Background and study aims Use of fluoroscopy in gastrointestinal endoscopy is an essential aid in advanced endoscopic interventions. However, it also raises concerns about radiation exposure. This study aimed to develop consensus-based statements for safe and effective use of fluoroscopy in gastrointestinal endoscopy, prioritizing the safety and well-being of healthcare workers and patients. Methods A modified Delphi approach was employed to achieve consensus over three rounds of surveys. Proposed statements were generated in Round 1. In the second round, panelists rated potential statements on a 5-point scale, with consensus defined as ≥80% agreement. Statements were subsequently prioritized in Round 3, using a 1 (lowest priority) to 10 (highest priority) scale. Results Forty-six experts participated, consisting of 34 therapeutic endoscopists and 12 endoscopy nurses from six continents, with an overall 45.6% female representation (n = 21). Forty-three item statements were generated in the first round. Of these, 31 statements achieved consensus after the second round. These statements were categorized into General Considerations (n = 6), Education (n = 10), Pregnancy (n = 4), Family Planning (n = 2), Patient Safety (n = 4), and Staff Safety (n = 5). In the third round, accepted statements received mean priority scores ranging from 7.28 to 9.36, with 87.2% of statements rated as very high priority (mean score ≥ 9). Conclusions This study presents consensus-based statements for safe and effective use of fluoroscopy in gastrointestinal endoscopy, addressing the well-being of healthcare workers and patients. These consensus-based statements aim to mitigate risks associated with radiation exposure while maintaining benefits of fluoroscopy, ultimately promoting a culture of safety in healthcare settings.

Global incidence of non-alcoholic fatty liver disease: A systematic review and meta-analysis of 63 studies and 1,201,807 personsJournal of HepatologyVol. 79Issue 2PreviewThe prevalence of non-alcoholic fatty liver disease (NAFLD) is increasing. We aimed to estimate the pooled global NAFLD incidence. Full-Text PDF We read with interest the systematic review and meta-analysis by Le et al. which demonstrates the rapidly increasing worldwide incidence of non-alcoholic fatty liver disease (NAFLD) likely associated with the obesity epidemic.[1]Le MH Le DM Baez TC Wu Y Ito T Lee EY Global incidence of non-alcoholic fatty liver disease: a systematic review and meta-analysis of 63 studies and 1,201,807 persons.J Hepatol. 2023; 79: 287-295Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar Recently, we have demonstrated that NAFLD is the second most common cause of liver disease in patients admitted to hospital with decompensated cirrhosis in the UK (14.4% of admissions).[2]The Trainee Collaborative for Research and Audit in Hepatology UKRegional variation in characteristics of patients with decompensated cirrhosis admitted to hospitals in the UK.Lancet Gastroenterol Hepatol. 2023; 8: 604-606Abstract Full Text Full Text PDF Scopus (2) Google Scholar We strongly agree that targeted public health interventions to reduce the incidence and prevalence of NAFLD combined with optimal outpatient management strategies are needed to mitigate against NAFLD-related complications.[3]McPherson S Armstrong MJ Cobbold JF Corless L Anstee QM Aspinall RJ et al.Quality standards for the management of non-alcoholic fatty liver disease (NAFLD): consensus recommendations from the British Association for the Study of the Liver and British Society of Gastroenterology NAFLD Special Interest Group.Lancet Gastroenterol Hepatol. 