Polyp detection rate: does length matter?

INTRODUCTION: Polyp detection rate is a surrogate marker for adenoma detection rate and therefore a surrogate marker of quality colonoscopy. To our knowledge, this is the first study that compares distance from the monitor to the endoscopist on polyp detection rate. METHODS: This was a retrospective study comparing polyp detection rate across two different endoscopy room set-ups. All colonoscopies performed between December 2013 and November 2014 were retrieved. The difference in the room set-up was the distance from the endoscopist to the endoscopy monitor. Room A had a distance of 219 cm and Room B had 147 cm. We used two identical rooms, C and D, as a control arm with a distance of 190 cm between the endoscopist and the monitor. RESULTS: There were significant differences in polyp detection rates between Room A and Room B in the bowel cancer screening lists. For these lists, the room with the closest distance from the endoscopist to the monitor (147 cm) had a statistically significant higher polyp detection rate than the room that had a further monitor to endoscopist distance of 219 cm (p<0.0006) and a trend towards a higher polyp detection rate compared with the room where the distance between the monitor and the endoscopist was 190 cm (p=0.08). This effect was not noticed across the service lists. CONCLUSIONS: This study has suggested that the distance from the endoscopist to the monitor can affect polyp detection rate. It appears that for bowel cancer screening lists, the further the endoscopist from the monitor the lower their polyp detection rate.

Provision of out-of-hours services for acute upper gastrointestinal bleeding in England: results of the 2014-2015 BSG/NHS England national survey.

BACKGROUND: There has been a drive to raise the standard of management of acute upper gastrointestinal bleeding (AUGIB) in the UK, including three previous audits, sponsored by the British Society of Gastroenterology (BSG). OBJECTIVE: To review the results of the latest BSG/National Health Service (NHS) England national survey of endoscopy services in England between 2014 and 2015. METHOD: All NHS hospitals accepting acute admissions in England (168) were invited to respond to the survey. RESULTS: Overall, 142 hospitals (84%) returned data. 85% of hospitals used a validated risk assessment score at the time of patient's admission. While 80% of hospitals provided a 24/7 endoscopy service for unstable patients, and another 10% were in network to provide an acute service, only 60% performed an endoscopy within 24 hours for stable acute admissions or inpatients with AUGIB. 11% of hospitals operated an out-of-hours ad hoc rota. 43% felt that pressure from routine work affected their ability to offer a next-day oesophagogastroduodenoscopy service, while 20% of hospitals struggled to recruit endoscopists. 28% of units reported that the previous national audit performed in 2013 had a positive influence on service development. CONCLUSIONS: This survey has revealed significant deficiencies in provision of services for patients with AUGIB in England, without a significant increase in number of hospitals providing an emergency AUGIB service since the last national audit in 2013.

Dietary iron does not impact the quality of life of patients with quiescent ulcerative colitis: an observational study.

BACKGROUND: In animal models, excess luminal iron exacerbates colonic inflammation and cancer development. Moreover, in inflammatory bowel disease (IBD) patients with mild to moderate disease activity dietary fortificant iron intake is inversely related to quality of life. Here we sought to determine whether dietary iron intakes were also related to quality of life in IBD patients in remission. METHODS: Forty eight patients with ulcerative colitis (UC), 42 of which had quiescent disease during this observational study, and 53 healthy control subjects completed quality of life questionnaires and 7-day food diaries. For comparative analysis, 34/group were matched and the linear relationship between dietary iron intakes (total, haem, non-haem or fortificant) and EuroQol quality of life measures was investigated. For UC patients the linear relationship between dietary iron intakes and the scores from the disease specific inflammatory bowel disease questionnaire (IBDQ) was also considered. RESULTS: The intake of dietary iron, and its various sub-fractions, were not associated with quality of life (EuroQol) in patients with quiescent disease or in healthy control subjects. The picture was similar for the 42 quiescent UC patients when disease-specific IBDQ was used. However, the 6 patients who relapsed during the study again showed an inverse association between IBDQ and dietary iron intake (p = 0.03). CONCLUSIONS: Our data suggest that dietary iron does not impact on quality of life in quiescent UC patients but support that, once the disease is triggered, luminal iron may be a permissive factor for exacerbation of disease activity resulting in lower quality of life.

The setting up and running of a cross-county out-of-hours gastrointestinal bleed service: a possible blueprint for the future.

OBJECTIVE: Acute upper gastrointestinal bleeding (AUGIB) results in 25 000 hospital admissions annually. Patients admitted at weekends with AUGIB have increased mortality, and guidelines advise out-of-hours endoscopy. We present retrospective data from our service involving the interhospital transfer of patients. DESIGN: We pooled resources of two neighbouring general hospitals, just north of London. Emergency endoscopy is performed at the start of the list followed by elective endoscopy in the endoscopy unit on Saturday and Sunday mornings. From Friday evening to Sunday morning, patients admitted to Queen Elizabeth II Hospital (QEII) are medically stabilised and transferred to Lister Hospital by ambulance. RESULTS: 240 endoscopies were performed out of hours from December 2007 to March 2011. Of these, 54 patients were transferred: nine had emergency endoscopy at QEII as they were medically unstable; eight of the patients transferred required therapeutic intervention for active bleeding. The mean pre-endoscopy Rockall score of those transferred was 2.5. We examined the records of 51 of the 54 patients transferred. There were three deaths within 30 days after endoscopy not associated with the transfer process. 19 (37%) patients had reduced hospitalisation after having their endoscopy at the weekend. CONCLUSIONS: The introduction of the out-of-hours endoscopy service in our trust has had multiple benefits, including patients consistently receiving timely emergency endoscopy, significantly reduced disruption to emergency operating theatres, and participation of endoscopy nurses ensures a better and safer experience for patients, and better endoscopy decontamination. We suggest our model is safe and feasible for other small units wishing to set up their own out-of-hours endoscopy service to adopt.

