The dedicated iron deficiency anaemia clinic: a 15-year experience.

OBJECTIVE: To report our cumulative experience from a dedicated iron deficiency anaemia (IDA) clinic over the last 15 years-with particular emphasis on referral rate, uptake of investigation, impact on endoscopy services, diagnostic yield of gastrointestinal (GI) investigation and the issue of recurrent IDA. METHOD: A series of analyses of a register of 2808 referrals to the Poole IDA clinic between 2004 and 2018. RESULTS: The study population of 2808 had a sex ratio of 1.9 (female/male ratio) and a median age of 72 years (IQR: 60-79). A rising referral rate over the study period appears to be plateauing at around 2 cases per 1000 population per annum. On the basis of a snapshot audit, investigation of IDA may now account for over 20% of all diagnostic endoscopies.Overall, 86% of cases underwent examination of the upper and lower GI tract. Significant GI pathology was identified in 27% of the investigated cohort. Adenocarcinoma of the upper or lower GI tract was found in 8.3%, the majority in the right colon. The prevalence of recurrent IDA was estimated at 12.4%, and the results of investigation of this subgroup are reported. CONCLUSION: Unexplained IDA is common, particularly in those over 60 years, and may be the first indication of underlying GI malignancy in over 8% of cases. Unresolved challenges include accommodating the resulting endoscopy workload, establishing a risk/benefit ratio for investigating those with major comorbidities and the management of recurrent IDA.

Interspecialty referral of oesophagogastric and pharyngolaryngeal cancers delays diagnosis and reduces patient survival: A matched case-control study.

OBJECTIVES: Pharyngolaryngeal and oesophagogastric cancers present with swallowing symptoms and as such, their clinical evaluation traverses boundaries between different specialties. We studied the incidence and significance of interspecialty cancer referrals (ICRs), that is, pharyngolaryngeal cancers first evaluated by gastroenterology and oesophagogastric cancers first evaluated by otolaryngology. DESIGN: A subset analysis of our Integrated Aerodigestive Partnership's audit dataset, of all ICR patients, and an equal number of controls matched for age, sex and cancer subsite. MAIN OUTCOME MEASURES: Information about patient age and presenting symptoms was recorded. The relationship between symptoms and ICR risk was examined with binary logistic regression. Referral-to-diagnosis latency was compared between ICR and control patients with unpaired Student's t test. Cox regression was used to identify independent predictors of overall survival. RESULTS: Of 1130 patients with pharyngolaryngeal and oesophagogastric cancers between 2008 and 2018, 60 diagnoses (5.3%) were preceded by an ICR. Referral-to-diagnosis latency increased from 43 ± 50 days for control patients to 115 ± 140 days for ICR patients (P < .0001). Dysphagia significantly increased the risk of an ICR (odds ratio 3.34; 95% CI 1.30-8.56), and presence of classic gastroesophageal reflux symptoms (heartburn or regurgitation; OR 0.25; 95% CI 0.08-0.83) and "distal" symptoms (nausea/vomiting, abdominal pain or dyspepsia; OR 0.23; 95% CI 0.08-068) significantly reduced the risk. Eleven pharyngolaryngeal cancers (of 26; 42%) were missed by gastroenterology, and eight (of 34; 24%) oesophageal cancers were missed by otolaryngology. An ICR was an independent adverse prognostic risk factor on multivariable analysis (hazard ratio 1.76; 95% CI 1.11-2.73; P < .02; log-rank test). Two systemic root causes were poor visualisation of pharynx and larynx by per-oral oesophago-gastro-duodenoscopy (OGD) for pharyngolaryngeal cancers, and poor sensitivity (62.5%) of barium swallow when it was used to 'evaluate' oesophageal mucosa. CONCLUSIONS: An interspecialty cancer referral occurs in a significant proportion of patients with foregut cancers. It almost triples the time to cancer diagnosis and is associated with a high incidence of missed cancers and diminished patient survival. It is a complex phenomenon, and its reduction requires an integrated approach between primary and secondary care, and within secondary care, to optimise referral pathways and ensure appropriate and expeditious specialist evaluation.

A Comparison of Endoscopic Ultrasound-Guided Fine-Needle Aspiration and Fine-Needle Biopsy in the Diagnosis of Solid Pancreatic Lesions.

