Introduction There is an unprecedented burden on UK endoscopy units and the current demand for endoscopic procedures is disproportionate to the capacity to deliver endoscopy activity. Units are addressing this in various ways including insourcing of staff to carry out endoscopy work. This is especially useful at weekends when the Unit would often be inactive. Medinet is a well-established provider of endoscopy insourcing across the UK. Their endoscopists hold substantive posts within the NHS and nurses are highly experienced specialised endoscopy nurses. Methods Medinet's database was interrogated for the total numbers of endoscopic procedures carried out over a 12 month period (1 st Jan – 31 Dec 2017). This endoscopy work was carried out in NHS hospitals all over the UK. Medinet has a robust governance process (which includes regular governance meetings) where all complaints and adverse incidents are discussed and dealt with in a timely fashion. Such incidents were reviewed over this 12 month period. Results Over the 12 months 25 347 endoscopic procedures were carried out: 12 137 colonoscopies, 10 564 gastroscopies and 2646 flexible sigmoidoscopies. Over this period only 17 complaints were received (0.07%). Most of these related to patient perception and general operational issues. At governance meetings it was agreed that no or minimal harm was done. Over the same period there were a total of 28 adverse incidents (0.11%). These included one perforation, procedure related bleeds, a missed early malignant lesion, incorrect labelling of specimens, drug documentation errors and problems with the reporting system. There were no deaths related to the procedures but there was one reversal of sedation, which was deemed a never event. Conclusion Insourcing of endoscopy services has grown dramatically over the last few years and gives UK endoscopy units a viable alternative to ensure they keep up with the tremendous pressures to maintain capacity and timeliness in a time of growing demand, limited resources and increasing quality standards. This data confirms that with the correct personnel and governance in place, insourcing is extremely safe with low level of complaints and adverse incidents.

BackgroundSmall bowel Crohn's disease has a heterogeneous presentation leading to a delay in diagnosis. Capsule endoscopy is now a well-established diagnostic tool; however, few studies have evaluated the role of double-balloon enteroscopy (DBE) in patients with suspected Crohn's disease. Histology obtained at DBE is useful in addition to clinical symptoms, blood parameters and capsule endoscopy findings to aid diagnosis and further management.ObjectiveThe aim of this study was to evaluate the impact of DBE and histology on the management of patients with suspected small bowel Crohn's disease.MethodsDBE procedures including histology for suspected Crohn's disease from 2006 to 2014 were retrospectively reviewed. Follow-up data for all patients were collected.ResultsIn our series of 399 double-balloon enteroscopies, 122 procedures were performed in 100 patients for suspected Crohn's disease. Positive DBE findings were found in 60% of patients. Forty-five per cent of patients were treated as Crohn's disease on the basis of a combination of histology, endoscopic appearance, clinical symptoms and blood parameters. Histology was diagnostic of Crohn's disease in 8% and supportive of it in 15%. In 12%, an alternative diagnosis was made, of whom two patients were diagnosed with small bowel malignancy on histology.After a median follow-up period of 27 months, the actual prevalence for a new diagnosis of Crohn's disease in our study was 38%.ConclusionDBE has a useful place in clarifying the diagnosis in patients with suspected Crohn's disease. Although histology can be nondiagnostic, the combination of the macroscopic appearance with clinical correlation is useful in the diagnosis and management.

Introduction Faecal calprotectin (FC) is less accurate at identifying inflammation in the small bowel than in the colon. Small bowel capsule endoscopy (SBCE) is a useful tool to detect small bowel inflammation. We investigated the diagnostic accuracy of FC and SBCE and their correlation in patients with suspected isolated small bowel Crohn’s disease. Patients and methods This was performed as a prospective single centre study including patients attending for SBCE with suspected small bowel Crohn’s disease. Patient demographics, symptoms, medications and blood parameters were collected. Capsule endoscopy findings were analysed against calprotectin values, final diagnosis and blood parameters. Results A total of 146 patients were included (99 females and 47 males) with a mean age of 38±14 years. FC of more than 50 mg/kg was not significantly associated with clinically relevant capsule endoscopy findings (P=0.25), correlation coefficient was 0.11. Sensitivity, specificity, positive and negative predictive values for FC at a cut-off of more than 50 mg/kg were 88.9% [95% confidence interval (CI): 65.3–98.6], 25.0% (95% CI: 17.8–33.4), 14.3 (95% CI: 8.4–22.2) and 94.1% (95% CI: 80.3–99.3), respectively. A raised FC was not significantly associated with an elevated C-reactive protein or the presence of anaemia (P=0.19 and 0.10, respectively). Conclusion FC performs modestly as a screening test to exclude small bowel inflammation. However, we recommend interpretation within the overall clinical context to avoid overlooking the infrequent patient with small bowel inflammation and a negative FC.

