Changing trends in the UK management of upper GI bleeding: is there evidence of reduced UK training experience?

OBJECTIVE: The aim of this study was to evaluate UK trainee experience in endoscopy for acute upper gastrointestinal bleeding (AUGIB). METHODS: Data was prospectively collected from all patients presenting to South Yorkshire Hospitals with AUGIB from September 2011 to December 2011 and compared with data from 1996. Concurrently, all gastroenterology trainees registered with the British Society of Gastroenterology were invited to respond to a web-based questionnaire regarding their experience in AUGIB management. RESULTS: 77% (589/766) of the patient cohort underwent endoscopy for AUGIB; 15% (90/589) were performed by trainees. 7.2% (9/125) of the out of hours endoscopy case load was performed by trainees; all were low-risk or medium-risk cases (pre-endoscopy Rockall score ≤4). During the study period, dual therapy was delivered by a trainee on only four occasions. Comparison with the 1996 cohort demonstrated a marked reduction in the number of trainee performed endoscopies (76% vs 15%; p<0.001). Questionnaires were returned by 51% (245/478) of British Society of Gastroenterology trainees. 81% (198/245) thought that <10% of the gastroscopies they had performed involved therapeutic intervention. 23% (57/245) felt they would not be competent in AUGIB endoscopy by completion of specialty training. CONCLUSIONS: This study demonstrates the decline over time in trainee experience in AUGIB endoscopy. It also highlights a lack of trainee exposure to more challenging cases, out of hours endoscopy and therapeutic procedures. Furthermore, trainees are concerned that a level of competency may not be attained during specialty training. We advocate reviewing UK endoscopic training provision for AUGIB to ensure that experienced endoscopists are produced to meet future service needs.

Non-centralised service for palliative stenting of malignant gastric outlet obstruction.

INTRODUCTION: Malignant gastric outlet obstruction (GOO) is a common, debilitating and frequently pre-terminal symptom of intra-abdominal malignancies. Traditional 'gold standard' treatment has been palliative surgical gastro-enterostomy. Over the past two decades, use of self-expanding metallic stents (SEMSs) to relieve malignant GOO has become first-line treatment. We present the results from a single district general hospital in the UK in which malignant GOO was treated with SEMSs over a six-year period. METHODS: All patients who underwent palliative stenting for malignant gastro-duodenal tumours in our centre for six years up to January 2013 were assessed retrospectively. Outcomes were assessed with regard to: technical and clinical success; return to oral nutrition; prevalence of complications and re-intervention; and overall survival. RESULTS: Thirty-two stents were implanted in 29 patients. Technical success was 100%. Clinical success and return to oral nutrition were both 91%. The prevalence of complications was 16%. The prevalence of re-intervention was 13%. Mean survival was 91 (range, 5-392) days. Median wait from decision to implant a stent to stent implantation was 1 (range, 0-14) day. Overall, 25 covered and nine uncovered stents were implanted. CONCLUSION: Stent implantation for GOO in this patient group is an established and preferable alternative to surgical intervention. Much of the treatment for malignancies of the upper gastrointestinal tract has now been centralised. Our data showed comparable results with published data for these procedures, with a high prevalence of success and low prevalence of major complications. It is of considerable benefit to these patients not to have to travel to a regional centre for stent implantation.

Treatments for Crohn's disease that minimise steroid doses are associated with a reduced risk of osteoporosis.

Crohn's disease is associated with an increased prevalence of osteoporosis. Corticosteroids, commonly used to control exacerbations, appear to be a major risk factor for subsequent development of osteoporosis. Exclusion diets, avoiding foods that precipitate symptoms, frequently allow control of the disease avoiding the use of corticosteroids and may thereby reduce the risk of osteoporosis. To investigate this we performed bone mineral density measurements of the proximal femur and spine in 95 patients, 31 treated predominately by corticosteroids, 33 by dietary manipulation with a low life-time corticosteroid dose and 31 by treatments other than diets but also with a low life-time corticosteroid dose. In both groups with a low life-time corticosteroid dose bone mineral density was comparable to that of age-matched normal controls, whereas bone mineral density was significantly reduced in those treated predominately by corticosteroids. We conclude that corticosteroid therapy is an independent risk factor for osteoporosis in patients with Crohn's disease and should be used as little as possible.

Food intolerance and allergy in gastrointestinal disorders.

Approximately 60 tonnes of food passes through the gastrointestinal tract in an average lifetime. With a surface area second only to the respiratory tract, it is surprising that adverse reactions to food do not occur more frequently.

Colonoscopic hydrostatic balloon dilatation of Crohn's strictures.

Recurrent strictures cause considerable morbidity among many patients with Crohn's disease. We present a retrospective review of the outcome of patients who underwent endoscopic hydrostatic balloon dilatation of Crohn's strictures in our hospital over the past 7 years. All patients were under observation at Addenbrooke's Hospital, Cambridge. An initial assessment of all strictures was made radiologically, and any patient with active disease was treated before consideration of endoscopic dilatation. Dilatation was carried out with Microvasive Rigiflex balloons. Outcome after dilatation was assessed by review at subsequent clinic visits. Sixteen of 22 patients had resolution of their obstructive symptoms after dilatation, although one third of patients required more than two dilatations over the follow-up period. Six of 22 patients had persisting symptoms after endoscopic treatment, requiring surgery. There were no complications noted after any of the 71 dilatations that were performed. We conclude that hydrostatic balloon dilatation is a safe and effective alternative to surgery in the management of Crohn's strictures within the reach of the colonoscope.