2022; 7: 755-769Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar However, efforts to better characterise and stratify this cohort are similarly required. Utilising more robust phenotypic data should allow for the development of NAFLD-specific risk prediction models and may encourage implementation of precision approaches to improve overall patient outcomes. We analysed data from a UK multicentre, retrospective observational cohort study, including patients admitted to hospitals with decompensated cirrhosis in November 2019[4]The Trainee Collaborative for Research and Audit in Hepatology UKAdmission care bundles for decompensated cirrhosis are poorly utilised across the UK: results from a multi-centre retrospective study.Clin Med (Lond). 2023; 23: 193-200Crossref PubMed Scopus (4) Google Scholar (Table S1 provides regional submission data). We compared admissions for patients with NAFLD to the rest of the predominately alcohol-related liver disease (ARLD) cohort. Details of methods and statistical analyses are presented in the supplementary materials. The NAFLD cohort were significantly older (69.0 (IQR 62.3-77.0) vs. 55.5 (IQR 47.0-65.0), p <0.0001∗) and less likely to be male (50.6% vs. 63.5%, p = 0.001∗) (Table 1A). Whilst we note Le et al. demonstrated a higher incidence of NAFLD amongst male patients, this may reflect previous findings that mortality is comparable across male and female patients with NAFLD, reflecting a similar prevalence of advanced disease.[5]Simon T.G. Roelstraete B. Khalili H. Hagström H. Ludvigsson J.F. Mortality in biopsy-confirmed nonalcoholic fatty liver disease: results from a nationwide cohort.Gut. 2021; 70: 1375-1382Crossref PubMed Scopus (248) Google Scholar No differences were demonstrated in the proportion of admissions with a previous history of decompensation or known liver disease, or a history of hepatocellular carcinoma (HCC) between cohorts. Patients admitted with NAFLD were significantly less likely to regularly consume alcohol (18.0% vs. 61.8%, p <0.0001∗) than the rest of the predominant ARLD cohort (Table 1A). However, alcohol consumption has been shown to be underreported in previous cohorts of NAFLD and markers of alcohol use may have highlighted individual’s regularly consuming alcohol above recommended limits.[6]Staufer K Huber-Shonauer U Strebinger G Pimingstorfer P Suesse S Scherzer TM et al.Ethyl glucuronide in hair detects a high rate of harmful alcohol consumption in presumed non-alcoholic fatty liver disease.J Hepatol. 2022; 77: 918-930Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar Admissions for patients with NAFLD were predominantly related to the management of ascites (40.9% vs. 32.1%, p = 0.02∗) or encephalopathy (25.6% vs. 15.8%, p = 0.002∗), and less likely to be for jaundice (2.8% vs. 17.2%, p <0.0001∗) (Table 1A). Ascites is associated with the highest risk of readmission for patients with NAFLD.[7]Paik JM Eberly KE Kabbara K Harring M Younossi Y Henry L et al.Non-alcoholic fatty liver disease is associated with greater risk of 30-day hospital readmission in the United States (U.S.).Ann Hepatol. 2023; 28: 101108Crossref PubMed Scopus (2) Google Scholar Patient-centred elective outpatient paracentesis provision is therefore a requisite component of modern hepatology services. Recently, data has implicated the premature onset of encephalopathy in NAFLD, while the association of hyperammonaemia with deleterious outcomes is also well-described.[8]Thomsen KL Eriksen PL Kerbert AJC De Chiara F Jalan R Vilstrup H Role of ammonia in NAFLD: an unusual suspect.JHEP Reports. 2023; 5: 100780Abstract Full Text Full Text PDF PubMed Scopus (2) Google Scholar A high index of suspicion for encephalopathy is required in this cohort, in addition to a low threshold in initiating therapies for hyperammonaemia. The reduction in the proportion of patients admitted with jaundice likely reflects the cohort of patients from the predominately ARLD cohort presenting with alcohol-related hepatitis.Table 1Characterising UK NAFLD admissions.A) VariableNNAFLD, n = 176NAlternate aetiology of liver disease, n = 1,048p valueAge17669.0 (62.3-77.0)1,04855.5 (47.0-65.0)<0.0001∗Male sex17689 (50.6%)1,048665 (63.5%)0.001∗Current alcohol use12222 (18.0%)813502 (61.8%)<0.0001∗Previously known liver disease176151 (85.8%)1,048890 (84.9%)0.82Previous