Cost-benefits and environmental impact of the no-biopsy approach for the diagnosis of coeliac disease in adults.

Objective: Recent evidence suggests that adult patients with IgA tissue transglutaminase levels of ≥10× the upper limit of normal could be accurately diagnosed with coeliac disease without undergoing endoscopy and biopsy. We aimed to evaluate the cost-benefits and the environmental impact of implementing the no-biopsy approach for diagnosing coeliac disease in clinical practice. Design: We calculated the overall direct and indirect costs of the conventional serology-biopsy approach and the no-biopsy approach for the diagnosis of coeliac disease based on the national average unit costs and the Office of National Statistics data. We further estimated the environmental impact of avoiding endoscopy based on the estimated greenhouse gas emissions from endoscopy. Results: Approximately 3000 endoscopies for suspected coeliac disease could be avoided each year in the UK. Implementing the no-biopsy approach for the diagnosis of coeliac disease in adults could save the National Health Service over £2.5 million in direct and indirect costs per annum and reduce endoscopy carbon footprint by 87 tonnes of CO2 per year, equivalent to greenhouse gas emissions from driving 222 875 miles, carbon emissions from charging over 10 million smartphones and the carbon sequestrated by 1438 trees grown for 10 years. Conclusion: The implementation of this non-invasive green approach could be an essential first step in the 'Reduce' strategy advocated by the British Society of Gastroenterology and other international endoscopy societies for sustainable endoscopy practice.

Idiopathic terminal ileitis: myth or true entity?

PURPOSE OF REVIEW: Isolated terminal ileitis is an increasing phenomenon identified during colonoscopy. Idiopathic terminal ileitis (IDTI) is a diagnosis of exclusion, representing a significant challenge from a diagnostic and management point of view. This review provides an overview of the most recent and relevant evidence on idiopathic IDTI, focusing on its evolution, the natural history and the management strategies proposed in the literature. RECENT FINDINGS: IDTI is uncommon, with a reported prevalence between 0.5 and 7%. The main differential is with Crohn's disease and intestinal tuberculosis in endemic countries. A proportion of patients (0-50%) can progress and develop Crohn's disease; however, there are no reliable predictive factors to stratify IDTI patients. SUMMARY: IDTI is a challenging entity, with a small proportion of patients progressing to Crohn's disease over time thus requiring follow-up. Noninvasive modalities such as capsule endoscopy are useful for follow-up, but further research is required to better understand this entity.

Small bowel angioectasia-The clinical and cost impact of different management strategies.

BACKGROUND: The management of patients with recurrent anaemia and small bowel angioectasia (SBA) is costly and challenging. AIMS/METHODS: In this retrospective cohort study, we examined the clinical and cost implication of a combination therapy of Somatostatin analogues (SA) and endoscopic ablation, endoscopic therapy alone, and conservative management. RESULTS: Median number of bleeding episodes reduced from 3.5 (IQR 4) in the year before, to 1 (IQR 2) in the year after starting combination therapy with SA (p = 0.002). There were no differences in number of bed days (13.7 vs. 15.3, p = 0.66) and cost (£10,835 vs £11,653, p = 0.73) in the year before and after starting combination therapy. There was a trend towards a reduction in median number of blood transfusions episodes (17 vs 5, p = 0.07) and therapeutic endoscopies (1 vs. 0, p = 0.05) after starting SA. In patients suitable for endoscopic therapy alone, time spent in hospital was reduced (-3.5 days, p = 0.004), but bleeding episodes, transfusions and cost of treatment were not different. Patients requiring a combination therapy were significantly more co-morbid with a mean (± sd) Charlson comorbidity index (CCI) of 7.1 (± 2.7). Higher CCI (OR 2.1, 95% CI 1.1-3.9) and presence of chronic renal failure (OR 4.1, 95% CI 1.4-12.4) predicted escalation to combination therapy. CONCLUSIONS: SAs may be a useful adjunct to endoscopic therapy for transfusion dependent comorbid patients. In the first year they reduce bleeding episodes. Cost in the 1-year before and after adding on SA are no different suggesting additional clinical benefit can be gained without additional cost.

