Background National root cause analysis of post-endoscopy upper gastrointestinal (UGI) cancer in England has found wide variations in UGI endoscopy quality. This guidance aims to provide a practical UGI endoscopy guide to improve procedural quality, optimise early malignant and pre-malignant lesion detection and common pathology managment. Methods An initial consensus document was drafted in 2023 by the Scottish National Endoscopy Training Programme. A Guidance Development Group including endoscopy academy and regional endoscopy leads, devolved nation, JAG, AUGIS and BSG representatives was subsequently convened to adapt the document for UK-wide use. Targeted literature reviews were undertaken to provide evidence where available and recommendations were refined through expert consensus. Results High quality UGI examination is facilitated by closed mouth local anaesthetic spray application and combined sedation with opioids and benzodiazepines when sedation is needed. Mucosal cleansing with Simethicone and N-Acetyl Cysteine is recommended. Systematic inspection is recommended during diagnostic UGI endoscopy: first full oesophageal assessment using both white light and digital chromoendoscopy (facilitates squamous neoplasia detection); then complete gastric examination with white light in retroflexion and antegrade, with virtual chromendoscopy for any focal abnormality; and finally duodenal examination. In Barrett's oesophagus, following mucosal cleansing and white light examination, virtual chromoendoscopy and acetic acid enhance dysplasia detection. When gastric atrophy or intestinal metaplasia are suspected, virtual chromoendoscopy with targeted biopsies, if a focal lesion is present, and Sydney protocol biopsies to establish the extent of atrophy/metaplasia are recommended. Conclusions Optimising mucosal visualisation through sedation when appropriate, mucosal cleansing and chromoendoscopy enhances recognition of pre-malignant and early maligant lesions in the oesophagus and stomach and is recommended.

BackgroundCurrent BSG/ACPGBI and NICE guidance recommends that faecal haemoglobin (f-Hb) >= 10 ug/g measured by faecal immunochemical test (FIT) in symptomatic patients should prompt referral through cancer prioritised diagnostic pathways. However, limited long term CRC outcome data exist. This study compared CRC specific survival (CSS) between patients by f-Hb concentration and referral priority in a large primary care f-Hb prioritised lower GI symptomatic pathway.MethodsRetrospective single health board study of symptomatic patients submitting FIT in primary care, 2019-2022. CRC diagnoses up to 3 years after pathway entry, and CRC deaths (ICD10 18, 19, 20) to end 2024 were recorded from cancer audit and MCN datasets. Patients were grouped by f-Hb concentration and referral priority. Univariable and multivariable Cox regression estimated CSS.ResultOf 126,984 patients, 1453 (1%) were diagnosed with CRC within 3 years of f-Hb result or referral, of which 444 (31%) died due to CRC. At multivariable analysis, referral without FIT (HR 1.42, 95% CI 1.06-1.91), and f-Hb >= 10 ug/g diagnosed outwith CRC prioritised pathways (HR 1.47, 95% CI 1.03-2.10) were associated with worse CSS independent of TNM stage.ConclusionReferral and investigation through cancer prioritised pathways guided by f-Hb concentration is safe in relation to CSS.

AIM:The aim of this work was to quantify post-colonoscopy colorectal cancer (PCCRC) rates in National Health Service (NHS) Scotland using World Endoscopy Association guidelines, compare incidence between health boards and referral streams and explore comparisons in results with published data from other healthcare systems. METHOD:This is a population-based cohort study using NHS Scotland data between 2012 and 2018. All people undergoing colonoscopy between 2012 and 2018 and subsequently diagnosed as having bowel cancer up to 3 years after their investigation were included. The main outcome measures are national trends in the PCCRC rate at 3 years (PCCRC-3yr). with comparison between bowel screening and non-screening referral routes, board of referral and analysis of factors associated with occurrence. RESULTS:The overall unadjusted PCCRC-3yr was 7.9% (7.4%-8.3%). There was no change in the annual rate over the 7-year study period. The PCCRC rate was lower for the Scottish Bowel Cancer Screening Programme (6.7% vs. 8.3%), but compared unfavourably with rates reported by the NHS England Bowel Cancer Screening Programme from an earlier time period. There was wide variation in rates between health boards of similar population size. Rates were higher in women, with increasing age and in patients with a history of inflammatory bowel disease or diverticular disease. CONCLUSION:Despite advances in technology, there has been no improvement in the PCCRC rate in Scotland between 2012 and 2018. Rates in bowel screening colonoscopy are better than in nonscreening colonoscopy but compare unfavourably with NHS England, possibly as a result of less robust endoscopist selection and training. Quality improvement is required in colonoscopy in order to improve patient outcomes nationally, and to allow equitable access to higher-quality colonoscopy in different regions of the country.