known decompensation176116 (65.9%)1,048706 (67.4%)0.73Known HCC17610 (5.7%)1,04854 (5.2%)0.72Reason for admission Ascites17672 (40.9%)1,048336 (32.1%)0.02∗ Encephalopathy17645 (25.6%)1,048166 (15.8%)0.002∗ Gastrointestinal bleeding17619 (10.8%)1,048161 (15.4%)0.13 Jaundice1765 (2.8%)1,048180 (17.2%)<0.0001∗ Sepsis17610 (5.7%)1,04869 (6.6%)0.74Prognostic scores MELD score14713.0 (11.0-18.0)95517.0 (12.0-21.0)<0.0001∗ UKELD score14753.0 (51.0-60.0)95557.0 (52.0-62.0)<0.0001∗ Child-Pugh score1398.0 (7.0-10.0)9329.0 (8.0-11.0)0.0005∗Post 24-hour care Managed by a specialist176125 (71.0%)1,048776 (74.1%)0.41 Predominately managed on a specialist ward17693 (52.8%)1,043597 (57.2%)0.29 Critical care admission during stay1769 (5.1%)1,048123 (11.7%)0.008∗ Transfer to another centre1765 (2.8%)1,04819 (1.8%)0.37 Admission mortality17127 (15.8%)1,029160 (15.6%)0.91 Length of stay1427.0 (4.0-13.0)8597.00 (3.0-13.0)0.60B) VariableNSurvivors, n = 144NNon-survivors, n = 27p valueAge14469.0 (62.0-76.0)2773.0 (65.0-78.0)0.17Male sex14472 (50.0%)2715 (55.6%)0.68Current alcohol use10220 (19.6%)172 (11.8%)0.74Previously known liver disease144125 (86.8%)2722 (81.5%)0.54Previous known decompensation14496 (66.7%)2717 (63.0%)0.83Known HCC1448 (5.6%)272 (7.4%)0.66Reason for admission Ascites14459 (41.0%)2711 (40.7%)>0.9999 Encephalopathy14438 (26.4%)275 (18.5%)0.47 Gastrointestinal bleeding14416 (11.1%)272 (7.4%)0.74 Jaundice1444 (2.8%)271 (3.7%)0.58 Sepsis14410 (6.9%)270 (0.0%)0.37Prognostic scores MELD score11913.0 (10.0-17.0)2321.0 (15.0-27.0)<0.0001∗ UKELD score11953.0 (50.0-57.0)2359.0 (54.0-61.0)0.0001∗ Child-Pugh score1138.0 (7.0-9.0)2210.0 (8.8-11.0)0.0002∗Post 24-hour care Managed by a specialist144100 (69.4%)2721 (77.8%)0.49 Predominately managed on a specialist ward14478 (54.2%)2712 (44.4%)0.40 Critical care admission during stay1445 (3.5%)274 (14.8%)0.04A) Comparison of admissions for patients with NAFLD compared to patients with alternate aetiologies of liver disease. B) Comparison of NAFLD admissions resulting in patient survival with those that did not. Non-normally continuous data were analysed using Mann-Whitney U tests and presented as median (IQR). Categorical data were analysed using Fisher’s exact tests and presented as number (%). ∗Statistical significance set as per Benjamini-Hochberg procedure with a false discovery rate of 0.05.HCC, hepatocellular carcinoma; MELD, model for end-stage liver disease; NAFLD, non-alcoholic fatty liver disease; UKELD, UK end-stage liver disease. Open table in a new tab A) Comparison of admissions for patients with NAFLD compared to patients with alternate aetiologies of liver disease. B) Comparison of NAFLD admissions resulting in patient survival with those that did not. Non-normally continuous data were analysed using Mann-Whitney U tests and presented as median (IQR). Categorical data were analysed using Fisher’s exact tests and presented as number (%). ∗Statistical significance set as per Benjamini-Hochberg procedure with a false discovery rate of 0.05. HCC, hepatocellular carcinoma; MELD, model for end-stage liver disease; NAFLD, non-alcoholic fatty liver disease; UKELD, UK end-stage liver disease. Following admission, no differences were noted between cohorts in the proportion of patients managed by a specialist Gastroenterologist/Hepatologist on specialist wards, or in patients transferred to specialist centres. No differences were demonstrated between patient cohorts for mortality during admission (15.8% vs. 15.6%, p = 0.91) despite admissions with NAFLD having significantly lower prognostic scores and being less likely to access critical care (5.1% vs. 11.7%, p = 0.008∗) (Table 1A). Whilst this may reflect the older age of this cohort and concomitant comorbidity, previous concerns have been raised regarding limited access to critical care for patients with ARLD with stigma amongst healthcare professionals suggested as a potential barrier for this cohort.