Cost comparison of oral, transnasal and magnet assisted capsule endoscopy in the examination of the upper gastrointestinal tract in patients with dyspepsia.

Introduction: Conventional oral upper gastrointestinal (GI) endoscopy can obe uncomfortable. By comparison, transnasal endoscopy (TNE) and magnet assisted capsule endoscopy (MACE) have superior tolerability. A cost comparison of competing upper GI endoscopic modalities have yet to be performed. Methods: We performed a cost comparison study of oral, TNE and MACE by a combination of activity-based costing and averaging of fixed costs over 24 481 upper GI endoscopies performed for dyspepsia over a 10-year period. Results: On average, 9.4 procedures were performed daily. TNE was cheapest at €125.90 per procedure, costing 30% less than oral endoscopy at €184.10 and threefold cheaper than MACE at €407.10. Flexible endoscope reprocessing cost €53.80. TNE was cheaper than oral endoscopy as sedation was not required. Oral endoscopies have a further rate of infectious complications, estimated to cost €16.20 per oral procedure in inpatient admissions. Oral and TNE equipment are more expensive to purchase and maintain than MACE costing €79 330 and €81 819, respectively compared with MACE at €15 420 per annum. However, capsule endoscopes cost significantly more per procedure at €369.00 than the consumables for flexible endoscopy (per oral €12.30, TNE €5.30). Conclusions: TNE cost less to perform than conventional per oral endoscopy. The cost of capsule endoscopes will need to be reduced significantly if routine use is to be expected.

Colon Capsule Endoscopy - Shining the Light through the Colon.

PURPOSE OF REVIEW: Colon capsule endoscopy (CCE) is a non-invasive, wireless capsule endoscope. In this article, we review its current applications, compare its performance with optical colonoscopy (OC) and alternative imaging modalities like CT colonography (CTC), and highlight developments that may increase potential future use. RECENT FINDINGS: By comparison to OC both CCE and CTC have a good sensitivity and specificity in detecting colonic polyps. CCE is more sensitive in detecting sub centimetre polyps. CCE is capable of detecting colonic inflammation and anorectal pathologies, commonly missed by CTC. However, rates of complete CCE examinations are limited by inadequate bowel preparation or incomplete colonic transit, whereas CTC can be performed with less bowel purgatives. Patients tolerate CCE better than OC, however patient preference between CCE and CTC vary. CCE and CTC are both reasonable alternatives to OC. Strategies to improve completion rates and adequacy of bowel preparation will improve cost and clinical effectiveness of CCE.

Small bowel obstruction: what a gastroenterologist needs to know.

PURPOSE OF REVIEW: Intrabdominal adhesions and intestinal hernias are the commonest cause of small bowel obstruction. Small bowel diseases, which cause small bowel obstruction, are rarer and often poses a challenge to gastroenterologists to diagnose and treat. In this review, small bowel diseases, which predispose to small bowel obstruction, are focused on, and their challenges in diagnosis and treatment. RECENT FINDINGS: Diagnosis of causes of partial small bowel obstruction is improved with computed tomography (CT) and magnetic resonance (MR) enterography. In fibrostenotic Crohn's strictures and NSAID diaphragm disease, endoscopic balloon dilatation can delay the need for surgery if the lesion is short and accessible; however, many may still inevitably require surgery. Biologic therapy may reduce the need for surgery in symptomatic small bowel Crohn's disease wherein the strictures are predominantly inflammatory. In chronic radiation enteropathy, only refractory small bowel obstruction and those with nutritional difficulties warrant surgery. SUMMARY: Small bowel diseases causing bowel obstruction are often challenging to diagnose and require numerous investigations over a period of time, which often culminate with surgery. Use of biologics and endoscopic balloon dilatation can help to delay and prevent surgery in some instances.

Comparison of patient tolerance and acceptability of magnet-controlled capsule endoscopy and flexible endoscopy in the investigation of dyspepsia.

