Background and objective: Endoscopic retrograde cholangiopancreatography ( ERCP) is a technically demanding endoscopic procedure that varies from a simple diagnostic to a highly complex therapeutic procedure. Simple outcome measures such as success and complication rates do not reflect the competence of the operator or endoscopy unit, as case mix is not taken into account. A grading scale to assess the technical difficulty of ERCP can improve the objectivity of outcome data.Methods: A I to IV technical difficulty grading scale was constructed and applied prospectively to all ERCPs over a 12 month period at a single centre. The procedures were performed by two senior trainees and two experienced consultants ( trainers). The grading scale was validated for construct validity and inter-rater reliability at the end of the study using the chi(2) test and. statistics.Results: There were 305 ERCPs in 259 patients over the 12 months study period ( males: 112, females: 147, age range 17-97, mean 70.3 years). There was overall success in 244 (80%) procedures with complications in 13 (4%): bleeding in five (1.6%), cholangitis in one (0.3%), pancreatitis in five ( 1.6%), and perforation in two (0.7%). Success rate was highest for grade I, 49/55 (89%), compared with grade IV procedures, 8/11 (73%). There was a significant linear trend towards a lower success rate from grade I to IV (p = 0.021) for trainees, but not for trainers. Complications were low in grade I, II, and III procedures, 12/295(4%), compared with grade IV procedures, 1/11(9%). The inter-rater reliability for the grading scale was good with a substantial agreement between the raters (kappa = 0.68, p < 0.001).Conclusion: Success and complications of ERCP by trainees are influenced by the technical difficulty of the procedure. Outcome data incorporating a grading scale can give accurate information when auditing the qualitative outcomes. This can provide a platform for structured objective evaluation.

Background: In the setting of endoscopy in an anticoagulated patient, the endoscopist must assess the risk of complications related to intercurrent bleeding or thrombosis and plan the endoscopic procedure accordingly. A recent survey across the Northern region of England revealed a huge variation in practice. This is not surprising in the absence of a national guideline. Recently the American Society for Gastrointestinal Endoscopy (ASGE) has published guidelines on this subject.Aim: To survey the current practice of endoscopy in anticoagulated patients among endoscopists across Wales using the ASGE guidelines as a benchmark.Methods: A postal questionnaire was sent to all endoscopists identified from each endoscopy department across Wales irrespective of qualification and experience. The questionnaire was constructed based on the ASGE guidelines as follows. (1) Procedure risk - bleeding related to an endoscopic intervention carried out in the setting of anticoagulation, and (2) Condition risk - a thromboembolism event related to interruption of anticoagulation for a particular condition. High-risk procedures were - polypectomy, dilatation, endoscopic sphincterotomy, PEG, laser ablation/coagulation and all the rest were low risk procedures. High-risk conditions were - mechanical prosthetic valve, atrial fibrillation with underlying heart disease, recurrent thromboembolism and the rest were low risk conditions.Results: A total of 90 questionnaires were sent and we received, 58 (52%) replies. There were 33 consultants, 7 middle-grade doctors, 4 general practitioners, 13 trainees and 1 nurse endoscopist. Twenty-seven (47%) respondents considered endoscopic biopsy as a high-risk procedure. Twenty-nine (50%) considered bioprosthetic valve as a high-risk condition. Twenty-four (41%) did not consider atrial fibrillation with underlying heart disease and recurrent thromboembolism as a high risk condition and 8 (14%) considered atrial fibrillation without underlying heart disease as a high risk condition. Six (10%) would not use intravenous heparin after stopping warfarin in high-risk conditions. All except 2 (3%) considered …

The patient was a 22-year-old woman who had presented in early childhood with gastroesophageal reflux and who subsequently underwent surgery. It was commented upon by the surgeons at that time that the esophagus was abnormally thickened. The patient subsequently presented during her first pregnancy with a vulval tumor, which proved histologically to be a leiomyoma. She was also found to have a grossly dilated esophagus and was thought to have achalasia. However, endoscopic ultrasound imaging showed gross hypertrophy of the mid- and distal esophageal wall, with only mild symptoms of dysphagia, which had been long-standing. The appearance of the esophagus was consistent with diffuse esophageal leiomyomatosis. In view of the associated vulval leiomyoma, the patient demonstrated esophagovulvar syndrome.

Background/Aims: The development of cholesterol gallstones, in some patients, has been associated with increased proportions of deoxycholic acid in the bile acid pool. Deoxycholic acid is a microbial product of cholic acid 7α-dehydroxylation in the intestines. The levels and activities of bile acid 7α-dehydroxylating bacteria have been reported to be increased in gallstone patients. The aim of the current study was to isolate 7α-dehydroxylating bacteria from gallstone patients and determine if these individuals are colonized by similar bacterial species.

The occurrence of primary hepatocellular carcinoma (HCC) in patients with genetic haemochromatosis (GH) with cirrhosis is well known. In the past it has been suggested that patients with GH without cirrhosis have the same risk of HCC and life expectancy as the general population. However, recently there have been cases of HCC arising in non-cirrhotic livers, and we report another such case. A review of the literature has been included.

Increasing evidence implicates prolonged intestinal transit (slow transit constipation) in the pathogenesis of conventional gallbladder stones (GBS), and that of gallstones induced by long term octreotide (OT) treatment. Both groups of GBS patients have multiple abnormalities in the lipid composition and physical chemistry of their gallbladder bile - associated with, and possibly due to, an increased proportion of deoxycholic acid (DCA) (percentage of total bile acids). In turn, this increase in the percentage of DCA seems to be a consequence of prolonged colonic transit. Thus, in acromegalic patients OT treatment significantly prolongs large bowel transit time (LBTT) and leads to an associated increase of the percentage of DCA in fasting serum (and, by implication, in gallbladder bile). LBTT is linearly related to the percentage of DCA in fasting serum and correlates significantly with DCA input (into the enterohepatic circulation) and DCA pool size. However, these adverse effects of OT can be overcome by the concomitant use of the prokinetic drug cisapride, which normalizes LBTT and prevents the rise in the percentage of serum DCA. Therefore, in OT-treated patients and other groups at high risk of developing stones, it may be possible to prevent GBS formation with the use of intestinal prokinetic drugs.