[9]Mitchison H. Saksena S. Hudson M. NCEPOD and alcohol-related liver disease, what are the views of those who deliver the service? A survey of consultants and trainees in North Eastern England.J R Coll Physicians Edinb. 2018; 48: 293-298Crossref PubMed Google Scholar Understanding potential barriers to patients with NAFLD accessing critical care is required to optimise management. Admissions for patients with NAFLD were not more likely to result in mortality after adjustment for age, critical care admission or MELD score (adjusted odds ratio 1.16; 95% CI 0.65-2.00; Fig. S1). Whilst comparisons between non-survivors and survivors are likely underpowered, conventional prognostic models discriminated admission survival (Table 1B). However, no prognostic scores significantly outperformed other models (p = 0.41), with no model achieving an AUC of greater than 0.8 (Fig. S2). After exclusion of admissions resulting in mortality or critical care admission, length of stay was no different to the rest of the cohort (Table 1A). Limitations of these analyses are discussed in the supplementary materials and include the retrospective design, coverage of only a single month, incomplete coverage of the UK with potential selection bias, lack of data regarding comorbidities and the subjective nature of aetiology assignment. Whilst accepting these limitations, this study is representative of a large, real-world cohort. With the likely increased incidence of patients being admitted to hospital with decompensated NAFLD, further work to understand how to optimally manage this cohort are necessary. This cohort is older, often more co-morbid and will likely require a tailored approach to their care. Understanding barriers to providing best care, including access to critical care, is essential when developing the hepatology services of the future. We are grateful for the funding support provided by Guts-UK. We are grateful for the support and endorsement from the British Society of Gastroenterology, British Association for the Study of the Liver, Scottish Society of Gastroenterology and the Welsh Association for Gastroenterology and Endoscopy. The authors declare no conflicts of interest that pertain to this work. Please refer to the accompanying ICMJE disclosure forms for further details. The following are the supplementary data to this article. 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Background and study aims Bile duct stones (BDS) represent approximately 50 % of the requirement for endoscopic retrograde cholangiopancreatography (ERCP) within most services. Significant variation in outcome rates for BDS clearance at ERCP has been reported, and endoscopy societies have set standards for expected clearance rates. The aim of this study was to analyze procedure outcomes across a national service. Patients and methods Using verified hospital episode statistics (HES) data for the National Health Service (NHS) in England, we analyzed all patients having first ERCPs for BDS from 2015 to 2017, and followed these patients for at least 2 years. Results In total 37,468 patients underwent a first ERCP for BDS, with 69.8 % undergoing only one procedure. This figure of less than 70 % of BDS cleared at first ERCP is below the Key Performance Indicators as set by the British Society of Gastroenterology (> 75 %) and the European Society of Gastrointestinal Endoscopy (> 90 %). Of 55,556 ERCPs done for BDS, 52.9 % were repeat procedures, with 11,322 patients needing multiple procedures. For hospitals performing significant numbers of ERCPs (more than 600 for BDS during the study period) patients undergoing repeat ERCPs for BDS ranged from 9 % to 50 %. Conclusions In this nationwide study, the performance at clearing BDS at first ERCP was suboptimal, with high numbers of repeat procedures required. This may have a negative impact on both patient outcomes and experience, and increase pressure on endoscopy services. Apparent variation of outcome between acute hospital care providers requires further analysis.

