A man in his 50s presented to the emergency department with melaena and syncope. There was a medical history of psychosis, treated with olanzapine, but no other comorbidity. He was a former smoker and did not drink alcohol. He was born in Central Africa, moving to the UK as a young adult. On

Introduction A significant amount of plastic is being used in endoscopy. We believed that plastic polypropylene water bottles for the transport of sterile water generates significant amount of plastic/cost and strategies need to be employed to reduce its use. In this study, we aimed to assess the amount of plastic generated by 1L single-use polypropylene water bottles in a year for a number of endoscopic procedures. Methods Data was obtained from the Endoscopy Database (Unisoft) regarding the number/type of procedures performed throughout 2019. We prospectively assessed the volume of sterile water used for a dedicated endoscopy list: oesophagogastroscopy (OGD), sigmoidoscopy and colonoscopy. For each type of procedure, the volume of sterile water/plastic was estimated for a minimum of 20 procedures. The weight of plastic was measured using a Salter-Arc Electronic scale after leaving the bottle to dry for 48 hrs. Results In our endoscopy unit, we estimated that we used 336 ml of sterile water per gastroscopy (7.05L for 21 OGDs); 241 ml per sigmoidoscopy (5.3L for 24 sigmoidoscopies); and 782 ml per colonoscopy (17.2L for 22 colonoscopies). For 2019, we performed 4436 OGDs, 2251 sigmoidoscopies and 3135 colonoscopies, which equates to a total estimated volume of sterile water of 4,485L (1490.5L for OGD; 542.49L for sigmoidoscopy; 2451.57L for colonoscopy). The dry weight of a single-use 1L plastic water bottle was 65 g while the cost of 1L of sterile water was 80p. Hence, the amount of plastic generated from water bottles in a year was approximated to 96.92 kg for OGD (21.85 g per OGD); 35.30 kg for sigmoidoscopy (15.68 g per sigmoidoscopy); and 159.38 kg for colonoscopy (50.84 g per colonoscopy). In 1 year, the total plastic generated from sterile water bottles alone for these procedures was 291.6 kg. The total cost for sterile water was £3588.80 (£1192.80 for OGD, £434.40 for sigmoidoscopy and £1961.60 for colonoscopy). Conclusion We conclude that significantly large volumes of sterile water and single use plastic are being used in endoscopy. This practice is not only costly but also has a detrimental impact on the environment due to the large amount of plastic generated. Reduction of single use plastic needs to be a priority for a greener and more sustainable practice of endoscopy.

Introduction Endoscopy other than essential or emergency cases was paused in March 2020 during the first wave of the Covid-19 pandemic leading to a significant backlog. In April 2020 the BSG issued new guidance for safe resumption of endoscopy services. Methods We here described how we managed the endoscopy backlog generated by the first wave of the Covid-19 pandemic in a Covid-minimised unit. We evaluated the impact of service suspension on backlog, recovery strategy, infection control policy, results of pre-procedure Covid-19 testing, and 7/14-day post-procedure Covid-19 symptom screening. Results 937 elective procedures were cancelled between 23 March and June 2020. A vetting tool linked to the booking system was used to categorise these as High-risk 2-week wait (n=57), Defer 3 months (n=439), Defer 6 months (n=300), Defer 12 months (n=9), Surveillance (n=45), Discharge back to referrer (n=87). Elective procedures restarted on 8 June 2020. Lists were initially booked with 50% reduction in volume compared to pre-Covid-19, to accommodate PPE, downtime and social distancing. We increased endoscopy administration from 2 to 5 staff, to implement 7-day pre-procedure ''SCOTS criteria' telephone screening, 3-day pre-procedure Covid-19 PCR testing, and 7/14-day post-procedure telephone follow-up. We introduced outpatient information leaflet and consent forms regarding Covid-19 risk. Inpatient endoscopy was carried out in the operating theatre until the end of August. On 17 July we removed downtime after lower GI endoscopy increasing capacity. Twice weekly evening lists resumed in August, with an extra evening list added in September. From 1 August until 10 October we used insourcing at weekend. We trialed outsourcing of 2 weekly lists for 4 weeks in August, but did not find this strategy effective. Additional Saturday and evening lists were performed by 6 endoscopists removed from the GIM rota. We were able to clear our waiting list by mid-October so that we could offer mutual aid to a neighboring hospital. Between June and November we performed endoscopy in 3,481 outpatients. Each patient had pre-endoscopy Covid-19 swab and 20 (0.57%) were positive. 23 out of 3,261 (0.71%) patients developed Covid-19 symptoms after 7 days and 29 (0.89%) after 14 days. Conclusions We demonstrated effective clearance of the endoscopy backlog in a Covid-19 safe environment over 4 months. Key interventions were advance vetting, increased administrative support, an endoscopy unit located in a separate building, quick implementation of infection control policies, insourcing and freeing of endoscopists from the GIM rota. Learning point was underestimating burnout of endoscopy nursing staff.

