Gut

McTaggart, S; Wyper, G; Harkins, L; Bishop, I; Bennie, M; Rance, M

doi: 10.1136/gutjnl-2014-307263.436pmid: N/A

Introduction Using real-world healthcare, routinely collected information we investigated the prevalence of irritable bowel syndrome (IBS) and associated consumption of healthcare resources in the Scottish National Health Service. Methods A consultation records database covering 56 general practitioner (GP) practices in Scotland (approximately 255,000 people; 5.8% of the population) was used to identify consultations primarily due to IBS with GP or practice nurses between April 2009 and March 2011 (Read codes: IBS, constipation, diarrhoea). Read codes suggesting other causes of diarrhoea or constipation and patients with inflammatory bowel disease, diverticular disease, coeliac disease or bowel cancer were excluded. A national primary care prescription database was used to identify use of antispasmodics, laxatives or antidiarrhoeals. Referrals to outpatient clinics and acute hospital admissions between January and December 2011 in antispasmodic-treated patients were also analysed using national datasets. Results Based on consultation records, an estimated 341,180 adults (≥18 years) in Scotland suffer from IBS, representing an estimated prevalence of 7.7% (females: 9.8%; males: 5.5%). Patients consulted 1.05 times during 2010/11 for IBS symptoms and consulted more frequently overall than the general population (9.3 vs. 4.7 times per annum). During 2011, 142,738 adults received ≥1 prescription for antispasmodics, most commonly mebeverine (40.1%), hysocine butylbromide (35.7%) or peppermint (18.0%), giving an estimated prevalence of antispasmodic-treated IBS of 3.4% (females: 4.7%; males: 2.0%). One-third of these patients were also prescribed laxatives (24.5%), the antidiarrhoeal loperamide (6.7%) or both (2.5%). Of the antispasmodic-treated patients, 11,645 (9.0%) visited a gastroenterology outpatient clinic in 2011 (11.7% of all gastroenterology clinic attendances) and 1,869 (1.3%) were acutely admitted to hospital due to IBS or symptoms likely to be associated with IBS, most frequently constipation (80.3%). The average length of hospital stay was 2.1 days (2.4 days for admissions due to constipation). A further 1,141 people with no record of antispasmodic prescriptions were admitted with a primary diagnosis of IBS. Conclusion Based on consultation records, the estimated prevalence of IBS in Scotland is 7.7%, and 3.4% based on prescription records; these estimates exclude patients who do not consult a GP or who use laxatives alone or over-the-counter medicines. The prevalence estimates and levels of treatment in this study were consistent with other published information, and show that patients with IBS consume significant healthcare resources. Study commissioned by Almirall UK. Disclosure of Interest S. McTaggart Grant/research support from: This study was undertaken as a commercially contracted piece of work for Almirall UK, G. Wyper Grant/research support from: This study was undertaken as a commercially contracted piece of work for Almirall UK, L. Harkins Grant/research support from: This study was undertaken as a commercially contracted piece of work for Almirall UK, I. Bishop Grant/research support from: This study was undertaken as a commercially contracted piece of work for Almirall UK, M. Bennie Grant/research support from: This study was undertaken as a commercially contracted piece of work for Almirall UK, M. Rance Employee of: Almirall.