Introduction Colon capsule endoscopy (CCE) is a novel non-invasive means of directly imaging the colonic mucosal surface. Limited data is available regarding the utility of CCE in the diagnosis and re-assessment of inflammatory bowel disease (IBD), but it is attractive to patients due to its non-invasive nature and ability to obtain small bowel and pan-colonic images. We present a large series of patients with known or suspected IBD undergoing CCE. Methods Retrospective, single-centre, including 193 patients with known or suspected IBD attending for CCE using PillCam Colon (Given Imaging, Israel). All patients known to have IBD successfully passed a PillCam Patency device prior. Demographical and procedural data was collated together with final diagnosis and management outcome. Results Mean age 38.8 years (range 17–82), 129 female, median follow-up 43 months (range 3–99). 71 chose CCE over colonoscopy, 66 refused colonoscopy, 49 had an incomplete colonoscopy, and 7 were unfit for colonoscopy. Indication for the procedure: known IBD (n = 66, 5 with ulcerative colitis, 61 with Crohn’s disease) of which 30 patients were undergoing CCE for disease re-assessment after 12 months of anti-TNF therapy and 36 due to a relapse in symptoms. The remaining 127 had suspected IBD. Procedure completion rate 75.5%, bowel preparation was good or adequate in 64.3%. There were no adverse events. In the known IBD group, 45 patients were diagnosed with active disease based on the CCE findings. This lead to changes in management in 44 patients (67%); mainly in the form of medication alteration (40 patients), but also by further investigation (4 patients). In the suspected IBD group, CCE diagnostic yield for IBD was 6%, 5 patients were diagnosed with Crohn’s disease and 2 patients were diagnosed with ulcerative colitis. In the group with small bowel inflammation 1 patient was diagnosed with NSAID related enteropathy and 1 had non-specific histology and is undergoing further investigation. Other clinically relevant alternative findings are outlined in Table 1. Overall CCE made 37 clinically significant diagnoses in the small bowel rather than the colon; 27 in the known IBD group and 10 in the suspected IBD group. Abbreviations: IBD=inflammatory bowel disease Conclusion CCE is a useful patient friendly alternative for the diagnosis and re-assessment of patients with known or suspected IBD and impacts management. The distal small bowel is visualised with excellent clarity making CCE particularly useful for those with suspected or known ileocolonic disease. Disclosure of Interest None Declared

Introduction Magnetically assisted capsule endoscopy (MACE) of the stomach has been demonstrated to be safe and feasible.1 The aim of this prospective feasibility study was to compare the ability of MACE to recognise gastric landmarks compared to conventional flexible endoscopy in patients with recurrent or refractory iron deficiency anaemia. Methods Twenty patients with recurrent/refractory iron deficiency anaemia were enrolled between Jan-Nov 2015. After conventional oesophagogastroduodenoscopy, MACE was performed using MiroCam Navi (Intromedic, Seoul, Korea). Visualisation of major upper gastrointestinal landmarks was graded on a 1–5 scale (1 = poor, 5 = excellent), abnormalities were recorded. Primary outcome measure: gastric landmark recognition. Secondary outcome measures: pathology detection, patient tolerance. Results MACE achieved satisfactory visualisation (grade 4 or 5) in 11% for the gastro-oesophageal junction, 21% for the cardia, 16% for the fundus, 79% for the anterior wall of the gastric body, 79% for the posterior wall, 79% for the greater curvature, 84% for the lesser curvature, 95% for the antrum and 89% for the pylorus. 38 pathological findings were identified (Table 1). Patients experienced less pain, discomfort and distress during MACE compared to flexible endoscopy (p = 0.0009, p = 0.001 and p = 0.006 respectively). Conclusion MACE can visualise gastric landmarks, detect a variety of gastric pathology and is better tolerated than conventional endoscopy. Capsule identification of hiatal hernias is difficult and may improve with experience.2 Better oesophageal visualisation is possible with other models and it seems likely that Mirocam Navi could be developed to this end. Proximal gastric views may be more reliable using a double ended capsule, better depth of illumination, and perhaps with control of capsule movement, all of which need further study before MACE becomes a viable alternative to conventional endoscopy. References 1 Hale MF, Drew K, Sidhu R, McAlindon ME. Does magnetically assisted capsule endoscopy improve small bowel capsule endoscopy completion rate? A randomised controlled trial. Endosc Int Open. 2016 Feb; 4(2):E215–21. 2 Marelli L, Jaboli FM, Jackson L, Palmer H, Erian G, Hamilton M, Epstein O. A pilot study comparing ESO-2 capsule endoscopy with conventional upper endoscopy for the assessment of uncomplicated heartburn and dyspepsia. Frontline Gastroenterol201;4:96–101. Disclosure of Interest None Declared

