percentage. CONCLUSION: Nurse led fibroscan service shows effective monetary benefit in good enhanced care of liver disease. It gives a more accurate diagnosis as compared to USS and also helps in avoiding the invasive liver biopsy in majority of the cases. Utilised in a correct manner it can help in appropriate care of the liver disease patients.

British Society of Gastroenterology guidelines for oesophageal manometry and oesophageal reflux monitoring

These guidelines on oesophageal manometry and gastro-oesophageal reflux monitoring supersede those produced in 2006. Since 2006 there have been significant technological advances, in particular, the development of high resolution manometry...

British Society of Gastroenterology guidelines on the diagnosis and management of patients at risk of gastric adenocarcinoma

Gastric adenocarcinoma carries a poor prognosis, in part due to the late stage of diagnosis. Risk factors include Helicobacter pylori infection, family history of gastric cancer—in particular, hereditary diffuse gastric...

Editorial introductions

Current Opinion in Gastroenterology was launched in 1985. It is one of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of gastroenterology is divided into 12 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Section Editors for this issue. SECTION EDITORS Don C. RockeyDon C. RockeyDr Don C. Rockey completed internship, residency, chief residency and fellowship at the University of California, San Francisco, USA. He is currently Chairman of the Department of Medicine, the Medical University, Charleston, USA. He has active basic and clinical research interests in liver disease. He has worked on areas ranging from clinical management problems in liver diseases such as portal hypertension, hepatic blood flow, drug induced liver injury and complications of chronic liver disease to basic liver cell and molecular biology. The central theme of his laboratory research revolves around understanding the cell and molecular basis of fibrosis and portal hypertension. His laboratory initially demonstrated that a key player, the hepatic stellate cell, exhibits a contractile phenotype. Further, following liver injury, stellate cells exhibit exaggerated contractility, constrict liver sinusoids, and contribute to increased intrahepatic vascular resistance typical of portal hypertension. He and his laboratory have gone on to explore a number of molecular events important in this disease. Dr Rockey has had highly active clinical interests in multiple aspects of chronic liver disease as well as drug induced liver injury. Dr Rockey and his colleagues have published over 200 peer reviewed scientific papers related to his research and over 100 editorials, reviews, and book chapters. He has served in a number of capacities on behalf of major US Gastroenterology and Liver societies including for the American Gastroenterological Association (AGA) and the American Association for the Study of Liver Disease (AASLD). Among many responsibilities, he has served as Chair of The AGA Research Policy Committee, Chair of the AASLD Training and Workforce committee. He has also been active in the Alliance for Academic Internal Medicine (AAIM) having served as President for the Association of Subspecialty Professors (ASP). He has had a number of editorial responsibilities, including as Associate Editor for Hepatology, Associate Editor for Liver International and has served on various NIH and other study sections, and editorial boards. Reena SidhuReena SidhuDr Reena Sidhu is a Consultant Gastroenterologist and an Honorary Senior Clinical lecturer with the University of Sheffield, UK. Her main area of interest is the small bowel and she completed a clinical MD with the University of Sheffield on modern modalities of investigation of the small bowel. She is currently the lead for the tertiary double balloon enteroscopy service at Sheffield Teaching Hospitals and co-runs one of the biggest Capsule Endoscopy services in Europe. Both of these services are established regional services which have won national awards. She runs an international capsule endoscopy course for doctors and also directs a biannual national advanced nurse course on capsule endoscopy. She carries out clinical research related to the small bowel and continues to publish actively in this field. She has research fellows under her banner. She is regularly invited to speak at national and international meetings. As part of her work with the United Kingdom Small bowel Users group, she is setting up training standards for device assisted enteroscopy. She is also leading a curriculum for device Assisted Enteroscopy as part of her role in the ESGE curricula group. She has also been involved in formalising accreditation for capsule endoscopy in the UK. She was awarded the Hopkins Endoscopy Prize by the BSG in 2012, the first female gastroenterologist to have ever won this. She is the first author of the British Society of Gastroenterology guidelines on capsule endoscopy and enteroscopy, published in 2008 and is also a co-author on the 2015 ESGE guidelines on small bowel endoscopy. She has a young family and enjoys listening to music, cinema and collecting modern art.

High Adherence to Surveillance Guidelines in Inflammatory Bowel Disease Patients Results in Low Colorectal Cancer and Dysplasia Rates, While Rates of Dysplasia are Low Before the Suggested Onset of Surveillance.