Naghibi, M; Stroud, M; Smith, TR; Elia, M

doi: 10.1136/gutjnl-2014-307263.25pmid: N/A

Introduction There is controversy about the indications for home parenteral nutrition (HPN) during the palliative phase of malignancy causing inoperable gastrointestinal obstruction (IBO). This is partly due to uncertainty about the survival of patients. This study aimed to establish the survival characteristics of these patients in order to inform decisions about the use of HPN. Methods A systematic review with meta-analyses were carried out in accordance with the Cochrane protocol for adult patients (>18 years) with a confirmed diagnosis of malignancy causing IBO (in at least 80% of the patients) being treated with palliative HPN. A literature search was carried out in April 2013 using Medline, EMBASE, CINALH and Web of knowledge. Whenever possible, individual patient data were extracted to allow meta-analyses. Results 11 studies involving 420 patients, met the inclusion criteria. 3 studies reported individual patient data, 4 studies represented this using Kaplan Meier, one study using scatter plot and 3 studies only reported averages for survival length. The extraction procedure which gathered individual information on 220 patients from 8 studies, allowed a random effects model meta-analysis to be carried out. The mean age of patients within individual studies ranged between 45–61 years. 64% of patients were female. The underlying primary malignancy was gastrointestinal (53%), gynaecological (25%) (accounting for the female predominance), and others (22%). Four studies reported use of palliative chemoradiotherapy with 39–100% of the patients under going at least one cycle of treatment. Figure 1 shows the survival at monthly intervals for six months. The overall median survival is 83 days. 24% were still alive at 6 months but only about 2% at year. Abstract OC-025 Figure 1 Random effects meta-analyses of survival at monthly intervals up to 6 months (n=220 patients; 8 studies). The bars represent the 95% confidence intervals Conclusion This is first systematic review showing the survival in patients with malignant inoperable bowel obstruction receiving HPN during the palliative phase of care. We show, using the largest published cohort to date, that the median survival is only 83 days. The described variability in survival length between studies and between patients can be substantial. This information can help inform clinician decisions about the use of HPN in such patients. Disclosure of Interest None Declared.

Seagrove, A; Rapport, F; Williams, J

doi: 10.1136/gutjnl-2014-307263.135pmid: N/A

Introduction The qualitative element of CONSTRUCT, a randomised controlled trial comparing clinical and cost effectiveness of infliximab and ciclosporin in steroid resistant UC, contributed to the specific trial objectives of examining quality of life (QoL) across the two groups. The qualitative element concentrated on patient and professional perceptions, and we describe patients’ opinions about treatments and other UC therapies. Methods Semi-structured telephone interviews with patients three and 12 months after admission with acute severe UC and randomisation. Thematic analysis was conducted by three qualitative researchers, followed by group analysis by seven members of CONSTRUCT. This abstract concentrates on the three month data. Results 20 interviews were completed. Length of disease duration varied but similar stories emerged about living and coping with UC, the physical, mental and emotional impact of the disease, treatment options and concerns and hopes for the future. The main issues were: Patients favour infliximab because they perceive a more positive treatment outcome, easier treatment regime and fewer side effects The dramatically debilitating symptoms that impact on patients’ QoL, their family and friends, are particularly noticeable in this disease Patients live with the ongoing unpredictability of symptoms and treatment, making it particularly difficult for patients and healthcare professionals to manage care Unlike other chronic diseases, UC is considered embarrassing, making it an isolating and awkward experience for patients and difficult to manage work and life routines The lack of visibility of symptoms or outcomes impacts on patients’ ability to share and discuss openly with others Surgery is feared but most patients experience relief and subsequent recognition of health benefits following surgery Patients would like to understand what causes UC, its links to stressors and diet and would welcome more extensive information provision Ready access to IBD Nurses was considered important. Conclusion Study findings indicate that UC patients live with constant, unpredictable symptoms, where a flare-up becomes socially isolating along with anxieties of deteriorating health. Patients need support to manage the impact of UC on their lives, consider prompt diagnosis to be important, and need relevant treatment provided quickly. Patients clearly prefer infliximab because of the easier treatment regime and fewer side effects. The views of patients after surgery were generally positive, but more research is required into surgical treatment of UC to support those facing surgery and as an alternative to medical treatment. The profile of UC should be raised to destigmatise the disease and thus the embarrassment felt by sufferers and those living with the outcomes of surgery. Disclosure of Interest None Declared.