Background and study aims Oropharyngeal intubation during Esophagogastroduodenoscopy (EGD) is uncomfortable, associated with aerosol generation and transmission of airborne microbes. Less-invasive alternatives may be better tolerated. In this study, patient tolerance and acceptability of EGD and transnasal endoscopy (TNE) have been compared with magnet-controlled capsule endoscopy (MACE). Patients and methods A comparison of MACE with EGD and TNE in the investigation of dyspepsia was performed. Factors affecting patient tolerance and acceptability were examined using the Endoscopy Concerns Scale (ECS) and Universal Patient Centeredness Questionnaire (UPC-Q). Results Patients were significantly more distressed (scoring least to most distress: 1-10) by gagging (6 vs 1), choking (5 vs 1), bloating (2 vs 1), instrumentation (4 vs 1), discomfort during (5 vs 1) and after (2 vs 1) EGD compared to MACE (all P  < 0.0001). Patients were more distressed by instrumentation (5 vs 1) and discomfort during (5 vs 1) TNE compared to MACE ( P  = 0.001). Patients were more accepting of MACE than EGD and TNE with a UPC-Q score (scoring least to most acceptable: 0-100) lower for EGD (50 vs 98, P  < 0.0001) and TNE (75 vs 88, P  = 0.007) than MACE, and a post-procedure ECS score (scoring most to least acceptable: 10-100) higher for EGD (34 vs 11, P  < 0.0001) and TNE (25 vs 10.5, P  = 0.001) than MACE. MACE would be preferred by 83 % and 64 % of patients even if EGD or TNE respectively was subsequently recommended to obtain biopsies in half of examinations. Conclusions Gagging and choking during instrumentation, the main causes of patient distress during EGD, occurred less during TNE but tolerance, acceptability and patient experience favored MACE.

Training pathway for small bowel capsule endoscopy in the UK.

The demand for small bowel (SB) capsule endoscopy (CE) is increasing in the UK. However, there remains a wide variation in the number of CE procedures performed in different centres. Across the UK there is a lack of a clear training pathway or certification process. A standardised national Joint Advisory Group (JAG) on Gastrointestinal Endoscopy approved a 1-year training and accreditation programme accessible to all professional groups that may wish to train in SB CE. Structured training is delivered using JAG-accredited CE courses and an electronic learning module. Prior to setting a knowledge-based assessment, a minimum of 50 SB CE cases are recommended to be read in tandem with a trainer at a local centre, with proficiency documented using Direct Observation of Procedural Skill (DOPS) assessments.

Detachable string magnetically controlled capsule endoscopy for detecting high-risk varices in compensated advanced chronic liver disease (CHESS1801): A prospective multicenter study.

BACKGROUND: Gastroesophageal varices is a serious complication of compensated advanced chronic liver disease (cACLD). Primary prophylaxis to reduce the risk of variceal hemorrhage is recommended if high-risk varices (HRV) are detected. We performed this study to compare the accuracy, patients' satisfaction and safety of detection of HRV by detachable string magnetically controlled capsule endoscopy (DS-MCCE) with esophagogastroduodenoscopy (EGD) as the reference. METHODS: We prospectively recruited participants with cACLD from 12 university hospitals (11 in China and one in the United Kingdom) between November 2018 and December 2019 (ClinicalTrials.gov, NCT03749954). All participants underwent DS-MCCE, followed by EGD within a week in a blinded fashion. Following endoscopy, and on the same day, participants were asked to fill in a satisfaction questionnaire regarding their experience. FINDINGS: A total of 105 eligible participants were enrolled. With EGD as the reference standard, the concordance index, sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio of DS-MCCE in diagnosis of HRV were 0•90 (95% confidence interval [CI]: 0•83-0•95), 92% (95% CI: 78-98%), 88% (95% CI: 78-95%), 80% (95% CI: 70-92%), 95% (95% CI: 90-100%), 7•91 (95% CI: 4•10-15•30), and 0•09 (95% CI: 0•03-0•30), respectively. The kappa score of 0•78 (95% CI: 0•65-0•90) suggested substantial agreement between DS-MCCE and EGD. Moreover, in participants undergoing EGD without sedation, the satisfaction of DS-MCCE was significantly better than that of EGD (p < 0•0001, d = 1•15 [95%CI: 0•88-1•42]). All participants confirmed the excretion of the capsule, and no adverse events occurred. INTERPRETATION: DS-MCCE is an accurate alternative to EGD for detecting HRV in cACLD, which is safe and associated with better satisfaction. FUNDING: A full list of funding can be found in the Funding Support section.