Background and study aims: Delayed gastric emptying is a significant factor in incomplete small bowel capsule examinations. Gastric transit could be hastened by external magnetic control of the capsule. We studied the feasibility of this approach to improve capsule endoscopy completion rates. Patients and methods: Prospective, single-center, randomized controlled trial involving 122 patients attending for small bowel capsule endoscopy using MiroCam Navi. Patients were randomized to either the control group (mobilisation for 30 minutes after capsule ingestion, followed by intramuscular metoclopramide 10 mg if the capsule failed to enter the small bowel) or the intervention group (1000 mL of water prior to capsule ingestion, followed by positional change and magnetic steering). Outcome measures were capsule endoscopy completion rate, gastric clarity and distention, relationship of body habitus to capsule endoscopy completion rate (CECR), and patient comfort scores. Results: 122 patients were recruited (61 each to the control and intervention groups: mean age 49 years [range 21 – 85], 61 females). There was no significant difference in CECR between the two groups (P = 0.39). Time to first pyloric image was significantly shorter in the intervention group (P = 0.03) but there was no difference in gastric transit times (P = 0.12), suggesting that magnetic control hastens capsular transit to the gastric antrum but does not influence duodenal passage. Gastric clarity and distention were significantly better in the intervention group (P < 0.0001 and P < 0.0001 respectively). Conclusions: Magnetic steering of a small bowel capsule is unable to overcome pyloric contractions to enhance gastric emptying and improve capsule endoscope completion rate. Excellent mucosal visualisation within the gastric cavity suggests this technique could be harnessed for capsule examination of the stomach.

Introduction Historically the small bowel has been considered a black box, which is technically difficult to examine due to its length, tortuosity and location. Diagnosis and management of small bowel pathology has entered a new era with the advent of capsule endoscopy (CE) and enteroscopy. We have been providing a comprehensive small bowel endoscopy service and we present our experience from the last 13 years, evaluating demand, diagnostic yield and management. Method A retrospective analysis was conducted on patients who underwent CE, push enteroscopy (PE), double balloon enteroscopy (DBE) and intraoperative enteroscopy (IOE) between January 2002 and October 2014. Data collected included demographics, indications, diagnosis, subsequent change in management and complications. Results A total of 4288 CEs, 294 PEs, 399 DBEs and 19 IOEs were performed over 142 months. The most common indication across all 4 modalities was obscure gastrointestinal bleeding (OGB). The majority of patients (91%) had CE prior to DBE or PE, which helped direct the route and modality of enteroscopy. The diagnostic yield for CE, PE, DBE and IOE were 29%, 43%, 49% and 89% respectively (p < 0.0001). Whilst the demand for CE has continued to rise over the years (p < 0.0001), the diagnostic yield has fallen (p < 0.0001). The diagnostic yield was highest for the indication of OGB (36%) in CE compared to Crohn’s disease (30%, p < 0.001). Significant pathology was found outside the small bowel in 8% of patients (colon 36%, gastric 64%). With the advent of DBE, the demand for PE has fallen (p = 0.03, r = -0.6) and was mainly used for proximal lesions seen on CE. In contrast, the demand for DBE has risen gradually in tandem with the diagnostic yield (p < 0.0001, r = 0.9). Management was altered by CE in 25%, 43% for PE and 41% for DBE. The rate of therapeutics for PE and DBE were 21% and 24% respectively. In 2014, for every 13 CEs performed, one patient underwent DBE locally. Whilst there were no complications for PE, the complication rate for DBE was 1.25% and 10.5% for IOE. Capsule retention data was collected for patients undergoing CE from 2010. Of the 2882 procedures done in this period, CE retention >2 weeks occurred in 6 patients (0.2%), of which 5 were due to a stricture (Crohn’s n = 4, non-steroidal n = 1) and 1 was due to delayed gastric emptying. Three patients required further intervention for capsule removal (endoscopic n = 2, surgery n = 1). Conclusion This is the largest series to date comparing the clinical utility of all four small bowel endoscopic modalities. Enteroscopy has an important role in altering management post CE in patients with small bowel pathology as reflected by the rising demand and yield. Future tariffs for the modalities particularly CE are likely to influence this demand. Disclosure of interest None Declared.