BACKGROUND & AIMS:Evidence for the benefit of scheduled imaging for early detection of hepatobiliary malignancies in primary sclerosing cholangitis (PSC) is limited. We aimed to compare different follow-up strategies in PSC with the hypothesis that regular imaging improves survival.METHODS:We collected retrospective data from 2975 PSC patients from 27 centres. Patients were followed from the start of scheduled imaging or in case of clinical follow-up from 1 January 2000, until death or last clinical follow-up alive. The primary endpoint was all-cause mortality.RESULTS:A broad variety of different follow-up strategies were reported. All except one centre used regular imaging, ultrasound (US) and/or magnetic resonance imaging (MRI). Two centres used scheduled endoscopic retrograde cholangiopancreatography (ERCP) in addition to imaging for surveillance purposes. The overall HR (CI95%) for death, adjusted for sex, age and start year of follow-up, was 0.61 (0.47-0.80) for scheduled imaging with and without ERCP; 0.64 (0.48-0.86) for US/MRI and 0.53 (0.37-0.75) for follow-up strategies including scheduled ERCP. The lower risk of death remained for scheduled imaging with and without ERCP after adjustment for cholangiocarcinoma (CCA) or high-grade dysplasia as a time-dependent covariate, HR 0.57 (0.44-0.75). Hepatobiliary malignancy was diagnosed in 175 (5.9%) of the patients at 7.9 years of follow-up. Asymptomatic patients (25%) with CCA had better survival if scheduled imaging had been performed.CONCLUSIONS:Follow-up strategies vary considerably across centres. Scheduled imaging was associated with improved survival. Multiple factors may contribute to this result including early tumour detection and increased endoscopic treatment of asymptomatic benign biliary strictures.

Introduction Distanced learning has become common place in recent years. This online basic skills in ERCP course was developed in line with the JAG training pathway and certification standards. Considering previous JAG approved courses have been hands-on, we assessed whether a distanced learning format is effective at meeting trainee expectations and curriculum learning outcomes. Methods The course was delivered to 8 delegates through an online platform. Four half-day sessions introduced the theory and practical aspects of ERCP training, covering: pre-procedure, intra-procedure and post-procedure topics. Although not a hands-on course, the format was based on recorded cases to highlight the different learning points. Feedback, in the form of Likert scales (strongly disagree (1), disagree (2), neutral (3), agree (4), strongly agree (5)) assessed the effectiveness of the course at delivering learning outcomes drawn from the JAG curriculum, and whether it was suited to a distanced learning format. Pre and post course questionnaires asked delegates their confidence in managing the different learning outcomes. Results Feedback for the course format was positive, with agreement that it was suitable for theory-based learning (median response 4.0). There were mixed views regarding the separation of theory and practical content, and whether this was detrimental to learning (3.0). Overall, there was agreement that this course is useful for training (5.0) and would be recommended to a colleague (5.0). Post-course responses were more positive than those pre-course for all learning outcomes. Particularly notable was the shift from disagreeing (pre-course) to agreeing (post-course) about confidence in biliary cannulation techniques (2.0 to 4.0), methods for cannulation when selective cannulation fails (2.0-4.0), biliary stent choices (2.0-4.5), and on the spot decisions about managing jaundiced patients (2.5-4.0). Conclusion JAG certification in ERCP will soon require attendance on basic skills courses and e-learning has been proposed as a novel way to deliver such courses in the recovery of endoscopy training following Covid-19. Feedback for this distanced learning course suggests this format is suitable for the theory-based learning, improving participants confidence in managing specific aspects of ERCP theory and knowledge. Further courses are needed to assess the impact on a wider audience, and a longer follow would allow evaluation of the impact on the ERCP learning curve.

See also: Early double-guidewire versus repeated single-guidewire technique to facilitate selective bile duct cannulation: a randomized controlled trialEndoscopy 2022; 54(02): 120-127DOI: 10.1055/a-1395-7485

[This corrects the article DOI: 10.1055/a-1629-7540.].

A 58-year-old woman with liver cirrhosis, previously decompensation with ascites, presented with jaundice. Abdominal ultrasound identified a shrunken, cirrhotic liver with intrahepatic duct dilatation within the left liver lobe, gallbladder calculi, and a normal bile duct. Subsequent magnetic resonance cholangiopancreatography identified dilated left and right intrahepatic ducts containing several filling defects, with stricturing of the left main duct and a normal-caliber common bile duct (▶Fig. 1). Endoscopic retrograde cholangiopancreatography (ERCP) with cholangioscopy was performed to assess the stricture and remove presumed intrahepatic stones. ERCP revealed similar features, with stricturing of the left and right main hepatic ducts and significant dilatation of the left intrahepatic ducts, which contained apparent filling defects (▶Fig. 2). Cholangioscopy was performed with the SpyGlass DS II (Boston Scientific). The scope was passed to the left and right intrahepatic ducts, where vascular structures were identified protruding into the lumen with focal dilatations occupying more than 75% of the lumen (▶Video 1). These structures followed the route of the bile ducts, consistent with choledochal varices. The common bile duct was spared and there were no biliary calculi throughout the intrahepatic and extrahepatic ducts. The patient was started on a nonselective β-blocker (carvedilol) and the jaundice improved slightly (from 65 to 45μmol/L). Abnormalities of the biliary tree relating to portal hypertension can be referred to as “portal hypertensive biliopathy” and are commonly seen in patients with extrahepatic portal venous obstruction (81%–100%), but less commonly in patients with cirrhosis (0%–33%) [1]. The abnormalities described include strictures, caliber irregularities, segmental dilatation, and indentations. There is also a predisposition to involvement of the left intrahepatic ducts (55%–100%) more than the right (40%–56%) [1]. The focus of treatment is to ensure adequate biliary drainage by endoscopy, or, if this fails, to consider portosystemic shunt.