Non-steroidal anti-inflammatory drugs and the gastrointestinal tract.

Non-steroidal anti-inflammatory drugs (NSAIDs) are used commonly but can cause foregut symptoms, peptic ulcer disease and small bowel enteropathy. Such iatrogenic injury can be complicated by gastrointestinal bleeding and perforation. Limiting NSAID use or co-administration with proton pump inhibitors (PPIs) reduce dyspepsia, peptic ulcer disease and rates of complications. Selective cyclo-oxygenase (COX)-2 inhibitors are as effective as adding PPIs in preventing upper and lower gastrointestinal complications. COX-2 inhibitors are suggested in those with high cardiovascular risk and the addition of PPI in those with high risk of bleeding. Where required, COX-2 inhibitor monotherapy may be preferred in unexplained iron deficiency anaemia.

Increased psychological distress and somatization in patients with irritable bowel syndrome compared with functional diarrhea or functional constipation, based on Rome IV criteria.

BACKGROUND: The Rome IV criteria for disorders of gut-brain interaction define irritable bowel syndrome (IBS) as a functional bowel disorder associated with frequent abdominal pain of at least 1 day per week. In contrast, functional diarrhea (FD) and functional constipation (FC) are relatively painless. We compared differences in mood and somatization between Rome IV IBS and FC/FD. METHODS: A total of 567 patients with Rome IV defined IBS or FD/FC completed a baseline questionnaire on demographics, abdominal pain frequency, mood (hospital anxiety and depression scale, HADS), and somatization (patient health questionnaire, PHQ-12). The primary analysis compared differences in mood and somatization between IBS and FC/FD, and the relative influence of abdominal pain frequency on these extra-intestinal symptoms. The secondary analysis evaluated differences across individual IBS subtypes, and also between FC and FD. KEY RESULTS: Patients with IBS-in comparison to those with FC/FD-had significantly higher mean PHQ-12 somatization scores (9.1 vs. 5.4), more somatic symptoms (6.0 vs. 4.3), abnormally high somatization levels (16% vs. 3%), higher HADS score (15.0 vs. 11.7), and clinically abnormal levels of anxiety (38% vs. 20%) and depression (17% vs. 10%). Increasing abdominal pain frequency correlated positively with PHQ-12, number of somatic symptoms, and HADS; p < 0.001. No differences in mood and somatization scores were seen between individual IBS subtypes, and nor between FC and FD. CONCLUSION & INFERENCES: Based on the Rome IV criteria, IBS is associated with increased levels of psychological distress and somatization compared with FD or FC. Patients reporting frequent abdominal pain should be comprehensively screened for psychosomatic disorders, with psychological therapies considered early in the disease course.

Functional gastrointestinal disorders are increased in joint hypermobility-related disorders with concomitant postural orthostatic tachycardia syndrome.