Background The faecal immunochemical test (FIT) has proven utility for colorectal cancer detection in symptomatic patients. However, most patients with a raised faecal haemoglobin (f-Hb) do not have colorectal cancer. We investigated alternative diagnoses and demographics associated with a raised f-Hb in symptomatic patients. Methods A retrospective, observational study was performed of patients with FIT submitted between August 2018 to January 2019 in NHS Greater Glasgow and Clyde followed by colonoscopy. Colonoscopy/pathology reports were searched for alternative diagnoses. Covariables were compared using the χ 2 test. Multivariate binary logistic regression identified independent predictors of a raised f-Hb. Results 1272 patients were included. In addition to colorectal cancer (odds ratio (OR), 9.27 (95% confidence interval (CI): 3.61–23.83; p < 0.001)), older age (OR, 1.52 (95% CI: 1.00–2.32; p = 0.05)), deprivation (OR, 1.54 (95% CI: 1.21–1.94; p < 0.001)), oral anticoagulants (OR, 1.78 (95% CI: 1.01–3.15; p = 0.046)), rectal bleeding (OR, 1.47 (95% CI: 1.15–1.88; p = 0.002)), advanced adenoma (OR, 7.52 (95% CI: 3.90–14.49; p < 0.001)), non-advanced polyps (OR, 1.78 (95% CI: 1.33–2.38; p < 0.001)) and inflammatory bowel disease (IBD) (OR, 4.19 (95% CI: 2.17–8.07; p < 0.001)) independently predicted raised f-Hb. Deprivation (Scottish Index of Multiple Deprivation (SIMD) 1-2: OR, 2.13 (95% CI: 1.38–3.29; p = 0.001)) independently predicted a raised f-Hb in patients with no pathology found at colonoscopy. Conclusions An elevated f-Hb is independently associated with older age, deprivation, anticoagulants, rectal bleeding, advanced adenoma, non-advanced polyps and IBD in symptomatic patients. Deprivation is associated with a raised f-Hb in the absence of pathology. This must be considered when utilising FIT in symptomatic patients.

Abstract Aim Analysis of the collaborative implementation of colon capsule endoscopy (CCE) within NHS Greater Glasgow and Clyde Methods Database collected prospectively from first 175 patients referred. Demographic data collected for those undergoing CCE. Primary outcomes: negative, positive and incomplete/complications. Secondary outcomes: those requiring further investigation and outcomes (normal, abnormal and not performed). Abnormal findings: benign disease, dysplastic changes, malignancy and unresulted. Results Of the first 175 patients put forward for CCE, 128 (73%) underwent CCE: n=47 deemed unsuitable due to patient preference (n=21) and consultant decision (n=15). Mean age 57.8 (+/-13.9 SD), 56% female, 32% had ≥2 co-morbidities, and 6% having colorectal cancer family history. CCE findings: negative 16% (n= 21), positive 71% (n=91), incomplete/complications 12.5% (n= 16). Time from referral to CCE (Mean 130 days, Median 86 days). Time from CCE to reporting (Mean 9.4 day, Median 8 days). Time from referral (CCE report) to colonoscopy (Mean 127 days, Median 106 days). Colonoscopies still awaited (Mean 271 days, Median 269 days). 80% required further tests: 77% (n=98) colonoscopy or sigmoidoscopy and 4% (n=5) imaging. Results: 20% normal, 48% abnormal, 30% not yet performed and 2% inadequate/no longer required. Pathology: benign disease 38%, dysplastic changes 45%, invasive malignancy 9%, 9% unreported. Conclusions CCE has received significant investment to attempt to reduce the workload of endoscopy departments. However, 77% of the patients who underwent CCE require further investigation by scope. With an excellent safety profile, defining patient selection is key to optimising the clinical applicability of this evolving technology.