Astle, VI; Lewis, NR

doi: 10.1136/gutjnl-2014-307263.446pmid: N/A

Introduction Calprotectin is a protein released by neutrophils in response to the presence of inflammation in the bowel 1. Based on secondary care data with a cut-off of 50 mcg using ELISA assay it has a sensitivity of 93% and specificity of 94% 2 to exclude inflammatory bowel disease (IBD) from functional bowel disorders. Calprotectin can be measured in a stool sample with this non-invasive test significantly cheaper than endoscopy and associated new patient referral 3,4. Faecal calprotectin (FC) has also been shown to correlate with mucosal disease activity and can help to predict response to treatment or relapse in IBD 1. We report the routine use of FC in gastroenterology practice at our hospital. Methods All FC tests performed between 01/07/12 and 31/12/12 were systematically collected and reason for testing determined. Endoscopic, histological, radiological, laboratory and clinical records were systematically searched to identify tests performed in patients with FC results. Results 294 FC tests were performed during the study period: 203 (69.0%) for assessment of IBD and 91 (31.0%) tests to exclude IBD in patients with suspected functional bowel disorders. Mean age of patients with suspected functional bowel disorders was 45 (SD 16.8) years and 62.6% were female. Of the patients with suspected IBS who had a normal FC value (n = 75), 50.7% had a colonoscopy, 20.0% had CT or MRI and 9.3% had a flexible sigmoidoscopy. Of the 75 patients with suspected functional bowel disorder with normal FC values, 2 patients were diagnosed with Crohn’s disease affecting the terminal ileum on colonoscopy. For patients with suspected IBS the test had a specificity of 80.2% and a negative predictive value of 97.3%. Conclusion Despite normal FC result, a significant proportion of young adults with suspected functional bowel disorder undergo colonoscopy with normal test results. As other studies have shown, consideration of the FC result before further investigations are ordered can reduce the number of patients requiring endoscopy or imaging and thus reduce cost 1. However, FC is less sensitive for small bowel Crohn’s disease and therefore careful history taking is required to ensure this is not missed due to a negative FC result. References Smith LA et al. World J Gastroenterol 2012 Dec 14; 18(46):6782–6789 Nice Guideline DG11 Faecal calprotectin diagnostic tests for inflammatory diseases of the bowel NHS England National Tariff Payment System. http://www.monitor.gov.uk/NT. Accessed on 22/1/14 Faecal Calprotectin - Is it Requested Appropriately and is it Cost Effective? Gut2013;62:A266-A267 Disclosure of Interest None Declared.

Chhaya, V; Saxena, S; Cecil, E; Subramanian, V; Curcin, V; Majeed, A; Pollok, R

doi: 10.1136/gutjnl-2014-307263.377pmid: N/A

Introduction Although thiopurines (TPs) have proven efficacy in the maintenance of remission in Crohn’s disease (CD) and may reduce the need for intestinal surgery, their impact on perianal disease is not firmly established since previous trials have not evaluated the efficacy of TPs on perianal disease as a primary endpoint. Our aim was to examine the temporal trends in perianal surgery and TP use using the Clinical Practice Research Datalink (CPRD). Methods Using electronic primary care records, we performed a UK population based study. Incident cases of CD were identified between 1995 and 2009 from the nationally representative CPRD which contains clinical records and prescribing data for 13 million people in the UK and is a validated research database. Patients were included if they had been registered with a practice for greater than 12 months. The primary endpoint was first perianal surgery defined by READ/OXMIS coding. The cohort was divided into two defined historical era; era 1 (1995–2002) and era 2 (2003–2009). We performed Kaplan-Meier survival analysis to establish the 5 year rates of first perianal surgery and trends in TP prescribing by era of diagnosis. Log-rank test for trend was used to compare survival outcomes between groups. Results 5235 patients met the diagnostic criteria for an incident case of CD. 2083 were diagnosed in era 1 (1995–2002) and 3152 in era 2 (2003–2009). The mean duration of follow up was 4.8 years/person. 56.3% of patients were female and median age at diagnosis was 38.5 years (IQR: 24.8–58.1 years). 124 patients underwent perianal surgery. The overall 5 year rate of perianal surgery was 2.2% (95% CI: 1.8–2.7%). Stratified by era of diagnosis the rate was lower in the more recent era: 2.7% (95% CI: 2.1–3.6%) and 1.7% (95% CI: 1.2–2.3%) in era 1 and era 2 respectively (log-rank test for trend p = 0.03). Conversely, during the same period, the 5 year cumulative probability of receiving a TP increased between era 1 and era 2 from 29.1% to 42.2% (log-rank test for trend p < 0.001). Abstract PWE-117 Figure 1 Conclusion Over the 15 year study period, the risk of perianal surgery fell by one third which coincided with a one third increase in TP use during the same period. Other changes in IBD management are also likely to have contributed to this fall in surgery. Further studies to determine independent risk factors associated with perianal surgery are in progress. Disclosure of Interest None Declared.