Introduction Historically the small bowel has been considered a black box, which is technically difficult to examine due to its length, tortuosity and location. Diagnosis and management of small bowel pathology has entered a new era with the advent of capsule endoscopy (CE) and enteroscopy. We have been providing a comprehensive small bowel endoscopy service and we present our experience from the last 13 years, evaluating demand, diagnostic yield and management. Method A retrospective analysis was conducted on patients who underwent CE, push enteroscopy (PE), double balloon enteroscopy (DBE) and intraoperative enteroscopy (IOE) between January 2002 and October 2014. Data collected included demographics, indications, diagnosis, subsequent change in management and complications. Results A total of 4288 CEs, 294 PEs, 399 DBEs and 19 IOEs were performed over 142 months. The most common indication across all 4 modalities was obscure gastrointestinal bleeding (OGB). The majority of patients (91%) had CE prior to DBE or PE, which helped direct the route and modality of enteroscopy. The diagnostic yield for CE, PE, DBE and IOE were 29%, 43%, 49% and 89% respectively (p 2 weeks occurred in 6 patients (0.2%), of which 5 were due to a stricture (Crohn’s n = 4, non-steroidal n = 1) and 1 was due to delayed gastric emptying. Three patients required further intervention for capsule removal (endoscopic n = 2, surgery n = 1). Conclusion This is the largest series to date comparing the clinical utility of all four small bowel endoscopic modalities. Enteroscopy has an important role in altering management post CE in patients with small bowel pathology as reflected by the rising demand and yield. Future tariffs for the modalities particularly CE are likely to influence this demand. Disclosure of interest None Declared.

BACKGROUND AND AIM:Excretion of the patency capsule (PC) within a certain time frame may be used to demonstrate luminal patency prior to capsule endoscopy (CE). We aimed to determine how often further radiological imaging is needed to confirm luminal patency after PC, assess radiologists' ability to locate the PC on plain abdominal films, and evaluate the outcomes of a novel computed tomography (CT) protocol for PC localization.METHODS:A study of the ability of radiologists to localize PC using plain abdominal films was performed. A novel protocol targeting a limited CT at the level of the PC identified on the "scout" film if retained 30 h post-ingestion was prospectively evaluated in 400 consecutive patients undergoing PC.RESULTS:In a study of the confidence with which radiologists could localize the PC on plain films, radiologists preferred abdominal CT to localize PCs identified on plain films in 74% of cases. In a protocol based on the use of a PC and targeted, limited CT scan to confirm small bowel patency in those failing to excrete the PC 30 h post-ingestion, the sensitivity, specificity, positive, and negative predictive value were 99.4%, 90.0%, 99.7%, and 81.0%, respectively. Crohn's disease was the only statistically significant predictor associated with higher risk of luminal stricture (P=0.001) in post-hoc analysis.CONCLUSIONS:Excretion of the PC 30 h post-ingestion reliably predicts safe CE passage. Plain abdominal radiology is unreliable and a scout film targeted, limited CT scan offers an accurate minimal radiation method of determining small bowel patency.

