Planning management for complex colorectal polyps: a qualitative assessment of factors influencing decision-making among colonoscopists.

OBJECTIVE: Endoscopic therapy is the recommended primary treatment for most complex colorectal polyps, but high colonic resection rates are reported. The aim of this qualitative study was to understand and compare between specialities, the clinical and non-clinical factors influencing decision making when planning management. DESIGN: Semi-structured interviews were performed among colonoscopists across the UK. Interviews were conducted virtually and transcribed verbatim. Complex polyps were defined as lesions requiring further management planning rather than those treatable at the time of endoscopy. A thematic analysis was performed. Findings were coded to identify themes and reported narratively. RESULTS: Twenty colonoscopists were interviewed. Four major themes were identified including gathering information regarding the patient and their polyp, aids to decision making, barriers in achieving optimal management and improving services. Participants advocated endoscopic management where possible. Factors such as younger age, suspicion of malignancy, right colon or difficult polyp location lead towards surgical intervention and were similar between surgical and medical specialties. Availability of expertise, timely endoscopy and challenges in referral pathways were reported barriers to optimal management. Experiences of team decision-making strategies were positive and advocated in improving complex polyp management. Recommendations based on these findings to improve complex polyp management are provided. CONCLUSION: The increasing recognition of complex colorectal polyps requires consistency in decision making and access to a full range of treatment options. Colonoscopists advocated the availability of clinical expertise, timely treatment and education in avoiding surgical intervention and providing good patient outcomes. Team decision-making strategies for complex polyps may provide an opportunity to coordinate and improve these issues.

Endoscopy in 2017: a national survey of practice in the UK.

INTRODUCTION: The Joint Advisory Group on Gastrointestinal Endoscopy (JAG), hosted by the Royal College of Physicians, London, oversees the quality assurance of endoscopy services across the UK. Additional questions focusing on the pressures faced by endoscopy units to meet targets were added to the 2017 annual Global Rating Scale (GRS) return. This provides a unique insight into endoscopy services across all nations of the UK involving the acute and non-acute Nation Health Service sector as well as the independent sector. METHODS: All 508 services who are registered with JAG were asked to complete every field of the survey online in order to submit their completed April 2017 GRS return. RESULTS: A number of services reported difficulty in meeting national waiting time targets with a national average of only 55% of units meeting urgent cancer wait targets. Many services were insourcing or outsourcing patients to external providers to improve waiting times. Services are striving hard to increase capacity by backfilling lists and working weekends. Data collection was done in most units to reflect productivity but not to look at demand and capacity. Some of the units did not have an agreed capacity plan. The Did Not Attend rates for patients in the bowel cancer screening programme were much lower compared with standard lists. CONCLUSION: This review highlights the increased pressure endoscopy services are under and the 'just about coping' situation. This is the first published overview of different aspects of UK-wide endoscopy services and the future challenges.

Olmesartan-associated severe gastritis and enteropathy.

Olmesartan is an angiotensin II receptor antagonist, used in the treatment of hypertension. We report a case of olmesartan-associated severe gastritis with enteropathy in a 74-year-old woman who presented with mainly upper gastrointestinal symptoms. There was significant endoscopic improvement in the mucosal inflammation on stopping the drug. Subsequent gastroscopy showed mucosal healing and normal gastric and duodenal mucosa. To our knowledge, this is the first case report of olmesartan-associated gastritis and enteropathy predominantly involving and affecting the whole of stomach with limited small bowel involvement.

Rare case of chorea-hyperglycaemia-basal ganglia (C-H-BG) syndrome.

An 83-year-old woman presented with acute-onset haemichorea and haemiballism particularly affecting the left side of the body. She was known to have type 2 diabetes, which was poorly controlled with sitagliptin. She was hyperglycaemic but not ketotic or acidotic. After she was started on insulin and good glycaemic control was achieved, her abnormal movements dramatically improved. MRI of the brain showed a T1-weighted hyperintense lesion on the right basal ganglia, which is typical of chorea-hyperglycaemia-basal ganglia syndrome. Other causes of chorea, for example, Huntington's disease, Sydenham chorea, Wilson's disease, malignancy, systemic lupus erythematosus, haemorrhage/infarction, thyroid dysfunction, drug-induced chorea and antiphospholipid syndrome, were excluded or deemed less likely given her rapid response to achieving near euglycaemia.