Introduction National guidelines on the management of primary biliary cholangitis (PBC) were published by the BSG and UKPBC in 2018.1 We examined a database of all patients who had undergone anti-mitochondrial antibody (AMA) testing over a five year period in a single centre (a district general hospital serving a population of 220,000), to examine adequacy of PBC diagnosis, ursodeoxycholic acid (UDCA) dosing, biochemical response, and referral for second line therapy in cases of UDCA intolerance or failure, using the thresholds and recommendations set out in the BSG UKPBC 2018 guidelines. Methods A laboratory database search was carried out to capture all AMA test results from 01 April 2014–31 March 2019. Laboratory records for all patients with a positive AMA at any titre were cross referenced, and a registry created of all patients with positive AMA and biochemical evidence of cholestasis (elevated alkaline phosphatase (ALP) above the upper limit of normal), or a pre-existing diagnosis of PBC regardless of ALP. Medical records were examined of all patients on this registry to establish history of diagnosis of PBC, treatment history, dosing of UDCA in mg/kg, adequacy of response to UDCA, and referral for second line therapy with obeticholic acid (OCA) where relevant. Results 20783 AMA tests were carried out with positive results for AMA at any titre recorded in 155 individual patients; 45 had evidence of cholestasis at the time of index AMA testing, 23 of whom had been diagnosed with PBC by the end of the study period. A further 6 AMA positive patients had an existing diagnosis of PBC with normalised ALP on treatment, giving a total PBC population of 29 patients. 25/29 (86%) of PBC patients were treated with UDCA, which was adequately dosed in 23/25 (92%). 15/19 (79%) of patients who had completed at least one year of adequately dosed UDCA responded adequately (ALP<1.67*upper limit normal); one patient could not tolerate UDCA. 4 patients were referred to a tertiary centre for second line therapy (3/4 (75%) of non-responders and the patient who did not tolerate UDCA). Conclusions AMA testing was commonly carried out in a district general hospital setting, but the cohort of PBC patients identified was small. In those diagnosed with PBC, UDCA dosing was done well overall, but more than 20% of patients did not respond adequately or could not tolerate UDCA. Even in a small PBC cohort such as this, there are likely to be patients who may benefit from second line therapy with OCA. Such cases can be identified through simple audit of UDCA dosing and biochemical response. Reference Hirschfield G et al. The British Society of Gastroenterology/UKPBC primary biliary cholangitis treatment and management guidelines. Gut 2018;0:1–27

Introduction: Following British Society Gastroenterology (BSG) recommendations in March 2020 [1], UK endoscopy other than essential or emergency cases was paused during the first wave of the Covid-19 pandemic. This led to a significant backlog of patients waiting for endoscopy. At the end of April 2020 the BSG issued new guidance for safe resumption of endoscopy services [2]. Aims & Methods: The aim of this study was to describe how we managed the endoscopy backlog generated by the first wave of the Covid-19 pandemic in a Covid-minimised unit utilising BSG guidance [2]. We evaluated the impact of service suspension on backlog;recovery strategy, infection control policy, results of pre-procedure Covid-19 testing, and 7/14-day post-procedure Covid-19 symptom screening. Results: 937 elective procedures were cancelled between 23 March and June 2020. A vetting tool linked to the booking system was used to categorise these as High-risk 2-week wait (n=57), Defer 3 months (n=439), Defer 6 months (n=300), Defer 12 months (n=9), Surveillance (n=45), Discharge back to referrer (n=87). Elective procedures restarted on 8 June 2020. A single endoscopy room operated for the first 3 days, 2 rooms until 22 June, and subsequently all 3 rooms. Lists were initially booked with 50% reduction in volume compared to pre-Covid-19, to accommodate requirements for PPE, downtime and social distancing. We increased endoscopy administration from 2 to 5 staff, to implement 7-day pre-procedure 'SCOTS criteria' telephone screening, 3-day preprocedure Covid-19 PCR testing, and 7/14-day post-procedure telephone follow-up. We introduced outpatient information leaflets and consent forms regarding risk of Covid-19. Inpatient endoscopy was carried out in the operating theatre rather than endoscopy unit until the end of August. On 17 July we removed the requirement for downtime after lower GI endoscopy (following clarification that this was not considered 'aerosol generating') and increased lower GI endoscopy volume accordingly. Twice weekly evening lists resumed in August. From 1 August until 10 October we utilised weekend insourcing delivered by an agency endoscopy team. We trialed outsourcing of 2 lists per week to an independent provider for 4 weeks in August, but did not find this strategy effective. In September we increased to 5 evening lists per week. Additional Saturday lists were performed by 6 endoscopists made available through removal from the general internal medicine (GIM) rota. Through these measures we were able to clear our waiting list by mid-October. In mid-November we offered mutual aid to a neighbouring hospital with 2 lists per week. Between June and November we performed endoscopy in 3,481 outpatients. Each patient had pre-endoscopy Covid-19 testing and 20 (0.57%) were positive. 3,261 patients were called at day 7 and 14 post-endoscopy: 23 (0.71%) patients developed symptoms compatible with Covid-19 after 7 days and 29 (0.89%) after 14 days. Conclusion: We demonstrate effective clearance of the endoscopy backlog in a Covid-19 safe environment over 4 months, which exceeded the expected pace of recovery [3]. The key interventions were advance vetting of procedures, increased administrative support, an endoscopy unit located in a separate building, quick implementation of infection control policies, insourcing and freeing of endoscopists from the GIM rota. Learning points were underestimating burnout of endoscopy nursing staff returning from redeployment and the decreased endoscopy demand due to reduced referrals and patients' fear of attending hospital.