Introduction Faecal calprotectin (FC) is a stool biomarker recommended as a simple, non-invasive test to distinguish between inflammatory bowel disease (IBD) and functional bowel disorders. Despite a good correlation with colonic inflammation, FC is felt to be less accurate at identifying small bowel (SB) inflammation. Small bowel capsule endoscopy (SBCE) has a high sensitivity for detecting SB mucosal inflammation. We investigated the correlation between FC and SBCE in patients with suspected IBD. Method We prospectively correlated the findings of SBCE with FC levels in patients under investigation for suspected IBD. Patient demographics, clinical symptoms, medications and blood parameters: haemoglobin (Hb), albumin, ESR and CRP were collected. SBCE findings including Lewis scores were analysed against FC values and final diagnosis. Results 127 patients were included, mean age 42 years (range 18–75 years), 85 female. Presenting symptoms included: a combination of diarrhoea, abdominal pain and bloating (74%), diarrhoea alone (13%), abdominal pain alone (12%), rectal bleeding (1%). Median time from FC measurement to SBCE was 62 days. 12% had a family history of IBD, 14% were current smokers. 6 patients with a diagnosis of colonic pathology were excluded. Results are presented in Table 1. Of the 61 patients with FC >100 µg/g, 14 (23.0%) had clinically significant SB findings (12 SB ulcers, 2 villous atrophy) and mean FC levels 468 µg/g (range 112–1010 µg/g). Overall a definitive diagnosis was made in 10 patients (9 Crohn’s disease, 1 NSAID enteropathy), the remaining 10 patients are undergoing further evaluation. FC >50 µg/g was significantly associated with clinically relevant SBCE findings (χ² p = 0.02). FC had a sensitivity 81%, specificity 40%, positive predictive value 42% and negative predictive value (NPV) 80%. Receiver operating curve analysis showed an area under the curve (AUC) of 0.626 for FC, similar to CRP (AUC 0.638) but better than ESR (AUC 0.524) and Hb (AUC 0.545). Albumin most closely correlated with an AUC 0.686. Multiple logistical regression showed serum albumin to be the only variable significantly associated with positive SBCE (p = 0.032). Lewis score significantly correlated with FC value (r = 0.793, p Conclusion With a reasonable sensitivity and NPV, FC could be most effectively utilised to screen out patients where further SB investigation is unnecessary. However, in our series 1 patient with FC ≤50 µg/g had SB Crohn’s disease. Thus at best, FC can be only be recommended as an adjunct to clinical decision making, when patient factors and other biochemical parameters are also taken into account. Disclosure of interest None Declared.

Background and study aims: Capsule endoscopy is well tolerated but control of its movement is needed in order to visualize the whole gastric surface. Technological developments have produced an external magnet to allow manipulation of the capsule within the gastric cavity. The aim of this study was to compare magnetically steerable gastric capsule endoscopy (MSGCE) with flexible endoscopy for the detection of beads in a porcine stomach. Materials and methods: Beads were sewn onto the mucosal surface of 12 ex vivo porcine stomachs. Each model was examined by flexible endoscopy and MSGCE by two blinded investigators. MSGCE was performed according to a protocol using positional changes and magnetic steering. Outcome measures were number and location of beads identified, and duration of procedure. Results: Flexible endoscopy identified 79 /90 beads (88 %), and MSGCE identified 80 /90 (89 %). The difference in sensitivities was 1.11 (95 % confidence interval 0.06 – 28.26). Thus, MSGCE was noninferior to flexible endoscopy. Mean examination times for flexible endoscopy and MSGCE were 3.34 minutes and 9.90 minutes, respectively. Conclusion: MSGCE was equivalent to conventional flexible endoscopy in the detection of beads in a porcine stomach model.