The management of constipation in hospital inpatients.

This article reviews the causes of constipation in hospital and how it can be prevented with simple measures. A review of laxatives available on hospital words is provided for the reader and recommendations are made.

Lack of efficacy of a reduced microparticle diet in a multi-centred trial of patients with active Crohn's disease.

BACKGROUND AND AIMS: Dietary microparticles, which are bacteria-sized and non-biological, found in the modern Western diet, have been implicated in both the aetiology and pathogenesis of Crohn's disease. Following on from the findings of a previous pilot study, we aimed to confirm whether a reduction in the amount of dietary microparticles facilitates induction of remission in patients with active Crohn's disease, in a single-blind, randomized, multi-centre, placebo controlled trial. METHODS: Eighty-three patients with active Crohn's disease were randomly allocated in a 2 x 2 factorial design to a diet low or normal in microparticles and/or calcium for 16 weeks. All patients received a reducing dose of prednisolone for 6 weeks. Outcome measures were Crohn's disease activity index, Van Hees index, quality of life and a series of objective measures of inflammation including erythrocyte sedimentation rate, C-reactive protein, intestinal permeability and faecal calprotectin. After 16 weeks patients returned to their normal diet and were followed up for a further 36 weeks. RESULTS: Dietary manipulation provided no added effect to corticosteroid treatment on any of the outcome measures during the dietary trial (16 weeks) or follow-up (to 1 year); e.g., for logistic regression of Crohn's disease activity index based rates of remission (P=0.1) and clinical response (P=0.8), in normal versus low microparticle groups. CONCLUSIONS: Our adequately powered and carefully controlled dietary trial found no evidence that reducing microparticle intake aids remission in active Crohn's disease.

Dietary sources of inorganic microparticles and their intake in healthy subjects and patients with Crohn's disease.

Dietary microparticles are non-biological, bacterial-sized particles. Endogenous sources are derived from intestinal Ca and phosphate secretion. Exogenous sources are mainly titanium dioxide (TiO2) and mixed silicates (Psil); they are resistant to degradation and accumulate in human Peyer's patch macrophages and there is some evidence that they exacerbate inflammation in Crohn's disease (CD). However, whether their intake differs between those with and without CD has not been studied. We aimed to identify dietary microparticle sources and intakes in subjects with and without CD. Patients with inactive CD and matched general practice-based controls (ninety-one per group) completed 7 d food diaries. Intake data for dietary fibre and sucrose were compared as positive controls. All foods, pharmaceuticals and toothpastes were examined for microparticle content, and intakes of Ca and exogenous microparticles were compared between the two groups. Dietary intakes were significantly different between cases and controls for dietary fibre (12 (SD 5) v. 14 (SD 5) g/d; P=0.001) and sucrose (52 (SD 27) v. 45 (SD 18) g/d; P=0.04) but not for Ca. Estimated median TiO2 and Psil intakes (2.5 and 35 mg/individual per d respectively, totalling 10(12)-10(13) microparticles/individual per d) were broadly similar to per capita estimates and while there was wide variation in intakes between individuals there was no significant difference between subjects with CD and controls. Hence, if exposure to microparticles is associated with the inflammation of CD, then the present study rules out excess intake as the problem. Nonetheless, microparticle-containing foods have now been identified which allows a low-microparticle diet to be further assessed in CD.

Intake of dietary iron is low in patients with Crohn's disease: a case-control study.

Patients with Crohn's disease (CD) often experience Fe deficiency (ID) and frequently alter their diet to relieve abdominal symptoms. The present study set out to assess whether patients with CD have dietary habits that lead to low Fe intakes and/or reduced bioavailable Fe compared with control subjects. Patients with asymptomatic CD were matched to controls (n 91/group). Dietary intakes of Fe and contributions from different food groups were compared using a 7 d food diary. Promoters and inhibitors of non-haem Fe absorption were investigated and a recently published algorithm was applied to assess bioavailable Fe. Fewer patients than controls met the reference nutrient intake for Fe (32% CD patients v. 42% controls). Overall, patients had significantly lower mean Fe intakes (by 2.3 mg/d) and Fe density (by 0.26 mg/MJ (1.1 mg/1000 kcal)) compared with controls (both P<0.001). Differences were mainly due to a preference among CD patients for low-fibre non-Fe fortified cereals, particularly breakfast cereals. In particular, control subjects had higher Fe intakes than matched CD subjects for men (P<0.001) and women less than 50 years (P=0.03). Intakes of both ascorbic acid (P<0.001) and phytic acid (P<0.01), but not animal tissue (P=1.0), were lower in patients with CD, but these had no overall effect on the predicted percentage of bioavailable Fe. Thus total bioavailable Fe was reduced in patients with CD due to lower intakes (P<0.01). Dietary Fe intakes are low in CD patients, which may contribute to an increased risk of ID and anaemia. Changing dietary advice may compromise perceived symptoms of the disease so the need for Fe supplementation should be carefully considered.