The diagnosis period can mark a turning point in life for patients diagnosed with chronic conditions. Being diagnosed with ulcerative colitis (UC) can be a stressful and disruptive time for patients, not only because of the effects of symptoms and disease activity, but also because of the need to understand and adapt to the implications of diagnosis more broadly. Very little qualitative research focussing on patients’ experience of diagnosis with UC has been conducted to date. Such research might help us understand these processes more fully. The aim of this presentation is to explore qualitative research data collected from patients resident in the UK describing their perspectives on the period immediately pre and post diagnosis with UC. In-depth semi-structured interviews were carried out with 40 UC patients as part of qualitative studies integrated with two separate pilot trials. Patients who withdrew from the trials, or who declined to take part, were also interviewed. The majority of patients had no awareness or knowledge of UC before being diagnosed with the condition. This contributed to patients being anxious about how the disease would advance and what to expect in the future. Prior to diagnosis, some primary care physicians dismissed patients’ reported symptoms, thereby increasing the length of time it took to be referred to a gastroenterologist and adding to their distress. Finally, patients reported feeling a range of emotions after being diagnosed with UC, including shock, relief, and confusion about whom to turn to for help. They also expressed a lack of emotional support during this particularly upsetting and difficult time. The diagnosis period is a very emotional time for patients who suffer from UC. In addition to feeling distressed before being diagnosed and anxious about their future, patients also felt isolated and lacked emotional support after their diagnosis. Some emotional support is currently available from various sources throughout the diagnosis period, including health services (IBD nurse, hotline), charities (peer support groups, hotline), and families and friends. However, these support initiatives do not seem to meet all the patients’ requirements. Having an early multi-disciplinary assessment as soon as possible after diagnosis could be vital to minimise the psychological impact of the diagnosis. Future research should concentrate on how patients’ needs could be met more efficiently to improve patients’ experience of being diagnosed with UC. In turn, this may help patients adapt more effectively and rapidly to their diagnosis.

Introduction Mucosal healing is the desired therapeutic endpoint for clinical trials in ulcerative colitis (UC). However, conventional white light endoscopy may fall short of capturing the full spectrum of inflammatory change; and virtual electronic chromoendoscopy (VEC) can show ongoing disease activity even when Mayo scores suggest healing (Iacucci et al. Endoscopy 2015 and 2017). Applicability of VEC scoring requires determination outside the expert setting; thus, our aim was to provide external validation among trainees, consultant gastroenterologists and colorectal surgeons, practicing across six general and specialist centres. Method 15 participants reviewed a computerised training module outlining HD and i-Scan modes. Anchor points for the VEC score indicated mucosal changes (crypt distortion, 0 [A–C]; microerosions, I [1–3]; erosions, II [1–3]; and ulceration, III [1–3]) and vascular alterations (non-dilated vessels, 0 [A–C]; dilated/crowded vessels, I [1–3]; mucosal bleeding, II [1–3]; and intraluminal bleeding, III [1–3]). Performance accuracy was tested using a video library pre-/post-training (n=30). Agreement between raters was tested for the Mayo score, UCEIS and VEC score, and results correlated with histology (New York Mount Sinai system). Results The inter-rater agreement was very good for the Mayo score, UCEIS scoring erosions/ulcers and overall, and for VEC scoring mucosal patterns in both modules (Table 1). For the vascular components of UCEIS agreement was only moderate, and did not improve post-training; unlike the agreement for VEC vascular patterns which improved significantly to very good. Correlation between histology and VEC score was highly significant for mucosal and vascular scoring (Spearman’s ρ: 0.910, p<0.001; and 0.907, p<0.001; respectively, Figure 1). This was superior to the Mayo score (0.876, p<0.001) and UCEIS (0.887, p<0.001). Conclusion The VEC score demonstrates very good inter-observer agreement across all levels of experience and provides excellent correlation with histology. Unlike UCEIS, the VEC score does not have subjective elements (e.g. mucosal erythema, incidental/contact friability) and may better delineate vascular changes due to filter technology. Given the ability to define subtle endoscopic features, VEC may be applied to further stratify treatment paradigms for patients with UC. Disclosure of Interest P. Trivedi Conflict with: Received funding from the National Institute for Health Research (NIHR), Conflict with: This article presents independent research funded by the NIHR. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health, S Ghosh: None Declared, M Iacucci: None Declared