Introduction Small bowel ulcers are frequently reported on capsule endoscopy (CE) and double balloon enteroscopy (DBE). The aetiology is not always clear. Histology is useful in addition to clinical symptoms and blood parameters to aid diagnosis and further management. Enteroscopy allows both direct visualisation of the mucosa and histological sampling. The aim of this study was to evaluate the impact of DBE on management of patients with small bowel ulcers. Method A retrospective review of DBE’s performed for suspected Crohn’s disease from 2006–2014 was carried out. Data was collected for demographics, clinical symptoms and blood parameters. Findings at DBE, histology and subsequent follow up were noted. Results In our series of 399 DBEs, 122 procedures were performed in 102 patients (male = 44; female = 58; mean age 46 (range 18–84)) for suspected Crohn’s disease (53 oral; 69 retrograde). Ninety percent (n = 92/102) of patients had a prior CE. Ten patients were unable to have CE due to a retained patency capsule or contraindications, however had abnormal radiology preceding DBE. Positive DBE findings were found in 56% of patients (n = 57; ulcers n = 47; stricture n = 8; abnormal mucosa n = 2). Forty percent of patients (n = 41/102) were eventually treated for Crohn’s disease. In 22 patients the histology was diagnostic (n = 7) or supportive (n = 15) for Crohn’s disease. Fifty-eight percent of patients with small bowel ulceration had non-diagnostic histology (normal n = 22; non-specific changes n = 11). Of the 33 patients with non-diagnostic histology, 58% (n = 19) were subsequently treated for presumed Crohn’s disease based on clinical symptoms, blood parameters and macroscopic findings on endoscopic investigations. Thirteen patients who were treated as Crohn’s disease had immunosuppressive therapy (azathioprine +/- anti-TNF or methotrexate). Eleven patients were empirically treated with steroids only and two patients were referred for surgery. The mean follow period for patients in the Yorkshire region was 29 months (range 1–104 months). The remainder of patients were treated for vasculitis (n = 1), latent TB (n = 1), functional symptoms (n = 4) and nsaid enteropathy (n = 3) in whom NSAIDs were discontinued. In 15% of patients no specific cause was found. Two patients were found to have carcinoid (n = 1) and follicular lymphoma (n = 1) on histology. Conclusion DBE has a useful place in clarifying the diagnosis in about half of patients with small bowel ulcers. Although histology can be non-diagnostic, the combination of the macroscopic appearance with clinical correlation is helpful in the diagnosis and management. Longer term follow up data would be useful. Disclosure of interest None Declared.

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.

Capsule endoscopy remains at the forefront of small bowel investigation, offering the only non-invasive means of directly imaging the mucosa of the small bowel. Recommended for the investigation of obscure gastrointestinal bleeding, Crohn's disease, coeliac disease, small bowel tumours and hereditary polyposis syndromes, the uptake of small bowel capsule endoscopy has been widespread in the UK. However, despite a wealth of published literature supporting the utility of capsule endoscopy in clinical practice, there are limited data regarding the actual practical aspects of service delivery, training and quality assurance. In this article, we attempt to address this by considering specific factors that contribute to provision of a high-quality capsule service. The role of formal training, accreditation and quality assurance measures is also discussed.

Background and Aims. The role of capsule endoscopy (CE) in the <50 years of age patients with iron deficiency anaemia (IDA) remains unclear. We aim to assess its utility in this cohort. Methods. All patients referred for CE for recurrent IDA were included retrospectively. Patients were divided into Group 1 (<50 years) and Group 2 (≥50 years). Results. There were 971 patients with recurrent IDA and 28% belonged to Group 1. The mean age was 40 years in this group with a DY of 28% (n = 76). Significant diagnoses included erosions and ulcers (26%; n = 71), small bowel (SB) angioectasia (AE) (10%; n = 27), SB tumours (3%; n = 7), Crohn's disease (3%; n = 7), SB bowel strictures (1%; n = 3), and SB varices (1%; n = 2). On logistic regression, the presence of diabetes (P = 0.02) and the use of warfarin (P = 0.049) was associated with increased DY. The DY in Group 2 was 38% which was significantly higher than in Group 1 (P = 0.02). While SB tumours were equally common in both groups, AE was commoner in Group 2 (P < 0.001). Conclusion. A significant proportion of patients <50 years are referred for CE. Although the DY is lower compared to those ≥50 years, significant pathology is found in this age group. CE is advisable in patients <50 years old with recurrent IDA and negative bidirectional endoscopies.