Conclusions Short segment Barrett ’ s can be difficult to assess accurately. In our analysis, cases that did not meet the criteria for Barrett ’ s diagnosis on endoscopy, had segment < 1cm or an atypical Z line. We have shown a potential 49% reduction in unnecessary gastroscopies, which could result in avoidance of unnecessary health and procedural anxiety for patients, and cut waiting lists and associated costs. In addition, we suggest that patients with previous suspected Barrett ’ s should be evaluated on dedicated surveillance lists, by endoscopists with expertise in Barrett ’ s assessment

See also: Laparoscopy-assisted versus balloon enteroscopy-assisted ERCP after Roux-en-Y gastric bypass Endoscopy 2020; 52(08): 654-661DOI: 10.1055/a-1139-9313

Introduction PSC carries a 15–20% lifetime risk of developing cholangiocarcinoma (CCA). The distinction between benign and malignant strictures in this patient cohort is uniquely challenging. A 2016 meta-analysis has shown that single operator cholangioscopy (SOC) with targeted biopsies appears to be the most accurate method.1 We report our experience of SOC and PSC stricture assessment. Methods In 2 tertiary UK referral centres all patients who had a Spyglass DS™ SOC for stricture assessment in PSC were retrospectively enrolled. From clinical records and the endoscopy reporting tool patient demographics, degree of suspicion on referral, degree of suspicion during the endoscopy, histological diagnosis, and eventual diagnosis were assessed. Pre-test suspicion of malignancy was judged as high (eg. new stricture; presentation with obstructive jaundice; rising CA19.9; lesion on imaging) or low (eg. pre-transplant stricture assessment). Results Data on 49 patients who had undergone 52 ERCPs and Spyglass DS™ SOC was analysed. Four cases of malignancy were confirmed; 3 had a high level of suspicion at SOC and 1 had a low level of suspicion Nine cases (17.3%) had prior suspicious brushings locally which warranted further investigation. Three of these had CCA confirmed and 6 had no evidence of malignancy on SOC. Three of those with histological confirmed malignancy had cytology highly suggestive of high-grade dysplasia or adenocarcinoma from previous ERCPs. Another patient had negative histology at SOC but was referred for surgery on the basis of a mass lesion on imaging. One patient developed CCA within 1 year of negative SOC and another was found to have CCA on transplant explant at site of stricture assessed 6 years earlier with SOC. A negative SOC enabled 12 patients to be referred for transplantation. Conclusion The role of SOC in stricture assessment in PSC remains unclear. In this series SOC picked up 1 case of CCA not detected on standard ERCP as well as not detecting at least 1 case of CCA. Despite improved image quality using Spyglass DS™ SOC visual diagnosis remains challenging. It is hoped that advances in tissue acquisition will improve the yield from targeted biopsies. However, SOC appears to have an important role in assessing strictures where brush cytology is indeterminate. Reference Njei B, et al. Systematic review with meta-analysis: endoscopic retrograde cholangiopancreatography-based modalities for the diagnosis of cholangiocarcinoma in primary sclerosing cholangitis. Aliment Pharmacol Ther 2016;44(11–12):1139–51.