Introduction Tuberculosis (TB) carries significant morbidity. It is most commonly pulmonary but it can also affect the gastrointestinal (GI) tract (6% of total cases in UK). Abdominal tuberculosis (A-TB) is a rare disease which can present a unique diagnostic challenge mimicking various GI diseases. We reviewed a 10 year cumulative regional TB database to report results on this unusual condition. Method A retrospective review of patients diagnosed with A-TB between 2006 & 2016 in a single tertiary centre in South Birmingham covering a multi-ethnic urban population of ~7 50 000. A central surveillance database managed by Respiratory Physicians and Public Health England was used to identify patients with A-TB. We reviewed clinical data from electronic records including radiology, chemical pathology, histopathology, endoscopy databases, surgical notes and letters. Results Of 41 patients [M=22 (54%);mean age 42y (SD ±17y)] identified with A-TB, 17 (41%) were Pakistani, 6 (15%) were other Asian and 8 (19%) were Afro-Caribbean with no data on country of origin or ethnicity recorded for the remainder. Thirty three (80%) were residents of economically deprived areas of Birmingham which were among the 10% of most deprived constituencies in UK, with an overall lowest national decile of 1#.(# Index of multiple deprivation as per local council) The most frequently reported symptoms were abdominal pain (n=23; 56%), weight loss (n=17; 41%), fever (n=10; 24%) and vomiting (n=9; 22%). Twelve (29%) patients were first seen in the surgical clinic and 9 (22%) in a medical gastroenterology clinic. A-TB was confirmed on tissue biopsy in 24 (58%) of which 2 were post-bowel resection. Seventeen (41%) patients had positive cultures with full drug sensitivity and only 5 (12%) patients had polymerase chain reaction (PCR) tests. Eight patients (20%) had concurrent pulmonary TB. Thirty seven patients (90%) received full, successful treatment for A-TB. Conclusion Asian ethnicity and low socioeconomic status appear to be risk factors for A-TB in a single tertiary centre. Histological diagnosis at endoscopic or surgical biopsy is a reliable diagnostic tool for confirming TB. Both gastroenterologists and surgeons need to consider A-TB in their differentials, as once diagnosed, most are successfully treated. Disclosure of Interest None Declared

Background: The pathogenesis of inflammatory bowel disease (IBD) is understood to be a result of a complex interplay between genetics, host immune response and gut microbiota. There is however emerging data to highlight the role of the environment as supported by the evidence of extensive geographic variation in IBD and migrant studies in the South Asian population. The distinct genetic background as well as the lack of certain risk loci in South Asian IBD patients in contrast to their Caucasian counterparts, and the emergence of Western diet and lifestyle highlight a crucial role of the environment in disease pathogenesis. As the gut microbiota has been shown to be different in the native South Asian population compared to those in developed countries, we aimed to investigate if there were ethnic differences in dysbiosis in IBD patients. Methods: We recruited ten Caucasian (8 with ulcerative colitis, 2 with Crohns; 2 had moderately active disease) and six South Asian (5 with ulcerative colitis, 1 with Crohns; 2 had moderately active disease) patients with IBD attending routine out-patient appointments in to the study. Patient characteristics and disease demographic data was collected along with a stool sample. Microbial DNA was extracted using a modified method of the QIAamp Stool mini kit. To analyse community structure, we amplified the V3-V4 hyper-variable region of the 16S rRNA gene from faecal DNA, using barcoded sequencing primers. These products were sequenced using the Illumina MiSeq and data analysis was performed using the QIIME pipeline and GreenGenes database to compare differences in microbial composition and diversity between. Results: We found no differences in the microbial diversity nor phylae and genera in luminal gut microbiota between South Asian and Caucasian patients with IBD. This observation did not vary regardless of patient and disease characteristics or medications. Similar to previous observations both groups of patients with IBD demonstrated reduced bacterial diversity and an expansion in Proteobacteria, Bacteroides and Clostridiales along with a decrease in Firmicutes. The Firmicutes to Bacteroides ratio was characteristically low as expected in IBD. Conclusions: The gut microbiota in South Asian IBD patients is similar to Caucasian IBD patients. A larger cohort of IBD patients are needed to validate these findings and study the role of travel and diet to changes in gut microbiota associated IBD disease activity.

