is but there are few high-level recommendations on when not to biopsy. Taking a biopsy cost of £103 a potential of £ 10330 could have been saved during our study period. Findings from our study mandate development of such guidance, by training of all endoscopists UK-wide audit of local to ensure compliance with guidelines.

Multiple techniques exist for the management of colorectal polyps. Recent (2017) ESGE guidelines defined an evidence based approach to the optimal polypectomy technique for different sizes of polyps. We examined polypectomy practice amongst United Kingdom endoscopy trainees with reference to these guidelines.

Introduction Multiple techniques exist for the management of colorectal polyps. Recent ESGE guidelines1 have defined an evidence based guide to the optimal technique for removing different sizes of polyps. Previously this decision often depended on an individual operator’s experience and training. We sought to examine current polypectomy practice amongst United Kingdom endoscopy trainees with to these guidelines. Methods The ESGE polypectomy guideline1 suggests polyps<10 mm should be removed using cold snare polypectomy (CSP) or cold biopsy forceps (CBF) [≤3 mm only], 10–19 mm using endoscopic mucosal resection (EMR) or hot snare polypectomy (HSP) and ≥20 mm using EMR. The JETS database is a prospectively collected record of trainee colonoscopic procedures in the United Kingdom and its use during training is mandatory for accreditation. Data is entered by trainees on their own endoscopic procedures. Adverse events were classified as delayed bleeding or delayed perforation. We retrospectively analysed procedures entered into the JETS database from Jan 2008 to December 2017 for polypectomy technique and compared this to the 2017 ESGE guideline. Results 2 91 778 polypectomies were performed in 1 76 569 trainee-performed procedures by 3395 trainees over the study period. 10 584 polypectomies were missing data. 2 81 194 polypectomies were analysed. Of 2 50 783 polyps<10 mm in size removed, 29.5% were performed using CBF, 27.9% by CSP, 25.1% by HSP, 9.5% by HBF, and 8.0% by EMR. Of 26 605 polyps 10–19 mm in size, 55.3% were removed by HSP, 31.0% by EMR and 3.5% by CSP. 8.4% of lesions were biopsied and not removed. Of 3806 polyps≥20 mm in size, 39.4% were removed by EMR, 36.3% by HSP, 1.1% were removed by CSP and 21.9% of these lesions were biopsied and not removed. Overall, adherence to the ESGE guidance was observed in 1 54 948 polypectomies (55.1%). Nurse endoscopists were more adherent (61.7%), versus physicians (57.9%) versus surgeons (44.3%), p<0.001. Of 219 (0.1%) adverse events reported amongst all polypectomies, 50.8% were amongst HSP, 19.2% EMR, 16.9% CSP and 12.7% after HBF p<0.001. Of 20 delayed perforations (event rate 0.01%), 55% were due to EMR, 30% to HSP and 15% to HBF. No perforations resulted from CSP. Conclusions Cold snare polypectomy is under-utilised for diminutive polypectomy, despite its proven safety and efficacy; its use amongst trainees should be promoted in line with ESGE guidance. Trainees are likely to follow the example of their trainers and, as such, this study likely provides an insight into current polypectomy practice in the wider UK endoscopic community. Trainees in the United Kingdom predominantly remove diminutive polyps with extremely low rates of adverse events. Reference . Ferlitsch M, et al. Colorectal polypectomy and endoscopic mucosal resection (EMR): Endoscopy. 2017 Mar 1;49(3):270–97.