Patients with Crohn's disease [CD] and ulcerative colitis [UC] are at increased risk for colorectal dysplasia [CRD] and colorectal cancer [CRC]. Adherence to CRC surveillance guidelines is reportedly low internationally. To evaluate surveillance practices at the tertiary IBD Center of the McGill University Health Center [MUHC] and to determine CRD/CRC incidence. A representative inflammatory bowel disease cohort with at least 8 years of disease duration [or with primary sclerosing cholangitis] who visited the MUHC between July 1 and December 31, 2016 were included. Adherence to surveillance guidelines was compared to modified 2010 British Society of Gastroenterology guidelines. Incidence rates of CRC, high-grade dysplasia [HGD], low-grade dysplasia [LGD] and colorectal adenomas [CRA] were calculated based on pathology. In total, 1356 CD and UC patients (disease duration: 12 [interquartile range: 6-22) and 10 [interquartile range: 5-19] years) were identified. The surveillance cohort consisted of 680 patients [296 UC and 384 CD]. Adherence to surveillance guidelines was 76/82% in UC/colonic CD. An adequate number of biopsies were taken in 54/54% of UC/colonic CD patients. The incidence of CRC/HGD in UC and CD with colonic involvement was 19.5/58.5 and 25.1/37.6 per 100,000 patient-years, respectively. The incidence of dysplasia before 8 years of disease duration was low in both UC/CD [19.5 and 12.5/100,000 patient-years] with no CRC detected. The CRA rate was 30/38% in UC/colonic CD. High adherence to surveillance guidelines and low CRC and dysplasia, but not CRA rates were found, suggesting that adhering to updated, stratified, surveillance recommendations may result in low advanced neoplasia rates. The incidence of dysplasia before the start of surveillance was low.

Dedicated service improves the accuracy of Barrett’s oesophagus surveillance: a prospective comparative cohort study

ObjectivesStandards for Barrett’s oesophagus (BO) surveillance in the UK are outlined in the British Society of Gastroenterology (BSG) guidelines. This study aimed to assess the quality of current surveillance delivery...

Gastrointestinal pathologists' perspective on managing risk in the distal esophagus: convergence on a pragmatic approach.

Here, we discuss recent updates and a continuing controversy in the diagnosis and management of Barrett's esophagus, specifically the recommendation that the irregular Z-line not be biopsied, the diminished status of ultrashort-segment Barrett's esophagus, the evidence basis for excluding and including the requirement of goblet cells for the diagnosis of Barrett's esophagus, and the conclusion that histologically confirmed low-grade dysplasia is best managed with endoscopic ablation rather than surveillance. We reference the American Gastroenterological Association and College of Gastroenterology and the British Society of Gastroenterology guidelines throughout, with the thesis that the field is converging on the concept of applying scarce medical resources to the diagnosis, surveillance, and therapy of patients most likely to derive benefit.

Association of Coloproctology of Great Britain & Ireland (ACPGBI): Guidelines for the Management of Cancer of the Colon, Rectum and Anus (2017) - Follow Up, Lifestyle and Survivorship.

Association of Coloproctology of Great Britain & Ireland (ACPGBI): Guidelines for the Management of Cancer of the Colon, Rectum and Anus (2017) - Follow Up, Lifestyle and Survivorship.

Duodenal biopsies for the diagnosis of coeliac disease: are we adhering to current guidance?

BackgroundThe British Society of Gastroenterology guidelines recommend taking at least four duodenal biopsy specimens at the time of upper gastrointestinal (UGI) endoscopy if coeliac disease (CD) is suspected and it...

HISTOPATHOLOGICAL DIAGNOSTIC CRITERIA OF BARRETT ESOPHAGUS AND ITS ASSOCIATION WITH ENDOSCOPY FINDINGS

Background : In the last decades, the incidence of esophageal adenocarcinoma has significantly increased. Barrett Esophagus (BE) is widely known as a precursor lession of esophageal adenocarcinoma, and it could increase the risk of adenocarcinoma to 30-120 times higher than non-BE patient. The controversy about BE definition is still a problem amongst pathologist. BE is defined as the transition of normal esophageal squamous epithellium into metaplastic columnar epithellium that can be seen through endoscopy at the upper region of gastroesophagus transitional area, and confirmed with hystological examination. Objective : To re-evaluate hystopathological presentation of BE and the classification of dysplasia as well as its association with clinical finding in the form of endoscopy results. Methods : Clinical and hystopathological datas of 71 cases of BE was collected and re-evaluated based on British Society of Gastroenterology Guidelines 2005 criteria, as well as re-evaluating the grade of dysplasia based on WHO Classification of tumours of the digestive system 2010. Results : 51 cases of BE were obtained with male:female ratio 33:18 patients. BE cases were predominated by 51-60 years old age group, in which the mean of patients age was 55 years old. The results of dysplasia grade re-evaluation showed 72,55% non-dysplasia BE case, 3,9% was BE indefinite; 23,53% was BE with low grade dysplasia; and 1,97% was BE with hard grade dysplasia. There were 15 cases (21,12%) that were changed in diagnosis, from BE to non-BE cases. Conclusion : The diagnosis of BE could be made if there are compatibility between endoscopy examination and hystopathological examination, in which BE presentations was found, either in category 1, 2 or 3based on British Society of Gastroenterology Guidelines 2005 and endoscopy indicated supicion of BE. Changes in diagnosis of BE cases into non-BE cases could happen not because there are incompatibilities of the results of these examinations. This might happen due to nescience regarding the importance of the results of endoscopy examination and its compatibility with the results of hystopathological examination.

Effectiveness of the British Society of Gastroenterology guidelines for surveillance colonoscopies on colonic adenomas

Effectiveness of the British Society of Gastroenterology guidelines for surveillance colonoscopies on colonic adenomas