Introduction Helicobacter pylori is a Gram-negative bacterium, which infects over 50% of the population worldwide. However, only a subset of these infections result in gastrointestinal diseases, such as peptic ulceration (10%) and gastric cancer (2%). Several epidemiological studies have revealed that people who carry H. pylori are at a decreased risk of developing IBD. However, a mechanistic understanding of the association between H. pylori infection and IBD is still unknown. Unlike any other microbial species, once H. pylori colonises its gastric niche, it is able to dominate the gastric microbiome, representing 90%–95% of the total microbial population. Therefore, we hypothesised that the presence of H. pylori in the upper gastrointestinal (GI) tract prevents the colonisation of the lower GI tract with microbial species associated with the pathogenesis of IBD. Method To test this, we collected stool samples from IBD patients (comprising Ulcerative Colitis and Crohn’s disease patients) and determined their H. pylori status using a stool antigen test. We then characterised the intestinal microbiota of H. pylori positive (n=9) and negative IBD patients (n=18), by amplifying the V4 hyper-variable region of the 16S rRNA gene from faecal DNA. To determine the predominant phyla, these products were sequenced using the Illumina MiSeq and data analysis was performed using the QIIME pipeline and GreenGenes database. Results Interestingly, bacterial community structure revealed that there is a strong trend towards a decrease of Proteobacteria and an increase of Bacteroidetes in H. pylori positive IBD patients. Of note, IBD is generally characterised by an increase in Proteobacteria and a decrease in Bacteroidetes. Furthermore, using PICRUSt to investigate the functional composition of the metagenomes, we found that the H. pylori positive IBD patients displayed significant functional differences, including decreased bacterial motility and chemotaxis (p= Conclusion Our preliminary data suggests that the presence of H. pylori infection may promote a less pathogenic intestinal microbiome in patients with established IBD. This data provides the rationale to extend our studies with increased patient numbers and healthy controls to determine the mechanistic basis for the negative association of H. pylori infection and IBD. Disclosure of Interest None Declared

Background: Evidence is accumulating for an important role of vitamin D in aetiopathogenesis and outcomes in Crohn's disease (CD) [1]. Vitamin D monitoring and supplementation is now recommended for the general population in the UK: however, there is no recent European guidance on this in CD [2]. We undertook an audit to assess awareness of vitamin D monitoring in our regional CD outpatients. Methods: We randomly selected 146 patients from the South Birmingham University CD cohort, covering a total population of around 750,000. Using clinical and informatics databases, we retrospectively collected data concerning patient demographics, concomitant steroids and smoking status. We determined whether vitamin D level had been measured within past 2 years. In those vitamin D deficient patients, we assessed whether parameters of bone metabolism (calcium, phosphate and parathyroid hormone) had been measured and if vitamin D supplementation had been provided or recommended. Results: The mean age of our sample was 41 years and 85/146 (58%) were female. Around 20% (29/146) patients were current smokers and 71% (103/146) had some/variable degree of diagnosed small bowel CD. Vitamin D levels were checked in 46% (68/146) patients, of which 47% (32/68) patients had vitamin D deficiency (<50 nmol/L) and 21/32 patients had severe vitamin D deficiency (<30 nmol/L). Among these deficient patients, there were no clear gender or ethnic differences, but current smokers were more common (37% (12/32)). 63% (20/32) of the deficient patients had some/variable degree of small bowel disease. All had normal calcium: none had parathyroid hormone checked whilst only 22% (7/32) patients had phosphate checked (all normal). Four patients (13%) were taking concomitant steroids. Supplementary treatment or request to GP to prescribe vitamin D supplement was undertaken in 56% (18/32) of vitamin D deficient patients. Conclusions: In this single-center random UK sample, vitamin D levels were checked in less than half of the sampled population. Of those checked, around half were vitamin D deficient, and around one third were severely deficient, with smokers. Whilst about half of them did receive required supplements following their tests, many did not, highlighting that increased awareness of the role of vitamin D in CD is required. References: [1] Ananthakrishnan et al. Higher predicted vitamin D status is associated with reduced risk of CD. Gastroenterology 2012 Mar;142(3):482–9. doi: 10.1053 [2] BSG Guidelines for osteoporosis in inflammatory bowel disease and coeliac disease, June 2007.

Introduction Biliary anastomotic strictures are among the commonest biliary complications following liver transplantation. Endoscopic therapy including balloon dilatation of stricture and maximal stent placement, is widely used as the preferred means of managing these patients.12 However, endoscopic therapy is not standardized and there is very limited prospective data to support the long-term efficacy of this approach. The aim of our study is to assess the safety and long-term efficacy of endotherapy in the management of biliary anastamotic strictures complicating liver transplantation. Methods This was a prospective observational study carried out at the liver transplantation unit, