Endoscopic retrograde cholangiopancreatography (ERCP) is the mainstay of management for most patients with common bile duct stones (CBDS). Duct clearance at initial ERCP may not be achieved in a third of patients, many of whom may be elderly with multiple comorbidities rendering them at potentially high risk for further procedures. We aimed to quantify the rate of biliary sequelae and mortality among a large cohort undergoing a single ERCP with sphincterotomy and stent insertion without having undergone complete ductal clearance (permanent stent insertion, PSI), and to examine factors that may predispose to adverse outcomes.

Bacteraemia is common following some forms of gastrointestinal endoscopic therapy, such as dilatation or injection sclerotherapy, and can occur with diagnostic endoscopy alone. Fortunately complications resulting from dissemination of endogenous bacteria are uncommon, and infective endocarditis is an extremely rare complication. Furthermore, for most diagnostic and therapeutic procedures there is scant evidence that antibiotic prophylaxis can reduce the incidence of infective complications. The area that has attracted the most controversy in recent years has been the use of antibiotics to prevent infective endocarditis. The recommendations by the American Heart Association (AHA)1 have traditionally guided the advice of the national bodies representing endoscopic practice,2 3 including the British Society of Gastroenterology (BSG).4 The traditional guidance has been that patients at high risk of endocarditis, such as those with a prosthetic (ie, tissue or mechanical) valve and/or a past history of endocarditis should receive antibiotics for all endoscopic procedures. More recently the European Society of Cardiology recommended antibiotic prophylaxis to cover therapeutic endoscopy in patients with acquired valvular heart disease,5 and the British Cardiovascular Society went even further, advising antibiotic prophylaxis for patients at moderate risk of endocarditis undergoing any endoscopic procedure.6 The Endoscopy Committee of the BSG recognised the need for consensus on this issue, and convened a Working Party in the spring of 2006. The membership, comprised doctors with a special interest in gastroenterology, gastroenterologists, cardiologists and microbiologists. The gastroenterologists and microbiologists from this Working Party also took the opportunity to review the evidence underpinning the use of antibiotic prophylaxis in other areas of endoscopic practice, in particular endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous endoscopic gastrostomy (PEG). In view of new guidance from the AHA, and from the National Institute for Health and Clinical Excellence (NICE), the Working Party reconvened in 2008 to reconsider, in …

BACKGROUND:The number of colonoscopic procedures continues to rise rapidly. With widespread adoption of colonoscopy based bowel screening programmes, this rising trend is set to continue.AIMS:This study aimed to identify whether elective colonoscopy could provoke cardiac rhythm disturbances and/or myocardial ischaemia, as evidenced by 12 lead Holter ECG recordings and troponin I (cTnI) changes.MATERIALS AND METHODS:Patients were stratified into three groups based on the presence of cardiac disease or cardiovascular risk factors. They underwent real time 12 lead Holter monitoring before, during and after colonoscopy. Bloods were taken for pre- and post-procedure cTnI estimation.RESULTS:Holter ECG recordings of the three groups showed a high incidence of new but silent ischaemic and arrhythmic ECG changes during the colonoscopy in patients with documented but stable heart disease and to a lesser extent in those patients with one or more risk factors for heart disease. Three patients had high cTnI concentrations both before and after colonoscopy. Two patients with known heart disease died within 30 days of colonoscopy.CONCLUSIONS:This study demonstrates for the first time the occurrence of potentially clinically significant ST-T wave changes and rhythm disturbances during elective colonoscopy in patients with known heart disease and to a lesser extent in those patients with a known cardiovascular risk profile.