Introduction As part of the COVID recovery strategy, the GI unit in North Sector of GGC set up a telephone clinic manned by experienced endoscopy nurse specialists to triage urgency of dysphagia investigation by undertaking symptom assessment and utilising the Edinburgh Dysphagia Score (EDS). Patients with high EDS were vetted to (the highest) Category 1 (of 4) priority, and patients with low EDS were investigated at Category 2. The outcomes for all patients referred with dysphagia over a 6 month period commencing January 2021 were audited to determine the safety and clinical value of maintaining this approach in the longer term. Methods Information on all patients referred to the service was prospectively collected using a shared MS Teams Excel spreadsheet. We collected information on the EDS at interview, the decision to investigate and the designated priority of the investigation. Electronic cases records were then interrogated to ascertain the outcome of investigations. Statistical comparison of the frequency of diagnoses made at endoscopy was undertaken using the CHI square test. Results 296 patients were assessed via 40 nurse dysphagia triage clinics during this period, with 266 undergoing endoscopy. Only 14/296 (6.4%) patients avoided endoscopy solely on account nurse assessment and reassurance. Relative diagnostic frequency is detailed in table 1. 144 (48.6%) were triaged to Category 1 endoscopy and 122 (41.2%) to category 2 endoscopy. Oesophageal cancer was diagnosed in 9/128 (7%) patients with EDS ≥ 3.5 and only 1/106 with EDS < 3.5 (p<0.05). For all other diagnoses there was no significant difference in frequency between those with high or low EDS. 59% of all patients had no new gastroesophageal diagnosis made. New diagnosis of Barrett's oesophagus was uncommon, being found in 2.6%. Conclusions Routine use of the Edinburgh Dysphagia score can safely and effectively prioritise dysphagia investigation. While this can be delivered via a telephone triage clinic run by experienced nurse endoscopists, such an approach rarely avoids endoscopy and with the return of capacity the nurses may be better utilised delivering endoscopy sessions rather than triage clinics. Alternative means of utilising the EDS need urgently considered, such as embedding the calculation of the EDS directly into the GP referral process to allow prioritisation at time of vetting. This will be the next focus of our service

28 Background: The faecal immunochemical test (FIT) has proven utility for colorectal cancer (CRC) detection in symptomatic patients. Most studies have examined FIT in symptomatic patients subsequently referred from primary care. We investigated associations between CRC and FIT in both referred and non-referred symptomatic patients. Methods: A retrospective, observational study of all patients with a FIT submitted Aug’18-Jan’19 in NHS GG&C was performed. Referral to colorectal/gastroenterology and decision to perform colonoscopy were recorded. FIT results were grouped as f-Hb<10/10-149/150-399/≥400ug/g. The MCN cancer registry identified new cases of CRC. Covariables were compared using the χ 2 test. Multivariate binary logistic regression identified independent predictors of CRC. Results: 4968 patients were included. Raised FIT correlated with decision to refer (p<0.001) and scope (p<0.001). With 23-month median follow-up, 61 patients were diagnosed with CRC. These patients were older (median 69 vs. 59 years, cancer and no cancer respectively, p=0.001), more likely to be male (55.7% vs. 42.1%, p=0.033) and to report rectal bleeding (51.7% vs. 36.1%, p=0.013). FIT (<10 µg/g 8.2% vs. 76.7% and ≥400 µg/g 55.7% vs. 3.8%, p<0.001) and anaemia (45.9% vs. 19.7%, p<0.001) were associated with CRC. On multivariate analysis, age (p=0.023), male sex (p=0.04), FIT (≥400 OR 54.256 (95% CI: 20.683-142.325; p<0.001)) and anaemia (OR 1.956 (1.071-3.574;p=0.029)) independently predicted CRC. 1 patient (0.04%) with a negative FIT and normal haemoglobin had CRC. Conclusions: Referral from primary care and secondary care investigation patterns were influenced by FIT. The combination of normal Hb and f-Hb excluded CRC in 99.96% of cases, providing excellent reassurance to those prioritising access to endoscopy services.

Aim Lower gastrointestinal (GI) symptoms are poor predictors of colorectal cancer (CRC). The aim of this study was to examine the diagnostic yield of colonoscopy by faecal haemoglobin (f-Hb) concentration in symptomatic patients assessed in primary care by faecal immunochemical testing (FIT). Method In three Scottish NHS Boards, FIT kits (HM-JACKarc, Hitachi Chemical Diagnostics Systems Co., Ltd, Tokyo, Japan) were used by general practitioners to guide referrals for patients with lower GI symptoms (laboratory data studied for 12 months from December 2015 onwards in Tayside, 18 months from June 2018 onwards in Fife and 5 months from September 2018 onwards in Greater Glasgow and Clyde). Cases of CRC diagnosed at colonoscopy were ascertained from colonoscopy and pathology records. Results Four thousand eight hundred and forty one symptomatic patients who underwent colonoscopy after FIT submission were included. Of the 2166 patients (44.7%) with f-Hb <10 mu g Hb/g faeces (mu g/g), 14 (0.6%) were diagnosed with CRC, with a number needed to scope (NNS) of 155. Of the 2675 patients (55.3%) with f-Hb >= 10 mu g/g, 252 were diagnosed with CRC (9.4%) with a NNS of 11. Of the 705 patients with f-Hb >= 400 mu g/g, 158 (22.4%) were diagnosed with CRC with a NNS of 5. Over half of those diagnosed with CRC with f-Hb <10 mu g/g had coexisting anaemia. Conclusion Symptomatic patients with f-Hb >= 10 mu g/g should undergo further investigation for CRC, while higher f-Hb concentrations could be used to triage for urgency during the COVID-19 recovery phase. Patients with f-Hb <10 mu g/g and without anaemia are very unlikely to be diagnosed with CRC and the majority need no further investigation.

