Introduction Most data on bowel cancer presentation are from an acute hospital setting. There have not been many reports from a community hospital. Our audit looked into the presentation of bowel cancer from a community hospital setting. Methods We audited the results of bowel cancer presentation from our community hospital with data collected over a two year period from June 2010 to May 2012. We analysed the presenting symptoms, the male:female ratio, ages and location of bowel cancer. Results 1795 colonoscopies and 2589 flexible sigmoidoscopies were performed at our hospital during this two year period. The total number of colonic cancers found were 87(47 found on colonoscopy and 40 on flexible sigmoidoscopy), giving an incidence of about 2%. The ages ranged from 33 years to 86years with 49 males and 38 females. The main presenting symptoms were analysed and were as follows. Anaemia in 16 patients Abdominal pain in 8 patients. Per rectal (PR) bleeding in 45 patients Change in bowel habit in 25 patients. We followed the established norm of dividing colon cancers proximal to the splenic flexure as right colonic and distal to this as left colonic. On this basis, the locations of the bowel cancers were found to be 19 in the right colon and 68 in the left. We attempted to corelate clinical findings with site of tumours. It was observed that anaemia was more commonly associated with a right colonic lesion as compared to PR Bleeding which was seen with a left sided pathology. Abdominal pain and change in bowel habit were not strongly associated with any particular location for a tumour. Conclusion Our audit data of colon cancers from a community based setting is one of the few to be published in recent years. We have shown an incidence of about 2% of colon cancers from this setting. There appears to be a definite association between PR bleeding and left colon tumours as compared to anaemia which appeared to be associated with right colonic lesions. The overwhelming majority of cases referred to us were lesions located in the left colon suggesting that one-off flexible sigmoidoscopy as a tool for bowel cancer screening should have a very good diagnostic yield. Disclosure of Interest None Declared.

Introduction Patients experience of discomfort with Air insufflation during flexible sigmoidoscopy (FS) limits compliance and thus success of the procedure. There has been only one study1 which has shown that CO2 insufflation reduces discomfort as compared to Air in FS. Recently, we have been using CO2 insufflation for routine FS. We therefore conducted a prospective audit comparing the two modalities and to assess whether the use of CO2 during FS reduces discomfort both during and after the procedure using a standardised scoring system. Methods 200 consecutive patients undergoing FS, commonly for rectal bleeding, altered bowel habit and abdominal pain were selected to either Air or CO2 insufflation. There were 100 patients (42 males) in the CO2 group and 100 patients (5l males) in the Air group. The ages ranged from 19 to 92 years in both the groups. Any history of previous abdominal surgery was also noted. Patients were asked to grade discomfort during the procedure, post procedure in the recovery room and on discharge. We used the standardised comfort score of Wong and Baker (0==no discomfort and 10=extreme discomfort). Abdominal bloating was also assessed verbally after the procedure. Statistical analysis was done using Prism software. Results The mean comfort scores for CO2 compared to Air during the procedure was 1.02 vs 1.93 (p=0.0006), postprocedure 0.54 vs 1.12 (p=0.002) and on discharge 0.32 vs 0.8 (p=0.0008) respectively. Abdominal bloating appeared to be less with CO2 as compared to Air on verbal questioning. No differences in comfort scores were observed with a history of previous abdominal surgery. Conclusion This study has shown that CO2 insufflation reduces discomfort as compared to Air during FS, both during and after the procedure. Abdominal bloating was also significantly reduced. The use of CO2 will contribute to better public acceptance for FS, in particular for FS screening in colorectal cancer. Competing interests None declared. Reference 1. Bretthauer M, Hoff G, Thiis-Evensen, et al. CO2 insufflation reduces discomfort due to flexible sigmoidoscopy. Scan J Gastroenterol 2002;37:1103–7.

Macroenzymes are serum enzymes that have a greater molecular mass than the corresponding enzyme normally found in serum (Klonoff. West J Med 1980; 133: 392–407). Serum AST (aspartate aminotransferase) has rarely been reported to complex with immunoglobulins, resulting in an elevation in serum AST activity. Physicians should be aware of this condition so that patients are not subjected to invasive and costly procedures unnecessarily (Litin et al. Mayo Clin Proc 1987; 62: 681–687). We report on such a patient with a raised AST due to macroenzyme formation.

This report concerns four patients in a district general hospital who died from malignant liver tumours associated with Thorotrast (thorium dioxide) deposits in the liver. Three were known to have had diagnostic angiographic studies performed 36 to 43 years previously using Thorotrast as the contrast agent. In the fourth case no previous relevant information could be obtained. There were two men and one woman with hepatocellular carcinoma and one woman with cholangiocarcinoma. In one of the hepatoma cases there was associated hypercalcaemia of malignancy. Reported latency intervals suggest that cases of Thorotrast-related hepatic malignancy may present up to the second decade of the twenty-first century.