OBJECTIVE:The aim of this study was to evaluate UK trainee experience in endoscopy for acute upper gastrointestinal bleeding (AUGIB).METHODS:Data was prospectively collected from all patients presenting to South Yorkshire Hospitals with AUGIB from September 2011 to December 2011 and compared with data from 1996. Concurrently, all gastroenterology trainees registered with the British Society of Gastroenterology were invited to respond to a web-based questionnaire regarding their experience in AUGIB management.RESULTS:77% (589/766) of the patient cohort underwent endoscopy for AUGIB; 15% (90/589) were performed by trainees. 7.2% (9/125) of the out of hours endoscopy case load was performed by trainees; all were low-risk or medium-risk cases (pre-endoscopy Rockall score ≤4). During the study period, dual therapy was delivered by a trainee on only four occasions. Comparison with the 1996 cohort demonstrated a marked reduction in the number of trainee performed endoscopies (76% vs 15%; p<0.001). Questionnaires were returned by 51% (245/478) of British Society of Gastroenterology trainees. 81% (198/245) thought that <10% of the gastroscopies they had performed involved therapeutic intervention. 23% (57/245) felt they would not be competent in AUGIB endoscopy by completion of specialty training.CONCLUSIONS:This study demonstrates the decline over time in trainee experience in AUGIB endoscopy. It also highlights a lack of trainee exposure to more challenging cases, out of hours endoscopy and therapeutic procedures. Furthermore, trainees are concerned that a level of competency may not be attained during specialty training. We advocate reviewing UK endoscopic training provision for AUGIB to ensure that experienced endoscopists are produced to meet future service needs.

Introduction Capsule endoscopy (CE) is a well-tolerated, first line small bowel (SB) investigative modality. A specifically adapted version is available to image the colon, thus providing an option for non-invasive, single visit imaging of the entire gastrointestinal tract. This study evaluates a novel panenteric protocol utilised to investigate patients with symptoms which could originate from the SB, large bowel or both sites. Method Retrospective, single centre, involving consecutive patients attending for panenteric CE between July 2008 and December 2014. PillCam SB (Given Imaging, Israel) or MiroCam (Intromedic, Korea) and PillCam Colon 2 (Given Imaging) were used. All patients with known inflammatory bowel disease (IBD) successfully passed a PillCam Patency device prior. Patient demographics, procedural data, final diagnosis and outcomes were collected. Results 108 procedures were performed, mean age 41.5 years (range 16–95), 72 female, median follow up 27 months (range 2–79). 41 patients had known IBD (37 Crohn’s, 4 ulcerative colitis (UC)) and were undergoing disease re-assessment after 12 months of anti-TNF therapy (12), or due to relapse in symptoms (29). The remaining 67 patients had suspected IBD with predominant symptoms of diarrhoea (33), abdominal pain (15), iron deficiency anaemia (8), weight loss (6) and gastrointestinal bleeding (5). 51 patients refused colonoscopy, 37 chose CE over colonoscopy, 17 had an incomplete colonoscopy and 3 were unfit for colonoscopy. Panenteric capsule endoscopy completion rate (CECR) was 60.1% (65/108), SB CECR 86.1% (93/108) and colon CECR 71.3% (77/108). Colon CE bowel preparation was graded as good or excellent in 61.8%. 2 patients were excluded due to prolonged gastric retention of the colon capsule, 1 subsequently diagnosed with narcotic bowel syndrome. No complications were encountered. In the IBD group, 25 patients (61.0%) had evidence of active disease, leading to medication alterations in 21, surgery in 1 and conservative management in 3. Of the 16 patients in whom mucosal healing had been achieved, medication regimens were downgraded in 10 patients. In the suspected IBD group, this was identified in 13.4% (7 Crohns, 2 UC). Clinically relevant alternative findings included colon polyps (16), diverticular disease (9 colonic, 1 SB), angioectasia (6 SB, 1 colonic), and a small bowel carcinoid (1). The remaining 24 patients were diagnosed with functional bowel disorders and discharged. Of all the 34 patients with IBD identified, 22 had ileitis alone, 5 had ileocolonic disease and 7 had colonic disease alone. Conclusion Panenteric capsule endoscopy is feasible and can be performed safely in patients known to have IBD. It can be used to guide management without resorting to conventional endoscopy and identifies pathology in all areas of the GI tract. Disclosure of interest None Declared.

Introduction Colon capsule endoscopy (CCE) has been demonstrated to be a feasible alternative to colonoscopy for the detection of polyps and neoplasia1and avoids intubation and sedation. This study evaluates the utility of CCE in routine clinical practice and its impact on patient outcomes. Method Retrospective, single-centre, including symptomatic patients attending for CCE using PillCam Colon 2 (Given Imaging, Israel). All patients with known inflammatory bowel disease (IBD) successfully passed a PillCam Patency device prior. Patient demographics, procedural data, final diagnosis and management outcomes were collected. Results 101 patients were included, mean age 43 years (range 16–95), 73 female, median follow-up 29 months (range 1–52). 48% refused colonoscopy, 29% had an incomplete colonoscopy, 17% chose CCE over colonoscopy and 6% were unfit for colonoscopy. Indication for the procedure: anaemia (24%), IBD assessment (16%) and suspected IBD (60%). The latter had predominant symptoms of diarrhoea (77%), abdominal pain (18%) or weight loss (5%). Procedure completion rate 69%, bowel preparation was adequate in 75%. There were no complications. Results are summarised in Table 1. In the anaemia group, CCE altered management in 15%: 3 further procedures (1 double balloon enteroscopy (DBE) and argon plasma coagulation, 1 catheter embolisation and 1 small bowel capsule endoscopy) and 1 altered medication. The remaining 20 were managed conservatively. In the known IBD group, CCE altered further management in 69% (7 altered medication, 2 surgery, 2 further procedures (1 DBE, 1 colonoscopy), the remaining 5 patients were managed conservatively. In those suspected as having IBD, this was identified in 7%. Other clinically significant diagnoses were made in 36%. The remaining 57% patients were thought to have functional bowel disorders and were discharged. 3 patients were excluded due to a non-diagnostic examination. Conclusion CCE may be a useful alternative for detecting clinically relevant pathology in symptomatic patients and can help guide management. An incomplete examination (i.e. distal colon not visualised) was less relevant in the 29 patients who had already had an incomplete colonoscopy beforehand or the 24 patients whose incomplete CCE was sufficient to provide a diagnosis. Although marketed as a colonic imaging device, a third of pathology identified by CCE was in the SB, serving as a reminder that it may be difficult to distinguish symptoms arising from the small or large bowel, or both. Disclosure of interest None Declared. Reference Spada C, Hassan C, Munoz-Navas M, et al. Second-generation colon capsule endoscopy compared with colonoscopy. Gastrointest Endosc2011;74(3):581-89.e1