Chilkunda, DS; Beal, H; Khiyar, Y

doi: 10.1136/gutjnl-2014-307263.77pmid: N/A

Introduction Postgraduate Medical Education and Training Board (PMETB), now part of General Medical Council, reports on Foundation Schools have highlighted lack of consent training among Foundation Year 1 doctors (FY1s).1 This can impact on patient safety and misguide expectations, thus adversely affecting patient experience. It could also affect FY1s’ confidence as they often feel they obtain consent for procedures without adequate training. Robust consenting skills are integral to good medical practice and require urgent attention. Hence we developed a new teaching programme on consenting for diagnostic gastroscopy (DG), which is the commonest inpatient procedure undertaken in the endoscopy unit, and as this procedure is less complex with relatively rare serious complications. Methods We initiated an apprenticeship model of training for consenting as part of mandatory FY1 induction. To facilitate this, we designed a formal assessment tool called Direct Observation of Gastroscopy Consent Taking Skills (DOGCTS). We developed a three-stage process. Stage 1: FY1s were provided small group teaching on consent and procedure. Stage 2: FY1s chose from available list of training slots, which were published after liaison between Endoscopy Unit and East Riding Medical Education Centre. Stage 3: FY1s observed one consenting process and DG by experienced endoscopist and underwent formal assessment using DOGCTS tool. Results This pioneering programme was introduced to all FY1s working in Medicine and Surgery in HRI starting in August 2012. Since its inception, 139 FYs have been trained with 100% attendance rate. In order to avoid disruption to lists, only one FY1 was trained per list. Programme allowed FY1s to plan training around their clinical commitments. Successful completion of DOGCTS has been integrated into FY portfolio-requirements. Feedback from FYs has been positive and they have reported improved confidence. Patients have informally expressed that they had a better patient experience. Conclusion Development of such a novel apprenticeship model allows for trainees and trainers to interact in an open, inclusive and non-threatening manner. It provides FY1s flexibility to manage their learning needs and trainers a chance to give formative feedback in real-time. Such a dynamic approach can not only improve confidence of FY1s but also instil public confidence in healthcare training. It has provided an excellent training opportunity in addition to being useful evidence for training-portfolios. It also caters to quality assurance and medico-legal aspects (pertaining to consenting) for NHS Trusts. We aim to undertake a formal survey of patient satisfaction annually and roll out this programme for flexible sigmoidoscopy consent as well. Reference 1PMETB Report on Quality Assurance of FY1 programme visit to London deanery 2009 Disclosure of Interest None Declared.

Leet, F; Sharif, M; Agrawal, A

doi: 10.1136/gutjnl-2014-307263.298pmid: N/A

Introduction CT PET scan with fluorine-18 (F-18) fluorodeoxyglucose (FDG), is a increasingly common investigation in the evaluation and management of several malignant and non-malignant conditions. (1–3). The usefulness of this technique in diagnosing incidental gastrointestinal lesions in literature is scanty. The purpose of this study was to assess the usefulness of PET scan in detecting incidental significant gastrointestinal disease. Methods 696 PET scans were undertaken in Doncaster and Bassetlaw NHS Trust from 2009 to 2012. The principal indications were malignancy (lung 57%, GI tract 16%, head and neck 7%, haematological 4%, breast 2%) and nonmalignant 11%, unknown indication 3%. Of these, 44 cases (males 61%, median age 70) of incidental increased focal FDG uptake in gastrointestinal tract were detected. All patients underwent endoscopic procedure (Gastroscopy 10, Flexible sigmoidoscopy 10 and colonoscopy 24). Results 21 of 44 (48%) had polyps (malignant n = 3, tubulovillous adenoma n = 11, hyperplastic n = 6, not retrieved n = 1). Other pathologies included vascular lesions, inflammation, and diverticular disease. 11 patients had a false positive PET scan. The overall correlation between PET scanning and Endoscopic findings were found to be 75%. Conclusion PET scan is a valuable tool in localising incidental gastrointestinal pathology and a positive incidental finding merits further follow up endoscopy. The technique detected 6% new gastrointestinal lesions of which nearly half were polyps and two-thirds of these were malignant or adenomatous. References 1 Wong PS, Lau WF, Worth LJ, Thursky KA, Drummond E, Slavin MA, Hicks RJ. Clinically important detection of infection as an ‘incidental’ finding during cancer staging using FDG-PET/CT. Int Med J 2012;42(2):(176–83) 2 Gambhir SS, Czernin J, Schwimmer J, Silverman DH, Coleman RE, Phelps ME. A tabulated summary of the FDG PET literature. J Nucl Med. 2001;42(suppl): 1S–93S 3 I Takayoshi, et al. Detection of unexpected additional primary malignancies with PET/CT. J Nucl Med. 2005;46(5):752–757 Disclosure of Interest None Declared.