Background: Colonoscopy is classed by the American Heart Association as a low risk procedure. However, there have been no detailed studies looking at the cardiac effects of colonoscopy. Aim of Study: To determine whether colonoscopy can provoke cardiac rhythm disturbances, myocardial ischemia or cardiac injury as evidenced by changes on ECG monitoring and/or Troponin I elevation. Methods: Patients who participated in this prospective cohort study were stratified into three risk groups: Group A -patients with any documented significant cardiac co-morbidities, Group B-patients with cardiovascular risk factors but no proven heart disease and Group C-patients with no risk factors for heart disease. All patients had 12-lead Holter monitoring for ECG recording during the colonoscopy along with a pre- and 24-hour post-procedure Troponin I estimation. All results were blinded and independently assessed0, by 2 cardiologists. Results: One hundred and ninety eight patients participated in the study. There was one 15-day and one 30-day mortality in Group A, from myocardial infarction. Four patients-three in Group A and one in Group B-had high pre-procedure Troponin I concentrations (0.06,0.12, 0.15 and 0.2) with some rise post-procedure (0.06, 0.13, 0.16 and 0.23). Four patients-three in Group A and one in Group C-had normal pre-procedure Troponin I concentrations (0.03,<0.01, 0.03 and 0.04) with elevations post-procedure(0.05, 0.05, 0.06,0.06)(Normal Troponin I value < 0.05 microgram/L). None of these eight patients had underlying renal dysfunction. Of the 195 patients for whom ECG analyses are available,8 patients(19%) in Group A had significant ST segment changes and 2 patients(5%) had transient bundle branch blocks during the procedure. One patient(2%) developed a significant asystolic pause>3 seconds,4 patients(10%) developed bradycardia and 1 patient(2%) atrial fibrillation during the procedure. In Group B,9 patients(8%) developed ST segment changes during the procedure. The following developed in one patient each: new onset bigemini, atrial fibrillation and a significant asystolic pause>3seconds. ST segment changes and atrial fibrillation each occurred in one patient in Group C. Discussion: This study demonstrates that colonoscopy can provoke significant cardiac strain. The ncidence of cardiac phenomena identified in the high and medium risk group could indicate that non-invasive bowel imaging procedures may need to be discussed as an alternative diagnostic procedure. If confirmed by others, these findings could have implications for colonoscopy-based bowel screening programmes. This study also adds a new dimension in the informed consent of patients requiring colonoscopy.

Background: Elective cesarean section (CS) may be recommended for patients with Crohn's disease and perineal involvement. Little is known about CS rates in parous women with inflammatory bowel disease (IBD), nor the possible long-term impact of vaginal delivery and episiotomy on continence in women with IBD.Methods: Questionnaires were sent to all 777 regional members of a Colitis and Crohn's Disease patient association. Male members were asked to request their unaffected female spouse/partner to complete the forms in order to give a "control" group for comparison.Results: Forms were returned by 491 members (response rate 63%). CS had been undertaken for 37 of the 229 parous women with 1BD (16%) versus 15 of the 116 without IBD (13%) (X-2 = 0.62, P - NS). Only 2 women had undergone CS due to IBD. Of the parous women with IBD, 75 (33%) had persisting problems with fecal incontinence, of whom 21 (28%) dated this back to the time of vaginal delivery. By contrast, only 2 (2%) of the parous control group had suffered persisting fecal incontinence following vaginal delivery (x(2) = 8.27, P < 0.01).Conclusions: Persisting fecal incontinence is reported by a significant minority of parous women with IBD, of whom over one-quarter date this back to vaginal delivery. CS is rarely recommended due to IBD alone. If our findings are confirmed in prospective studies, the threshold for recommending CS may need to be lowered for patients with 1BD.

BACKGROUND:British Society of Gastroenterology guidelines recommend that gastrointestinal investigations should be considered in males and post-menopausal women presenting with iron-deficiency anaemia (IDA).AIM:To compare the diagnostic yields and clinical effectiveness of upper and lower gastrointestinal (GI) investigation in detecting malignancy among patients presenting with IDA.DESIGN:Retrospective review of case notes, endoscopy records and radiology reports.METHODS:We reviewed the results of 3798 investigations in 2600 patients presenting to our hospital with IDA from October 1995 to December 2003. The findings of the 2318 gastroscopies were compared with those of the 896 colonoscopies and the 584 barium enemas. Patients diagnosed with GI malignancy were identified and their outcomes determined.RESULTS:Gastroscopy identified 44 patients with newly-diagnosed upper GI cancer (18 oesophageal, 26 gastric). Thus for patients being gastroscoped for IDA, the Numbers Needed to Investigate (NNI) to detect each cancer was 53. Five-year survival for these 44 patients was 10%, so the NNI to identify each curable upper GI malignancy was 527. Colonoscopy or barium enema identified 111 (7.5%) patients with newly diagnosed colorectal cancer, giving a NNI of 13. Their 5-year survival was 35%, giving a NNI to identify each curable colorectal cancer patient of 38.DISCUSSION:Potentially curable gastrointestinal malignancy was diagnosed over 13 times more commonly using colonoscopy or barium enema vs. gastroscopy. For patients presenting with IDA, our findings favour investigating the lower GI tract first, or performing both gastroscopy and colonoscopy during the same endoscopy list.

