Incidence of collagenous colitis in NHS Lothian: a population-based study.

Objective: Increases in incidence of collagenous colitis (CC) have been documented across Europe; however, previous data from NHS Lothian (1998-2003) demonstrated this to be a low-prevalence area. We aimed to assess incidence of CC in NHS Lothian over time by comparing a more recent cohort (2013-2018) with our existing cohort. Methods: All histologically confirmed diagnoses of CC between 2013 and 2018 were obtained from the NHS Lothian colorectal pathology department (Western General Hospital, Edinburgh). Case record review was performed to obtain relevant demographic and clinical data. Data were also collected regarding the availability of colonoscopy in NHS Lothian. Results: 224 cases of CC were diagnosed between 2013 and 2018, compared with 25 between 1998 and 2003. Mean annual incidence rose from 0.5/100 000 population to 4.3/100 000 population. Incidence in females ≥60 years old rose from 2.3/100 000 population to 22.4/100 000 population (p<0.001). The total number of colonoscopies performed increased by 179.1% from 15 262 (1998-2003) to 42 600 (2013-2018), with the number of CC cases per 1000 colonoscopies performed rising from 1.7 to 5.3 (p<0.001). Conclusion: We describe the increasing incidence of CC in Southeast Scotland, with temporal trends comparable to other European countries. The increase is particularly marked in older females and parallels increasing numbers of colonoscopies being performed.

Risk stratifying gastric ulcers: development and validation of a scoring system.

Objective: Debate is ongoing regarding the need for universal endoscopic follow-up to ensure gastric ulcer healing. We aimed to assess the value of follow-up oesophago-gastro-duodenoscopies (OGDs) for gastric ulcer healing and stratify patients according to risk of malignancy by developing a risk score. Design/method: All patients in National Health Service (NHS) Lothian with an index OGD and a diagnosis of gastric ulcer between 1 January 2014 and 31 December 2018 were identified. Data were analysed with logistic regression to identify factors significantly associated with a diagnosis of cancer; a risk score was derived and externally validated. Results: 778 patients were identified and 60.3% (469/778) of patients had a follow-up OGD. 8.6% (66/778) of patients were diagnosed with cancer. No cases of cancer were found on follow-up OGD of a benign appearing ulcer with negative biopsies. Macroscopic suspicion of malignancy was present at index OGD in 100% (3/3) of those diagnosed with cancer on subsequent OGDs. Older age (p=0.014), increased ulcer size (p<0.001) and non-antral location (p=0.030) were significantly associated with malignancy. A risk score (area under the curve (AUC) 0.868, p<0.001, minimum score=0, maximum score=6) was derived from these variables. 78.0% of patients with malignant ulcers scored ≥3, only 15.8% with benign ulcers scored ≥3 (negative predictive value (NPV) 97.4%). External validation yielded an AUC of 0.862 (p<0.001) and NPV of 98.6%; 84.0% of those with malignant ulcers scored ≥3. Conclusion: Ulcers with a combination of macroscopically benign appearances, at least six negative biopsies and a low risk score do not necessarily need endoscopic follow-up.

Unsedated Transnasal Endoscopy: A Safe, Well-Tolerated and Accurate Alternative to Standard Diagnostic Peroral Endoscopy.

Diagnostic unsedated transnasal endoscopy (uTNE) has been proven to be a safe and well-tolerated procedure. Although its utilization in the United Kingdom (UK) is increasing, it is currently available in only a few centers. Through consideration of recent studies, we aimed to perform an updated review of the technological advances in uTNE, consider their impact on diagnostic accuracy, and to determine the role of uTNE in the COVID-19 era. Current literature has shown that the diagnostic accuracy of uTNE for identification of esophageal pathology is equivalent to conventional esophagogastroduodenoscopy (cEGD). Concerns regarding suction and biopsy size have been addressed by the introduction of TNE scopes with working channels of 2.4 mm. Advances in imaging have improved detection of early gastric cancers. The procedure is associated with less cardiac stress and reduced aerosol production; when combined with no need for sedation and improved rates of patient turnover, uTNE is an efficient and safe alternative to cEGD in the COVID-19 era. We conclude that advances in technology have improved the diagnostic accuracy of uTNE to the point where it could be considered the first line diagnostic endoscopic investigation in the majority of patients. It could also play a central role in the recovery of diagnostic endoscopic services during the COVID-19 pandemic.