Introduction There is increasing interest in using Quantitative Faecal Immunochemical Testing (QFIT) for Haemoglobin as a ‘rule out’ test for significant colonic disease in symptomatic patients. It has been demonstrated elsewhere in Scotland that incorporating faecal haemoglobin testing into a primary care clinical assessment tool can safely and effectively prioritise referral for colorectal investigation. Here we present results of our own experience in the largest Scottish Health board (population 1.14 million) following adoption of a primary care colorectal referral pathway incorporating QFIT. Methods A new referral pathway incorporating primary care testing of faecal haemoglobin was incorporated into clinical practice in September 2018, regardless of patient age. Faecal haemoglobin was measured using the HMJack analyser (Kyowo-Medex), with a cut off for a positive test being 10 ug/g stool. The need for, and priority of, investigation, was determined according to the faecal haemoglobin concentration along with assessment for other pre-determined ‘red flag’ symptoms (iron deficiency anaemia, persistent rectal bleeding or daily diarrhoea > 4 weeks, rectal or abdominal mass). Ascertainment of significant colonic disease was determined after 1 year of follow up by linkage of faecal haemoglobin results to local endoscopy, radiology and pathology databases, and finally verified by linkage to the Scottish Cancer Registry. Results A minimum of 12 month follow up information is available for 3818 patients who submitted a QFIT sample between September and December 2018. A faecal haemoglobin result was available for 3547 patients, and positivity was 25.3%, with 4.4% of results being above the maximum quantifiable value (>400 ug/g stool). 1312 patients had undergone colonoscopy. 54 patients were diagnosed with colorectal cancer within 1 year of having faecal haemoglobin analysed. 51/54 (94.4%) patients had a positive QFIT test, and 53/54 patients (98.1%) had their investigation prioritised based on QFIT result or pre-determined ‘red flag’ symptoms. Only 1/3793 patients developed cancer within one year of an undetectable faecal haemoglobin and in the absence of ‘red flag’ symptoms. Advanced adenomas were found in 9.2% vs 2.1% investigated patients with detectable faecal haemoglobin, and inflammatory bowel disease was diagnosed in 6.2% vs 1.6%. In one sector of the board, introduction of this pathway has reduced demand for ‘direct to test’ colonoscopy by 20%, and demand for all luminal gastroenterology and colorectal surgery outpatient activity by 12.4%. Conclusion Adopting a pathway incorporating faecal immunochemical testing for haemoglobin in primary care as an adjunct to a formalised clinical assessment can safely determine a patient’s risk of significant colorectal pathology, particularly colorectal cancer, and help prioritise investigation.