Background and Aims: Endoscopic ultrasound (EUS) guided fine-needle aspiration (FNA) is the method of choice for sampling pancreatic lesions. This study compares the diagnostic accuracy and safety of FNB using a novel core needle to FNA in solid pancreatic lesions. Methods: A retrospective review of patients in whom EUS FNA or FNB was performed for solid pancreatic lesions was conducted. Diagnostic performance was calculated based upon a dual classification system: classification 1, only malignant pathology considered a true positive, versus classification 2, atypical, suspicious, and malignant pathology considered a true positive. Results: 43 patients underwent FNB compared with 51 FNA. Using classification 1, sensitivity was 74.0% versus 80.0%, specificity 100% versus 100%, and diagnostic accuracy 77.0% versus 80.0% for FNB versus FNA, respectively (all p > 0.05). Using classification 2, sensitivity was 97% versus 94.0%, specificity 100% versus 100%, and diagnostic accuracy 98.0% versus 94.0% for FNB versus FNA, respectively (all p > 0.05). FNB required significantly fewer needle passes (median = 2) compared to FNA (median = 3; p < 0.001). Adverse events occurred in two (4.5%) FNB patients compared with none in the FNA group (p > 0.05). Conclusion: FNA and FNB have comparable sensitivity and diagnostic accuracy. FNB required fewer passes.

A randomized trial comparing winged versus conventional plastic stents for malignant bile duct strictures.

BACKGROUND AND STUDY AIMS: Stent insertion at endoscopic retrograde cholangiopancreatography (ERCP) is an established therapy for managing malignant biliary obstruction. Conventional plastic stents with a tubular design are most commonly used despite limited patency. Plastic stents with a winged design may theoretically increase the duration of stent patency. The aim of this study was to compare stent patency of the winged versus conventional plastic stents in patients with malignant biliary obstruction. PATIENTS AND METHODS: A prospective, randomized subject-blinded trial was conducted. Patients with malignant biliary obstruction were randomized (1:1) to either a 10 French winged stent or 7 or 10 French conventional plastic stent. Strictures greater than 1 cm distal to the hilum were included. Patients were followed clinically to determine the frequency of stent failure until surgery, death or study closure. RESULTS: Fifty-eight patients were enrolled. Following 9 exclusions, 49 patients were randomized to a winged (n = 23) or conventional stent (n = 26). Median time to stent failure was 89 (95 % CI 26-NA) vs 143 (95 % CI 33 - 266) days ( P  = 0.963) for the winged and conventional group, respectively. Stent failure for the winged group occurred in 11 (48 %) compared to 14 (54 %) in the conventional group. Median survival was 123 (95 % CI 81 - 189) vs 342 days (95 % CI 123 - 704) (p = 0.084) in the winged and conventional group respectively. There were no procedure related adverse events. CONCLUSIONS: Improvement in stent patency was not seen with the winged stent when compared to the conventional plastic stent.

Drug therapies in liver disease.

The likelihood of a general physician encountering a patient with compensated and decompensated liver disease is increasing. This article provides an overview of pharmaceutical agents currently used in the management of cirrhosis and is designed to allow a better understanding of the rationale for using certain drugs in patients with often complex pathology.

Introducing an annualised contract for a consultant team in a district general hospital.

The majority of physicians work a weekly timetable consisting of programmed activities (PAs) defined by the consultant contract. This paper describes the implementation of an annualised contract within a gastroenterology department, which is located across two district general hospital sites within the same trust. The perceived benefits of the system include the introduction of a new out-of-hours emergency endoscopy service, more efficient backfilling of vacant endoscopy lists and greater transparency of work patterns and workload between colleagues and within the trust.

Fragility fracture risk in cirrhosis: a comparison of the fracture risk assessment tool, British Society of Gastroenterology and National Institute for Health and Clinical Excellence guidelines.

OBJECTIVE: Low bone mineral density (BMD) is common in chronic liver disease and predisposes to fracture. We aimed to compare British Society of Gastroenterology (BSG) and National Institute for Health and Clinical Excellence (NICE) osteoporosis guidelines with the fracture risk assessment tool (FRAX). FRAX is a web-based algorithm used to estimate fracture risk with or without dual-emission x-ray absorptiometry (DXA). Pre-BMD FRAX categorises patients to low, intermediate or high risk according to thresholds set by the National Osteoporosis Guidelines Group (NOGG) and recommends lifestyle advice, DXA or anti-osteoporosis treatment, respectively. DESIGN: The guidelines were applied to 132 patients with cirrhosis (91% Child-Pugh A). The number that would require DXA and be recommended treatment was determined. Using post-BMD FRAX/NOGG as a reference point, high-risk patients not recommended treatment and low-risk patients treated 'unnecessarily' were identified. RESULTS: BSG guidelines were applicable to 100% of the cohort, 88% required DXA and 30% would be recommended treatment. Equivalent figures for NICE guidelines were 30%, 17% and 12%, and for FRAX/NOGG guidelines were 78%, 27% and 15%, respectively. Using BSG guidance 8% of high-risk patients were not recommended treatment and 62% of those treated were low risk, compared with NICE: 3%, 60% and FRAX/NOGG: 13%, 40%, respectively. CONCLUSION: For patients with Child-Pugh A cirrhosis BSG guidelines are the most inclusive, but have high cost implications in terms of DXA scanning and unnecessary treatment. Risk stratification using FRAX requires fewer DXA scans with minimal impact in terms of missing high-risk patients, and yields a modest reduction in unnecessary treatment.