An Overview of Robotic Capsules for Drug Delivery to the Gastrointestinal Tract.

The introduction of capsule endoscopy two decades ago marked the beginning of the "small bowel revolution". Since then, the rapid evolution of microtechnology has allowed the development of drug delivery systems (DDS) designed to address some of the needs that are not met by standard drug delivery. To overcome the complex anatomy and physiology of the gastrointestinal (GI) tract, several DDS have been developed, including many prototypes being designed, built and eventually produced with ingenious drug-release mechanisms and anchoring systems allowing targeted therapy. This review highlights the currently available systems for drug delivery in the GI tract and discusses the needs, limitations, and future considerations of these technologies.

Artificial intelligence for the detection of polyps or cancer with colon capsule endoscopy.

Colorectal cancer is common and can be devastating, with long-term survival rates vastly improved by early diagnosis. Colon capsule endoscopy (CCE) is increasingly recognised as a reliable option for colonic surveillance, but widespread adoption has been slow for several reasons, including the time-consuming reading process of the CCE recording. Automated image recognition and artificial intelligence (AI) are appealing solutions in CCE. Through a review of the currently available and developmental technologies, we discuss how AI is poised to deliver at the forefront of CCE in the coming years. Current practice for CCE reporting often involves a two-step approach, with a 'pre-reader' and 'validator'. This requires skilled and experienced readers with a significant time commitment. Therefore, CCE is well-positioned to reap the benefits of the ongoing digital innovation. This is likely to initially involve an automated AI check of finished CCE evaluations as a quality control measure. Once felt reliable, AI could be used in conjunction with a 'pre-reader', before adopting more of this role by sending provisional results and abnormal frames to the validator. With time, AI would be able to evaluate the findings more thoroughly and reduce the input required from human readers and ultimately autogenerate a highly accurate report and recommendation of therapy, if required, for any pathology identified. As with many medical fields reliant on image recognition, AI will be a welcome aid in CCE. Initially, this will be as an adjunct to 'double-check' that nothing has been missed, but with time will hopefully lead to a faster, more convenient diagnostic service for the screening population.

What Becomes of the Frequent Hospital Attenders with Centrally Mediated Gastrointestinal Pain Syndrome?

OBJECTIVE: Centrally mediated gastrointestinal pain syndrome (CAPS) is an infrequently diagnosed functional condition. A small number of patients do, however, become heavy service users due to difficulty in controlling severe symptoms. We aim to review the outcomes of patients who required frequent hospitalisation with CAPS. METHODS: Medical records of patients with multiple CAPS presentations during 2015 (n = 18) were further analysed and reviewed until January 1st, 2019. RESULTS: Patients (female 15; male 3) had a median age of 33 (IQR 12) years. Gastrointestinal co-diagnosis was common (88.9%), most frequently irritable bowel syndrome (50%), cyclical vomiting syndrome (27.8%) or gastro-oesophageal reflux disease (16.7%). 66.7% were prescribed regular opiate analgesics. Psychiatric co-morbidity was present in almost all: depression (88.9%); anxiety/panic disorders (38.9%) and post-traumatic stress disorder (27.8%). Social stressors were cited in 33.3%. 27.8% were employed, frequently in healthcare. Over the 4-year study period, 18 identified patients accounted for 2,048 nights in hospital and 672 A+E attendances. In 2015, these patients spent a median of 19 (IQR 34) nights in hospital each with median hospitalisations of between 7 and 10 nights over the following 3 years. Median A+E attendance was 8 per patient (IQR 8) in 2015, remaining relatively constant between 5 and 6 A+E presentations per patient per subsequent year. CONCLUSION: CAPS is a complicated heterogenous condition resulting from an interplay of physical stimuli with cognitive and emotional factors. As such, management is difficult and requires a multidisciplinary approach with considerable patient ownership of the condition, which is often difficult to achieve.

Balloon-Assisted Colonoscopy after Incomplete Conventional Colonoscopy-Experience from Two European Centres with A Comprehensive Review of the Literature.