Introduction Compared to conventional endoscopy, capsule endoscopy (CE) is potentially safer, non-invasive, performed in out-patients and may be an alternative first line investigation in patients with suspected inflammatory bowel disease (IBD). In colon CE (CCE), a dormant mode (to save battery) is followed by device activation when small bowel mucosa is recognised. In this pilot study patients with suspected small and/or large bowel disease underwent a pan-enteric assessment using combined small bowel (SBCE) and CCE. Methods Patients underwent combined SCE and CCE using a novel protocol. Patients had new GI symptoms (group A: symptoms alone or those with additional abnormal results - GI symptoms plus) or underwent assessment of known IBD (group B). Main outcome measures: diagnostic yield (relevant findings only), complications, CE completion rates and colon cleanliness (scored 1–4: excellent to poor). Results Patients (group A, n = 56; group B, n = 26; mean age 41) had refused (50%), had incomplete (21%) prior colonoscopy or chose to have CCE (29%). Group A patients had diarrhoea (62%) and abdominal pain (54%); 17 had GI symptoms plus anaemia (13), acute phase response (9), hypoalbuminaemia (4), radiological abnormalities (3). Mean SBCE and CCE SB examination times: 255 and 92 mins respectively. Mean C examination time: 167mins; median cleanliness score 2. SBCE was complete in 73 (89%) and CCE in 58 patients (71%). In group B, pathology was identified in 62%, 16/26 (all active Crohn’s) which was significantly higher than in Group A (20%: 11/56, p = 0.0003). New diagnoses in Group A: Crohn’s disease (n = 5) and one each of NSAID colitis, proctitis, leiomyoma, angioectasia, diverticulae and idiopathic ulcerated small bowel stricture. 9/11 were in the symptoms plus group. 95% of pathology identified on SBCE was also identified on CCE. No complications were reported. Conclusion 62% of patients known to have IBD had active disease, but diagnostic yield was as high as 20% in those with new symptoms. IBD was the commonest and no complications occurred. Studies of the respective roles of faecal biomarkers, CE and histology in the diagnosis of IBD are needed. Almost all small bowel pathology was recognised by CCE suggesting its use as a remote panenteric endoscopic tool only awaits further battery development. Disclosure of Interest None Declared.

Introduction UGIB is a common emergency frequently requiring endoscopic intervention. Training in therapeutic endoscopy for UGIB is not mandatory. Furthermore UGIB endoscopic experience may be diminished by the European Working Time Directive and a Consultant delivered service. There has been no published data on trainees’ opportunities for UGIB endoscopic experience. This study evaluates GI trainee experience in the South Yorkshire (SY) region and nationally. Methods Rockall scores for patients requiring an endoscopy for an UGIB (n = 622, 5 hospitals) was prospectively collected in SY between Sept-Dec 2011. Trainee experience from this cohort was then compared with a historical SY UGIB cohort (n = 274) from 1996. Nationally, all BSG trainees (n = 478) were invited to respond to a custom designed web based questionnaire (Nov-Dec. 2012). Information was collected about OGD competency (both diagnostic and therapeutic) and trainees’ confidence of acquiring sufficient endoscopic skills in UGIB prior to completing specialty training. Results Regionally, comparison between the 2011 and 1996 SY UGIB cohorts demonstrated comparable 30-day mortality rates (8.5% vs 8.1%, p = 0.78), with similar median post-endoscopy Rockall scores (6 v 5). When comparisons were made between trainee and non-trainee performed procedures, no mortality difference was identified (p = 0.286). However, when comparing trainee undertaken procedures between the two cohorts, a significant decline was observed with 76% (208/274) of endoscopic procedures for UGIB being performed by trainees in 1996 compared with only 16% (97/622) in 2011 (p < 0.0001). Nationally, questionnaires were returned by 51% (245/478) of BSG trainees (median = 4 years registrar training, range 1–9 years). Of these, 42% (104/245) had completed a basic upper GI endoscopy training course and 40% a therapeutic course. Median number of OGD’s performed by trainees was 500, with therapeutic exposure < 10% in 76% of cases. 23% (57/245) of trainees felt their endoscopic skills in UGIB will be insufficient at the time of specialty training completion. Conclusion This study objectively demonstrates a decline in regional training for gastroenterology trainees in UGIB endoscopic procedures. Furthermore our regional audit is supported by the National audit, which suggests that trainees across the UK are both limited in their opportunities and concerned that a level of competency may not be attained during registrar training. We advocate reviewing UK endoscopic training provision for UGIB ensuring qualified and confident endoscopists are produced to meet future service needs. Disclosure of Interest None Declared