BACKGROUND: Individuals with hypermobility spectrum disorders/hypermobile Ehlers-Danlos syndrome (HSD/hEDS) frequently fulfill criteria for Rome IV functional gastrointestinal disorders (FGIDs). Postural orthostatic tachycardia syndrome (POTS) is also commonly reported in HSD/hEDS and may impact on co-morbidity with and severity of FGIDs, although this remains to be studied. We determined the impact of concomitant POTS and HSD/hEDS on their association with Rome IV FGIDs. METHODS: With the help of the charity organization Ehlers-Danlos Support UK, an online cross-sectional health survey was completed by individuals with HSD/hEDS. The survey enquired for (a) self-reported doctor diagnosis of POTS, chronic fatigue syndrome, and fibromyalgia, (b) the presence and symptom frequency of Rome IV FGIDs, and (c) anxiety and depression scores. KEY RESULTS: Of 616 subjects with HSD/hEDS, 37.5% reported a doctor diagnosis of POTS. POTS-positive individuals were significantly younger than POTS-negative subjects (37 vs 40 years, P = 0.002), more likely to report chronic fatigue syndrome (44% vs 31%, P < 0.0001), and showed a trend toward increased prevalence of fibromyalgia (44% vs 37%, P = 0.06) and higher depression score (P = 0.07). POTS-positive subjects were also more likely to fulfill criteria for Rome IV FGIDs across various organ domains and experienced both upper and lower gastrointestinal symptoms significantly more frequently. The increased associations for FGIDs and GI symptom frequency remained unchanged in HSD/hEDS subjects with POTS following adjustments for age, chronic fatigue syndrome, fibromyalgia, and depression scores. CONCLUSIONS AND INFERENCES: The high FGID burden in HSD/hEDS is further amplified in the presence of POTS. Future studies should elucidate the mechanism by which POTS arises in HSD/hEDS and is associated with increased GI symptoms.

Factors associated with oesophagogastric cancers missed by gastroscopy: a case-control study.

INTRODUCTION: There is increasing demand for gastroscopy in the United Kingdom. In around 10% of patients, gastroscopy is presumed to have missed oesophagogastric (OG) cancer prior to diagnosis. We examine patient, endoscopist and service level factors that may affect rates of missed OG cancers. METHODS: Gastroscopies presumed to have missed OG cancers performed up to 3 years prior to diagnosis were identified over 6 years in Sheffield, UK. Factors related to the patient, endoscopist and endoscopy lists were examined in a case-control study. Procedures which missed cancer were compared with two procedure controls: the procedures which subsequently diagnosed cancer in the same patient, and second, endoscopist matched procedures diagnostic of small benign focal lesions. RESULTS: We identified 48 (7.7%) cases of missed OG cancer. Endoscopy lists on which OG cancer diagnoses were missed contained a greater number of total procedures compared with lists on which diagnoses were subsequently made (OR 1.42 95% CI 1.13 to 1.78) and when compared with lists during which matched endoscopists diagnosed benign small focal lesions (OR 1.25, 95% CI 1.02 to 1.52). The use of sedation, endoscopist profession and experience, or time of procedure were not associated with a missed cancer. CONCLUSION: 7.7% of patients diagnosed with OG cancer could have been diagnosed and treated earlier. Our study suggests that endoscopy lists with greater numbers of procedures may be associated with missed OG cancers. The use of sedation, endoscopist background or time of procedure did not increase the risk of missed cancer procedures.

NSAIDs and the small bowel.

PURPOSE OF REVIEW: The review describes the effects of NSAID gastrointestinal toxicity on the small bowel, wherein injury is as prevalent as in the gastroduodenum. This is well documented by capsule endoscopy, which also provides an endoscopic endpoint for novel treatment strategies. RECENT FINDINGS: Appreciation of the prevalence of NSAID enteropathy has grown with capsule endoscopy and the use of composite end points that include obscure haemoglobin decreases in clinical studies. Along with dual cyclo-oxygenase isoform inhibition, gram-negative antigen presentation plays a role in the pathogenesis of NSAID enteropathy. The concomitant use of proton pump inhibitor (PPI) agents with both selective and nonselective NSAIDs in gastroduodenal protection exacerbates endoscopic enteropathy, which is thought to be due to intestinal dysbiosis. Strategies for small bowel mucosal protection include prostaglandin repletion and augmenting the intestinal flora. SUMMARY: NSAID- related enteropathy is common and often presents subclinically. The most common presentation is anaemia, which may be less common in those on cyclo-oxygenase (COX)-2 inhibitors than nonselective NSAIDs. PPI use worsens NSAID enteropathy with more occult bleeding and ulceration and has been linked to gram-negative intestinal dysbiosis. If NSAID cessation is not possible, COX-2 inhibition without PPI therapy should be considered in patients with upper gastrointestinal risk factors. Mucoprotective agents such as misoprostol and rebamipide show promise and probiotics may have a future role.