A 38-year-old man presented with symptoms of fever and dry cough. There was a past medical history of chronic plaque psoriasis with a single active psoriatic plaque affecting the lateral aspect of the right ankle. The patient was using no regular medication and no topical therapy for psoriasis at

HBV can lead to serious complications but the disease is generally asymptomatic. Homerton University Hospital has a large cohort of treatment naïve HBV patients requiring long term surveillance. Patients were being seen for follow-up on a six-monthly basis primarily to organise surveillance investigations, which impacted upon follow-up waiting time for other conditions and risked delaying surveillance investigations if clinics were cancelled or appointments missed. We created an electronic 'virtual surveillance pathway' commencing March 2018 based upon European guidelines. Patients triaged to this pathway are recalled by text message and postal invitation for Hepatocellular Cancer surveillance ultrasound, with blood tests and elastography performed on the same visit when required. If a focal liver lesion is detected on ultrasound, cross-sectional imaging can be immediately organised by the duty radiologist. results are reviewed in an electronic virtual clinic by a Consultant or Clinical Nurse Specialist with early recall to clinic or organisation of the next cycle of surveillance as dictated by results. Outcomes are electronically shared with the GP and patients receive a hard copy. The pathway is coordinated on the electronic patient record with patients booked into a timetabled 'paper clinic' after each cycle of surveillance tests. Results 168 patients were recruited in the first year, saving 336 outpatient appointments. Cancellation or non–attendance for surveillance investigations was less than 5% compared to just over 10% for conventional outpatient consultation. Liver clinic new to follow–up ratio improved from 14:22 to 16:16. Routine follow–up waiting time fell to 13 weeks. All respondents reported they were 'very satisfied or fairly satisfied' with the service. A virtual HBV pathway can deliver safe, evidence-based and timely surveillance with a high degree of patient engagement and satisfaction.

A 23-year-old woman presented with abdominal pain and iron-deficiency anaemia. She had recently used a non-steroidal anti-inflammatory for flu-like illness and had been taking oral iron supplementation for the last month. She was referred for upper GI endoscopy and the endoscopic image is shown in figure 1. The area of abnormality was biopsied, and the histology slide is shown in figure 2. What is the abnormality shown in the …

Introduction The gold standard investigation for upper gastrointestinal (GI) symptoms is oesophago-gastro-duodenoscopy (OGD). The British Society of Gastroenterology (BSG) released a position statement of quality standards in upper gastrointestinal endoscopy in August 2017, including the recommendation to photodocument 8 anatomical sites in the upper GI tract to optimise mucosal inspection and lesion recognition. We aimed to assess and improve the quality of OGD photodocumentation and lesion recognition in line with this recommendation. Methods 184 OGD reports were audited from three one-week audit cycles. Cycle 1: immediately following guideline release and prior to intervention; cycle 2: immediately following intervention (departmental teaching and poster display of recommended photos in endoscopy procedure rooms); cycle 3: 2 weeks after intervention. Total number of photos taken per procedure, number of anatomical sites photodocumented, and number of lesions detected were recorded. Results From cycle 1 (pre-intervention) to cycle 2 (post-intervention) the mean number of photos per OGD increased from 5.3 to 8.6 respectively (p=0.095) and mean number of anatomical sites documented increased from 3.8 (47%) to 6.9 (86%) (p<0.001). The mean number of lesions documented per OGD increased from 0.5 to 1.2 (p=0.230). Improvement in practice was sustained through audit cycle 3 (2 weeks after intervention): mean photos 8.5, mean required sites documented 7.4 (92%) and 0.7 diagnoses per OGD. Conclusions Immediately following release of BSG quality standards in upper GI endoscopy, departmental adherence to recommendations for photodocumentation was poor. A simple intervention of departmental teaching and poster displays resulted in a significant improvement in the quality of photodocumentation and a trend towards improvement in detection of lesions. Improvement in quality was sustained at re-audit.

A 27-year-old man developed extensive hepatic portal venous gas (HPVG) shortly after staging colonoscopy for active, ulcerating, terminal ileal Crohn's disease. Non-operative management was instigated with broad-spectrum antibiotics and thromboprophylaxis. Radiology at 72 h demonstrated resolution of HPVG but revealed fresh non-occlusive left portal vein thrombus. Anticoagulation with warfarin was continued for 1 year, during which the thrombus initially progressed and then organised with recanalisation of the portal vein. There were no long-term clinical consequences. HPVG has previously been documented as a rare complication of inflammatory bowel disease and endoscopic intervention. We hypothesise that the barotrauma sustained during endoscopy, in association with active ulceration and mucosal friability, predisposes to the influx of gas and bacteria into the portal system. We describe successful non-operative management of HPVG in this setting and draw attention to an additional complication of portal venous thrombosis, highlighting the importance of thromboprophylaxis and serial radiological examination.