BACKGROUND: Conventional colonoscopy (CC) allows access for colonic investigation and intervention; in the small group in whom CC is unsuccessful alternative imaging is often sufficient. There remains a subset, however, requiring full colonic visualisation or intervention. Balloon-assisted colonoscopy (BAC) gives a further option when access is difficult. Aims: This study aims to present the experience with BAC of two European tertiary referral centres. Methods: Procedures were carried out under local protocol over 15-years (2006-2020). Markers of procedural quality such as caecal intubation, complications and comfort were retrospectively compiled and analysed. Published evidence was summarised for comparison. Results: 122 procedures were undertaken, with polyps the most frequent indication and 90.2% having at least one previously incomplete CC. Features associated with difficult colonoscopy were common, including intraabdominal surgery (32.0%). 92.6% reached the caecum; completion was higher (96.3%) in those failing CC due to discomfort and lower in those failing due to anatomical difficulties (90.7%) or previous surgery (84.6%). Mean time to the caecum was 20.9 minutes and mean midazolam and fentanyl doses were 2.6 mg and 49.9 µg with low discomfort scores. Conclusion(s): Balloon-assisted colonoscopy is successful in >90% of patients, is well-tolerated, and is safe.

Small bowel angioectasia as a marker of frailty and poor prognosis.

Background and study aims This study aimed to establish 5-year survival of patients diagnosed with bleeding small bowel (SB) angioectasia, with the hypothesis that many will suffer deaths relating to comorbidity rather than gastrointestinaI bleeding. Patients and methods SB capsule endoscopy (SBCE) procedures, performed for suspected SB bleeding or iron deficiency anemia, with angioectasia isolated as the cause of SB bleeding and at least 5 years of follow-up data were isolated (n = 125) along with an age-matched group with "normal" SBCE procedures (n = 125). These were retrospectively analysed with further information on mortality and comorbidity gathered through hospital records. Results Those with angioectasia had a median age of 72.7 years and comorbidities were common. The 5-year survival was 64.0 % (80/125) compared to 70.4 % (88/125) in those with "normal" SBCE. Those with significant cardiac or vascular comorbidity had a poorer survival (52.9 % (37/70) at 5 years) but anticoagulation/antiplatelets/ number of lesions or requirement endoscopic treatment seemed to make little difference. In those with SB bleeding secondary to angioectasia none of the subsequent deaths were directly attributable to gastrointestinal bleeding. Conclusions In this cohort, SB angioectasia did not lead to any deaths but the 5-year survival was poor due to those diagnosed often being older and having comorbidities. This would support the hypothesis that a diagnosis of SB bleeding secondary to angioectasia suggests frailty.

Faecal Calprotectin and 7-α Cholestenone Levels in Microscopic Colitis: Experience from Edinburgh.

INTRODUCTION: Microscopic colitis (MC) is an important cause of chronic, watery diarrhoea. Currently, there is no specific biomarker available to guide diagnosis. The use of faecal calprotectin (FCP) as a potential marker has been addressed in only a few studies. Further, bile acid malabsorption (BAM) often accompanies MC. Current practice recommends the selenium-labelled homocholic acid-taurine (SeHCAT) test, but at our centre, 7 alpha-hydroxy-4-cholesten-3-one (7αC) is used as a simpler and less expensive alternative to SeHCAT, with values over 22ng/mL indicating BAM. This study aims to evaluate the use of FCP as a biomarker in the diagnosis of MC and the role of 7αC in detecting concomitant BAM with MC. METHODS: Pathology records were retrospectively reviewed for patients diagnosed with collagenous colitis (CC) between 2000 and 2018 and lymphocytic colitis (LC) between 1995 and 2011. FCP and 7αc results, if measured within 6 months of pathological diagnosis, were extracted for analysis. RESULTS: Between 2000 and 2018, 646 CC cases were confirmed on histology. Of 646 patients, 147 had FCP measured; in 111 (75.5%) FCP was elevated with mean levels 238.1µg/g (SD±273.0); 140/646 had 7αC measured; 16 (11.4%) indicated BAM. Mean levels were 10.2ng/mL (SD±9.4). During a 21-year period (1995-2011), 204 LC diagnoses were made: 14/204 had FCP measured; 8 (57.1%) were elevated. Mean levels were 128.4µg/g (SD±107.7). Of 204 LC patients, 20 had 7αC measured, 5 (25%) indicating BAM. Mean levels were 13.95ng/mL (SD±9.4). DISCUSSION: Both CC and LC were associated with raised FCP during the diagnostic phase, supporting the potential role of its use in clinical practice. Furthermore, we present results of using 7αC in identifying BAM amongst patients with MC. In our cohort, low levels of 7αC suggest relatively low concordance of BAM with MC.