We aim to compare the outcomes of patients undergoing R0 esophagectomy by a multidisciplinary team (MDT) with outcomes after surgery alone performed by surgeons working independently in a UK cancer unit. An historical control group of 77 consecutive patients diagnosed with esophageal cancer and undergoing surgery with curative intent by six general surgeons between 1991 and 1997 (54 R0 esophagectomies) were compared with a group of 67 consecutive patients managed by the MDT between 1998 and 2003 (53 R0 esophagectomies, 26 patients received multimodal therapy). The proportion of patients undergoing open and closed laparotomy and thoracotomy decreased from 21% and 5%, respectively, in control patients, to 13% and 0% in MDT patients (chi2 = 11.90, DF = 1, P = 0.001; chi2 = 5.45, DF = 1, P = 0.02 respectively). MDT patients had lower operative mortality (5.7%vs. 26%; chi2 = 8.22, DF = 1, P = 0.004) than control patients, and were more likely to survive 5 years (52%vs. 10%, chi2 = 15.05, P = 0.0001). In a multivariate analysis, MDT management (HR = 0.337, 95% CI = 0.201-0.564, P < 0.001), lymph node metastases (HR = 1.728, 95% CI = 1.070-2.792, P = 0.025), and American Society of Anesthesiologists grade (HR = 2.207, 95% CI = 1.412-3.450, P = 0.001) were independently associated with duration of survival. Multidisciplinary team management and surgical subspecialization improved outcomes after surgery significantly for patients diagnosed with esophageal cancer.

BACKGROUND:The aim of this study was to determine the incidence and spectrum of alarm symptoms in patients with newly diagnosed gastric cancer, and to examine the relationship between symptoms and outcome.METHODS:Three hundred consecutive patients with gastric adenocarcinoma were studied prospectively. The outcomes of 40 patients (13.3 per cent) without alarm symptoms (21 men; median age 69 years) were compared with those of the 260 patients (86.7 per cent) with alarm symptoms (175 men; median age 72 years).RESULTS:It was possible to perform an R0 gastrectomy more often in patients without alarm symptoms (21 patients; 52 per cent) than in those with alarm symptoms (71 patients; 27.3 per cent) (chi(2) = 10.35, 1 d.f., P = 0.001). The cumulative survival rate at 5 years was 38 per cent for patients without alarm symptoms versus 15.0 per cent for those with alarm symptoms (chi(2) = 10.18, 1 d.f., P = 0.001). In a multivariate analysis, distant metastasis (hazard ratio (HR) 2.73 (95 per cent confidence interval (c.i.) 2.04 to 3.66); P < 0.001), overall stage of cancer (HR 1.83 (95 per cent c.i. 1.53 to 2.19); P < 0.001) and persistent vomiting at diagnosis (HR 1.66 (95 per cent c.i. 1.26 to 2.18); P < 0.001) were independently associated with length of survival.CONCLUSION:Alarm symptoms are absent in a significant minority of patients with gastric cancer at diagnosis; these patients stand a better chance of curative surgery and long-term survival than those with alarm symptoms.

Objective  To review all preceding ‘negative’ large bowel investigations in patients with a final diagnosis of colorectal cancer, and to examine whether delayed diagnosis was associated with worse outcome.

Objectives: To examine prospectively the prevalence of iron deficiency among new patients presenting with colorectal cancer and to compare transferrin saturation and serum ferritin as markers of iron deficiency in this group of patients.Patients and methods: Data were gathered on all patients presenting with a new diagnosis of colorectal cancer over a 12-month period. Iron status was estimated and, when possible, confirmed by measurement of serum ferritin concentration and transferrin saturation. Iron status was further examined in relation to turnout site and Dukes' stage.Results: During the study 157 patients presented with a new colorectal cancer. Of these, 130 could be evaluated and 78[60%] had evidence of iron deficiency. Transferrin saturation was below the reference range in 55 patients, but serum ferritin was below in only 18 patients. Among the 49 patients with right-sided cancers, 39[80%] were iron deficient. Iron deficiency was significantly more likely in patients with right sided cancers compared with those with cancers at or distal to the 2 splenic flexure (chi(2) = 13, P < 0.001).Conclusion: The majority of patients with a new diagnosis of colorectal cancer are iron deficient at presentation. In such patients transferrin saturation measurement is a more sensitive marker of iron deficiency than serum ferritin. The potential role of measuring serum transferrin saturation as an adjunct to faecal occult blood screening should be explored further.