China, L; Johnson, G

doi: 10.1136/gutjnl-2014-307263.50pmid: N/A

Introduction The 2007 GI Bleed Audit highlighted significant deficiencies and inconsistencies in service provision and care of patients presenting with UGIB. There is a pressure on UK hospitals to provide a 24/7 endoscopy service to meet NICE guidance on timely endoscopic intervention in upper GI bleeding (UGIB), resulting in an urgent need to determine an endoscopist’s competence. JAG provide quality assurance in UK endoscopy by using compulsory summative assessment in diagnostic endoscopy and more recently polypectomy. There is currently no structured, formal tool or criteria with which to assess and provide feedback for the specific generic and endoscopic skills required for effective management of UGIB. DOPS are used as a tool to assess endoscopic skills by providing a framework for experts to observe, assess and provide feedback on a procedure. We developed a new DOPS tailored to the specific aspects of therapeutic endoscopic management of UGIB to improve training, with a view to developing the tool for use in summative assessment for JAG accreditation. Methods A working group of expert endoscopists was formed at University College London Hospital. UGIB task deconstruction was undertaken and, after multiple revisions, consensus was reached on the individual aspects of management, and then to define what was considered a satisfactory endoscopic performance in each of these domains. The performance rating scale was based on the degree of independence demonstrated by the trainee in each performance domain. These aspects of performance, definitions of standards and rating scales were then used to construct the UGIB-DOPS. We evaluated the feasibility, validity and educational impact of UGIB-DOPS using 8 trainees paired with trainers using questionnaires and semi-structured interviews. Abstract OC-050 Figure 1 Results The trainee cohort displayed a range of experience from novices (n = 2) to trainees who had managed >80 cases (n = 2). Qualitative assessment of the educational impact of UGIB-DOPS found universal agreement that the tool’s defined assessment criteria facilitated structured feedback and it was perceived the overall grade awarded reflected trainee’s current competence. Thematic interview analysis revealed recurring concepts of how UGIB-DOPS facilitated training: creation of an observed teaching event, knowledge of the required standards and concrete formulation of action plans. All found UGIB-DOPS feasible to use and the rating scale more transparent than currently used DOPS. Conclusion Creation of the UGIB-DOPS has for the first time introduced defined assessment standards in UK UGIB management facilitating formative assessment leading to a feasible improvement in workplace training. A larger pilot is now required to determine the reliability of UGIB-DOPS prior to considering its use as part of the summative assessment of endoscopist’s competence. Disclosure of Interest None Declared.