Introduction Meta-analysis evidence suggests that IV boluses of proton pump inhibitors (PPIs) are non-inferior to IV infusions post endoscopic treatment of high risk peptic ulcers in terms of re-bleed rates.1 Our trust guideline for PPI use post treatment of high risk ulcers was changed from IV infusion to IV bolus therapy. We have compared re-bleed rates for those treated with bolus therapy and those who were given infusions in line with the older guideline to see if real-world data from a UK DGH reflects the findings of the meta-analysis. Methods All endoscopy reports (electronically captured at the time of endoscopy) for the six month periods prior to and after the change in guidelines were retrospectively reviewed. Once patients who had been treated for high risk ulcers were identified, the method of PPI administration they received, as well as their re-bleed rates were compared. A Chi-squared test was performed using SPSS. Results The re-bleed rate prior to the change in guidelines was 14% (9 of 64) and after the change this fell to 10% (7 of 70) though the difference was not statistically significant (p-value 0.53). Conclusions Our real-world data mirror the current evidence from the meta-analyses; we found no deleterious effects from switching to IV bolus PPI as adjuvant treatment in high risk peptic ulcer disease that has been treated endoscopically. We recommend switching to from PPI infusions to IV boluses which has cost and nurse time advantages while maintaining efficacy. Reference . Sachar H, Vaidya K, Laine L. Intermittent vs continuous proton pump inhibitor therapy for high-risk bleeding ulcers: a systematic review and meta-analysis. JAMA Intern Med. 2014Nov;174(11):1755–62. doi:10.1001/jamainternmed.2014.4056

Question: A 59-year-old woman presented with a 4-day history of abdominal pain, diarrhea, and vomiting. During her stay she had an episode of melena and her hemoglobin dropped from 116 to 86 g/L. She had a past medical history of gallstone disease for which she underwent an elective laparoscopic cholecystectomy in 2014. Clinical examination revealed tenderness in the epigastric region. Esophagogastroduodenoscopy revealed a foreign object at anterior wall of the first part of duodenum (Figure A). There was no sign of recent bleeding at this site. A computed tomography scan was also undertaken and showed the changes illustrated in (Figure B). Based on the image findings, what is your diagnosis and how would you manage the condition? Look on page 1536 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and images in GI. Esophagogastroduodenoscopy showed a Hem-o-Lok clip at anterior wall of the first part of duodenum (Figure A). A computed tomography scan demonstrated a 10-mm hyperattenuating “clip” noted in the duodenal wall with no evidence of retroperitoneal or intraperitoneal collection or free air (Figure B). Our patient had a Hem-o-Lok clip for ligation of cystic duct and its proximity to duodenum could have led to fistula formation. The patient underwent laparoscopic removal of the clip and her hemoglobin increased to 124 g/L at 2 months after the procedure. Laparoscopic cholecystectomy and common bile duct exploration is the standard surgical procedure for patients with cholecystolithiasis. A Hem-o-Lok clip is a polymer ligation clip system used to ligate gallbladder vessels and cystic duct during laparoscopic cholecystectomy. Hem-o-Lok clips have been also used for vascular control in urologic, gynecologic, general, and colorectal laparoscopic surgery. Surgical clip migration into the common bile duct is a known but very rare complication.1Martinez J. Combs W. Brady P.G. Surgical clips as a nidus for biliary stone formation: diagnosis and therapy.Am J Gastroenterol. 1995; 90: 1521-1524PubMed Google Scholar Liu et al2Liu Y. Ji B. Wang Y. et al.Hem-o-lok clip found in common bile duct after laparoscopic cholecystectomy and common bile duct exploration: a clinical analysis of 8 cases.Int J Med Sci. 2012; 9: 225-227Crossref PubMed Scopus (12) Google Scholar showed that the Hem-o-Lok clip migrated in the common bile duct after laparoscopic cholecystectomy and common bile duct exploration in 8 of 1600 patients. Endoscopic removal is successful in most cases. In the international literature there is only 1 such similar report, where the clip was found to migrate into the duodenum without any features of upper gastrointestinal hemorrhage. In this previous report, Seyyedmajidi et al removed the clip safely at endoscopy.3Seyyedmajidi M. Hosseini S.A. Hajiebrahimi S. et al.Hem-o-Lok clip in the first part of duodenum after laparoscopic cholecystectomy.Case Rep Gastrointest Med. 2013; 2013: 251634PubMed Google Scholar In our case, because of the recent brisk hemorrhage, we felt it safer to remove the clip at laparoscopy. Therefore, there is risk that Hem-o-Lok clips can migrate during postoperative period and we should be aware of the potential complications that might occur.