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 Gastroscopy is uncomfortable for patients and incurs the risks of intubation and sedation. Capsule endoscopy is well tolerated and recently a handheld magnet has been developed to enable steering of the capsule to visualise all areas of the capacious stomach. Our preliminary data suggests that a novice can identify all beads sewn into a porcine stomach within 4 min after 40 consecutive examinations.1 We performed a double blind randomised controlled trial comparing MSGCE with conventional gastroscopy in the detection of beads in the same model. Methods Ex-vivo porcine stomach models were used in a standard housing unit. MSGCE was performed according to a standard protocol using 1000mls of water to distend each stomach and a combination of positional change (head down, 30° left lateral, 30° right lateral) and magnetic control to steer the capsule. Each model was examined in a standard fashion by gastroscopy and subsequently MSGCE using MiroCam Navi (Intromedic Ltd). Two blinded investigators (MFH and IR) competent to perform both procedures were allocated randomly to perform either gastroscopy or MSGCE on each model. This was performed as a non-inferiority study with an expected sensitivity of 90% for both (0 estimated difference), a specificity of 100% and a difference of interest 10 percentage points (i.e., 80% is significantly worse). A sample size of 85 beads was needed to achieve this statistical power. Twelve porcine stomachs were prepared with beads as follows: 2 × 0 beads, 2 × 1 bead, 2 × 2 beads, 2 × 3 beads, 2 × 4 beads, 2 × 5 beads, giving a total of 30 beads. The study was conducted in three rounds, giving a total of 90 beads to be identified. Number of beads identified and procedure duration was recorded. Results Gastroscopy correctly identified 88% (79/90) beads, MSGCE correctly identified 89% (80/90) beads and thus is non-inferior to gastroscopy in this setting (95% CI 82.54–95.46%). Mean examination times for gastroscopy and MSGCE were 3.34 min and 9.90 min respectively. MSGCE overestimated the number of beads present on a single occasion. Conclusion MSGCE is equivalent to conventional gastroscopy in the detection of beads placed in a porcine stomach model. Procedure duration was longer for MSGCE compared to gastroscopy. Further studies in humans are necessary to define the scope and utility of this exciting new technique. Reference Hale MF, Drew K, Baldacchino T, Anderson S, Sanders DS, Riley SA, Sidhu R, McAlindon ME. Gastroscopy without a gastroscope! Feasibility in a porcine stomach model using a magnetic capsule. Abstract. British Society of Gastroenterology Annual Meeting, Jun 2013 Disclosure of Interest None Declared.

Introduction Ambulatory care sensitive conditions are those where intervention may limit hospital admissions. Improvements in the management of these conditions may save the NHS £96–£238 million per annum and alleviate pressures on Accident and Emergency. This is directly applicable in Gastroenterology but few gastrointestinal (GI) conditions are conventionally listed as suitable for this approach. This study examined the effect of such a service providing rapid access to specialist services in a UK Gastroenterology Unit. Methods A Gastroenterology ambulatory care service was established as part of an investigation unit with on-ward endoscopy facilities. General practitioners (GPs) were given written guidelines and referred to a senior nurse via telephone. Patients considered suitable were those requiring urgent assessment but where admission might be avoided. Exclusion criteria: hypotension, suspected acute abdomen, or GP concern about potential for deterioration. Results 224 patients were referred by their GP from June 2011 to January 2013. 12 did not attend. Presentation and outcome are described in Table 1. 179 patients (84%) were seen on arrival by a consultant. 96 patients (45%) were admitted; 116 were discharged on the same day – of whom 94 (91%) were offered either same day (n = 67 (58%)) or outpatient (n = 27 (23%)) investigations. 30 day readmission rate was only 4% (n = 5). 51 patients had low risk GI bleeds (Rockall score 0–1). 30 (59%) of these were discharged the same day and 90% (n = 27) had an OGD within 24 h of assessment, either same day or returning the following morning. Conclusion The Ambulatory Care Service provides direct, rapid access to specialist opinion and investigation for a range of GI presentations, avoiding hospital admission for the majority referred. In contrast to other UK studies those with low risk GI bleeding were managed as out-patients but with gastroscopy undertaken. This is a model for a tiered approach to emergency care in Gastroenterology. Disclosure of Interest None Declared.

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.