Quarterman, C; Davies, M; Smart, HL; Taggart, N; Sarkar, S

doi: 10.1136/gutjnl-2014-307263.473pmid: N/A

Introduction NHS indicators for quality improvement (QI) are divided into key domains - safety, experience, outcome and effectiveness. Patient experience has been shown to be positively related to clinical effectiveness and safety and should not be overlooked when assessing the effectiveness of a service. The introduction of a new Anaesthesia-Led Propofol Sedation (ALPS) service in 2012 was pivotal in managing patients undergoing complex endoscopic procedures. Our aim was to establish a continuous quality improvement programme to take an already successful service and pursue excellence. Methods Measures and scores were agreed within the domains of patient optimisation, outcome and experience, and service efficiency. A composite score was used as an Excellence Score. All patient episodes were scored by the same anaesthetist using a 3-point qualitative scale; fully (>95% complete, 2 points), largely (75–95% complete, 1 point) and partially/not achieved (<75% complete, 0 points). Individual domain scores and the Excellence Score were presented as a percentage, in terms of the current service and “What If” scores to show the impact of changing practice. Patient experience was measured indirectly and with a telephone questionnaire at one-week post-discharge. Results were discussed in an MDT focus group, interventions instigated and the data recollected three months later and re-discussed. Results 40 consecutive patients attending for complex endoscopic procedures from January to June 2013 were reviewed. Table 1 shows scores during the first three months and the influence of implemented changes. Across all scores, improvement was seen, particularly in the Efficiency Score which increased by 22%. Abstract PTH-027 Table 1 Domain and excellence scores over the six-month QI period Jan-Mar Apr-Jun Outcome score 93% 97% Experience score 86% 93% Efficiency score 62% 85% Excellence score 68% 75% A patient optimisation score reflected a guideline-compliant service, but was initially low due to a lack of pre-assessment and individualised patient preparation, and sporadic use of an adapted WHO Surgical Safety Checklist. A “What If” score of 82% was presented, showing the potential service gains in the presence of these additions. Consequently managers agreed to fund use of the Hospital Preoperative Assessment Service and clinical staff agreed to implement regular use of an adapted WHO Safe Surgery Checklist. Conclusion Achieving excellence depends upon acknowledging weaknesses in practice that may already be very good. This study has shown the value of a quality improvement programme in improving a new, innovative service. Often adoption of care elements used routinely elsewhere within the hospital setting can lead to significant improvements in patient care and the efficiency of the service. Disclosure of Interest None Declared.

Dixon, SW; Valliani, T; Fayyaz, F; Tate, D; Arthurs, E; Lim, L; Dhanda, A; Lockett, M

doi: 10.1136/gutjnl-2014-307263.324pmid: N/A

Introduction Large (>2 cm) colonic polyps present a challenge to the colonoscopist. The British Colorectal Cancer Screening Programme (BCSP) recently drafted guidelines to standardise their management. We compared our current practice with the proposed guidelines. Methods This was a retrospective audit in four South-West hospitals with comparison between screening and non-screening patients. Patients were identified using clinical coding. Case notes were reviewed. Polyps were scored using SMSA system to standardise difficulty of endoscopic resection. Data was compared against 9 auditable outcomes. Results 104 cases were identified (24 BCSP, 80 symptomatic). There was no significant difference in mean size (2.9 cm BCSP, 2.7 cm symptomatic, p = 0.14) or mean SMSA grading (2.8 BCSP, 2.9 symptomatic, p = 0.46). 6 polyps were malignant (1 BCSP; 5 symptomatic); all had position marked by tattoo. 1 malignant polyp was resected endoscopically in the symptomatic group. Mean time to definitive resection was 34 and 30 days (BCSP and symptomatic respectively). Recurrence of adenoma at EMR site was low at 3 months (0/22 BCSP, 1/37 symptomatic) and 12 months (0/22 BCSP, 2/37 symptomatic). However fewer EMR sites were checked if the index endoscopy was performed by a non-BCS colonoscopist (10/13 vs. 8/24). Complication rates were low: 1 haemorrhage requiring admission (symptomatic group); 0 perforations. 17 benign polyps were referred for surgery (3 BCSP, 14 symptomatic; p = 0.49). In both groups the mode SMSA score was 4. Benign polyps were referred directly for surgery; only those polyps with malignant histology were discussed at a formal mutli-disciplinary meeting. There were no deaths or signficant morbidity associated with surgery for bening polyps. Conclusion Overall management was comparable to draft guidelines. The frequency of large polyps outside BCSP indicates that non-BCS endoscopists will gain experience with these lesions. Approximately 17% of benign polyps were referred for surgery, similar to other series. However, none had been discussed with local EMR experts. Consequently a large polyp referral pathway has been established at two centres within the region. Reference Gupta S, Miskovic D, Bhandari P, et al. SMSA scoring system: a novel scoring system for determining the level of difficulty of a polypectomy. Gastrointestinal Endoscopy 2011;73(4S):AB418–9 Disclosure of Interest None Declared.