Introduction IgG4-related hepatopancreatobiliary disease (IgG4-HPB) is part of a complex fibro-inflammatory systemic condition. It is critical to distinguish IgG4-HPB from malignant and inflammatory disease mimics to guide long-term management. The 2019 ACR/EULAR Classification Criteria for IgG4-related disease (IgG4-RD) were developed and validated in a large international cohort and reported to have excellent diagnostic specificity.1 We sought to evaluate this in real-world clinical practice through our supra-regional Oxford-London IgG4-RD multi-disciplinary meeting (MDM). Methods We prospectively collected data on 153 patients referred to our IgG4-RD MDM over 4-years with suspected IgG4-RD (Clin Med, Jan 2020 in press). Each was classified as definite, possible or not IgG4-RD based on existing diagnostic criteria (HISORt, CDC, Boston Histopathology) and speciality experience. We retrospectively applied the ACR-EULAR classification criteria to this cohort to assess concordance with MDM outcomes. Results All cases considered not IgG4-RD in the MDM (n=52) similarly did not meet ACR/EULAR criteria. Of those considered definite IgG4-RD (n=63) in the MDM, only half (33;52%) met ACR/EULAR criteria. In those with definite HPB involvement (n=48) in the MDM, just over half (27;56%) met ACR-EULAR criteria. Most of the IgG4-HPB patients not meeting ACR/EULAR criteria scored insufficient diagnostic points (n=17) due to reliance on pancreatic imaging characteristics; diffuse swelling and pseudocapsule, with no points awarded for cholangiopathy without pancreatic involvement, atrophy, or focal enlargement of the gland. Small and unrepresentative biopsies were an additional challenge. Specific exclusions were absence of glucocorticoid response in advanced (fibrotic) cholangiopathy, and Crohn’s disease or ulcerative colitis in isolated HPB involvement. Conclusions The ACR-EULAR classification demonstrated excellent specificity (100%) and will be an invaluable tool for clinical trials. Disparity between diagnosis according to our IgG4-RD MDM and the ACR/EULAR criteria are explained by specific pancreatic imaging characteristics, absence of cholangiopathy/hepatopathy as a unique entity, and the necessity for steroid responsiveness even if presenting with advanced cholangiopathy. Reference Wallace ZS, Naden RP, Chari S, et al. The 2019 American College of Rheumatology/European League against Rheumatism classification criteria for IgG4-related disease. Ann Rheum Dis 2020;79:77–87. doi:10.1136/annrheumdis-2019-216561

Aims Common Bile Duct Stones (CBDS) is a common indication for ERCP. There are British Society of Gastroenterology endorsed national standards for clearance rates with the expectation that 75% or more of initial ERCPs for CBDS should result in stone clearance(1). This paper will examine the NHS data set from all trusts in England to assess the treatment of CBDS.

Objective The COVID-19 pandemic has placed increased strain on healthcare systems worldwide with enormous reorganisation undertaken to support 'COVID-centric' services. Non-COVID-19 admissions reduced secondary to public health measures to halt viral transmission. We aimed to understand the impact of the response to COVID-19 on the outcomes of upper gastrointestinal (UGI) bleeds. Design/methods A retrospective observational multicentre study comparing outcomes following endoscopy for UGI bleeds from 24 March 2020 to 20 April 2020 to the corresponding dates in 2019. The primary outcome was in-hospital survival at 30 days with secondary outcomes of major rebleeding within 30 days postprocedure and intervention at the time of endoscopy. Results 224 endoscopies for 203 patients with UGI bleeds were included within this study. 19 patients were diagnosed with COVID-19. There was a 44.4% reduction in the number of procedures performed between 2019 and 2020. Endoscopies performed for UGI bleeds in the COVID-19 era were associated with an adjusted reduced 30-day survival (OR 0.25, 95% CI 0.08-0.67). There was no increased risk of major rebleeding or interventions during this era. Patients with COVID-19 did not have reduced survival or increased complication rates. Conclusion Endoscopy for UGI bleeds in the COVID-19 era is associated with reduced survival. No clear cause has been identified but we suspect that this is a secondary effect of the response to the COVID-19 pandemic. Urgent work is required to encourage the public to seek medical help if required and to optimise patient pathways to ensure that the best possible care is provided.