Introduction The Post-Colonoscopy Cancer Rate at 3 years (PCCR-3yr) is a key indicator of quality of a service. The bowel screening programme (BCSP) in NHS England has reported PCCR-3 of 3.6%.1 The bowel screening programme in Scotland has key differences to the English BCSP and does not rely on a specific accreditation programme with examination for screeners, although has concentrated investment in access by offering screening to age 50-74 years at outset. Our aim was to ascertain the PCCR in the bowel screening service in NHS Greater Glasgow and Clyde (the largest Scottish Health Board – population 1.14 million) during the period 2011-15, and compare with the rate in the symptomatic service for a similar age range (50-77yrs). Method For each year within the study period, the total number of known cancer diagnoses was ascertained from cancer audit data submissions, identifying the ‘true positive’ colonoscopies. Cancer audit data was then linked to identify cases where a cancer was detected between 6 and 36 months after the index colonoscopy, giving the number of ‘false negative’ colonoscopies. Post colonoscopy cancer rate was then determined by expressing the number of ‘false negative’ colonoscopies as a percentage of the sum of ‘true positive’ and ‘false negative’ colonoscopies. The rates of post colonoscopy cancers between the screening and non-screening pathways were compared using the chi squared test. Results There were 1909 true positive colonoscopies in the investigation period for the entire population. We found 102 cases of PCCR-3y, giving a rate of 5.2% (95% CI 4.6-5.6%). 678/2011 (34%) of all bowel cancers were screen detected. PCCR-3yr for the screening service was 4.4% (95% CI 3.6-5.2%), which was lower than 5.5% (95% CI 4.8-6.1%) for the symptomatic service but not statistically different. Conclusion The overall PCCR-3yr for NHS GGC between 2011 and 2015 of 5.2% is similar to rates reported for England between 2015 and 2013. Post colonoscopy cancer rates for screening colonoscopy in NHS GGC were slightly lower than for the symptomatic service but not statistically different. Our rates were higher than rates reported for the English BCSP, but within the threshold of 5.5%1 that has been proposed by some investigators. This is the first report of PCCR-3yr in NHS Scotland and we believe that regular continuous audit of this important quality indicator should be replicated all Scottish boards. In our service, PCCR-3yr rates appear acceptable within NHS GGC and are slightly better for bowel screening compared with non-screening colonoscopy. Reference Burr et al. BMJ 2019.

Background Up to 60% of patients with Crohn's disease need intestinal resection within the first 10 years of diagnosis, and postoperative recurrence is common. We investigated whether mercaptopurine can prevent or delay postoperative clinical recurrence of Crohn's disease.Methods We did a randomised, placebo-controlled, double-blind trial at 29 UK secondary and tertiary hospitals of patients (aged >16 years in Scotland or >18 years in England and Wales) who had a confirmed diagnosis of Crohn's disease and had undergone intestinal resection. Patients were randomly assigned (1:1) by a computer-generated web-based randomisation system to oral daily mercaptopurine at a dose of 1 mg/kg bodyweight rounded to the nearest 25 mg or placebo; patients with low thiopurine methyltransferase activity received half the normal dose. Patients and their carers and physicians were masked to the treatment allocation. Patients were followed up for 3 years. The primary endpoint was clinical recurrence of Crohn's disease (Crohn's Disease Activity Index >150 plus 100-point increase in score) and the need for anti-inflammatory rescue treatment or primary surgical intervention. Primary and safety analyses were by intention to treat. Subgroup analyses by smoking status, previous thiopurines, previous infliximab or methotrexate, previous surgery, duration of disease, or age at diagnosis were also done. This trial is registered with the International Standard Randomised Controlled Trial Register (ISRCTN89489788) and the European Clinical Trials Database (EudraCT number 2006-005800-15).Findings Between June 6, 2008, and April 23, 2012, 240 patients with Crohn's disease were randomly assigned: 128 to mercaptopurine and 112 to placebo. All patients received at least one dose of study drug, and no randomly assigned patients were excluded from the analysis. 16 (13%) of patients in the mercaptopurine group versus 26 (23%) patients in the placebo group had a clinical recurrence of Crohn's disease and needed anti-inflammatory rescue treatment or primary surgical intervention (adjusted hazard ratio [HR] 0.54, 95% CI 0.27-1.06; p=0.07; unadjusted HR 0.53, 95% CI 0.28-0.99; p=0.046). In a subgroup analysis, three (10%) of 29 smokers in the mercaptopurine group and 12 (46%) of 26 in the placebo group had a clinical recurrence that needed treatment (HR 0.13, 95% CI 0.04-0.46), compared with 13 (13%) of 99 non-smokers in the mercaptopurine group and 14 (16%) of 86 in the placebo group (0.90, 0.42-1.94; p(interaction)=0.018). The effect of mercaptopurine did not significantly differ from placebo for any of the other planned subgroup analyses (previous thiopurines, previous infliximab or methotrexate, previous surgery, duration of disease, or age at diagnosis). The incidence and types of adverse events were similar in the mercaptopurine and placebo groups. One patient on placebo died of ischaemic heart disease. Adverse events caused discontinuation of treatment in 39 (30%) of 128 patients in the mercaptopurine group versus 41 (37%) of 112 in the placebo group.Interpretation Mercaptopurine is effective in preventing postoperative clinical recurrence of Crohn's disease, but only in patients who are smokers. Thus, in smokers, thiopurine treatment seems to be justified in the postoperative period, although smoking cessation should be strongly encouraged given that smoking increases the risk of recurrence. Copyright (c) The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY license.