Self-harm by Sharp Foreign Body Ingestion.

OBJECTIVE: Ingestion of sharp foreign bodies is a less frequently encountered method of selfharm. This study aims to follow up patients presenting with foreign body (FB) ingestion requiring urgent endoscopic intervention under general anaesthetic in theatre, characterise each patient and establish whether admission or removal of the FB promotes further self-harm. METHOD: Eleven adult patients, totalling 38 presentations over a 28-month period were identified. Each was followed up from an initial presentation requiring endoscopy. RESULT: 9/11 (81.9%) where transferred either from prison or psychiatric care with an extensive history of multimodal and usually violent self-harm. Of these 8/9 (88.9%) had a formal psychiatric diagnosis linked to their previous self-harm. Objects retrieved included pens, razor blades, cutlery, wiring, batteries, a metal screw and a TV aerial. The median time between presentations with self-harm was 11 days. Those discharged from the emergency department re-presented after a median of 7.5 days. This was longer, at 14 days, if admitted to hospital; with those having endoscopic procedures re-presenting after a median of 11 days. CONCLUSIONS: Inpatient endoscopic removal of the FB was not associated with an earlier presentation with further self-harm when compared with discharge straight form A+E, but was frequently repeated, often in a characterised manner.

Colonoscopy quality with Entonox®vs intravenous conscious sedation: 18608 colonoscopy retrospective study.

AIM: To compare colonoscopy quality with nitrous oxide gas (Entonox®) against intravenous conscious sedation using midazolam plus opioid. METHODS: A retrospective analysis was performed on a prospectively held database of 18608 colonoscopies carried out in Lothian health board hospitals between July 2013 and January 2016. The quality of colonoscopies performed with Entonox was compared to intravenous conscious sedation (abbreviated in this article as IVM). Furthermore, the quality of colonoscopies performed with an unmedicated group was compared to IVM. The study used the following key markers of colonoscopy quality: (1) patient comfort scores; (2) caecal intubation rates (CIRs); and (3) polyp detection rates (PDRs). We used binary logistic regression to model the data. RESULTS: There was no difference in the rate of moderate-to-extreme discomfort between the Entonox and IVM groups (17.9% vs 18.8%; OR = 1.06, 95%CI: 0.95-1.18, P = 0.27). Patients in the unmedicated group were less likely to experience moderate-to-extreme discomfort than those in the IVM group (11.4% vs 18.8%; OR = 0.71, 95%CI: 0.60-0.83, P < 0.001). There was no difference in caecal intubation between the Entonox and IVM groups (94.4% vs 93.7%; OR = 1.08, 95%CI: 0.92-1.28, P = 0.34). There was no difference in caecal intubation between the unmedicated and IVM groups (94.2% vs 93.7%; OR = 0.98, 95%CI: 0.79-1.22, P = 0.87). Polyp detection in the Entonox group was not different from IVM group (35.0% vs 33.1%; OR = 1.01, 95%CI: 0.93-1.10, P = 0.79). Polyp detection in the unmedicated group was not significantly different from the IVM group (37.4% vs 33.1%; OR = 0.97, 95%CI: 0.87-1.08, P = 0.60). CONCLUSION: The use of Entonox was not associated with lower colonoscopy quality when compared to intravenous conscious sedation using midazolam plus opioid.

Responding to illicit drug use in family practice.

PURPOSE OF REVIEW: To examine and analyse recent published research on the impact and management of drug use and related disorders in primary care settings. Emerging trends in drug use and the development of new treatment approaches are making new demands on the primary care sector. RECENT FINDINGS: Most recent publications relate to descriptions of the drugs used and their impact on mental health. The use of cannabis and newer stimulants and 'legal highs' tends to coexist with opiate use, and their physical and mental health sequelae often overlap. Several studies address methadone and buprenorphine prescribing, its efficacy and limitations, and organizational issues in delivery of treatment. Other areas identified in this review are pain control, adverse consequences of drug use including morbidity from infections associated with drug taking and death due to overdose, and longer-term outcomes. Several publications cover management of chronic conditions in an ageing population of drug users with multiple health problems, and others examine the trend toward community instead of specialist care. SUMMARY: A picture is presented of extensive use of psychoactive substances in many communities. This ranges from club drug taking and low level cannabis use to more invasive and self-harming drug taking resulting from the use of opiates and stimulants. Treatment services are challenged with the need to change.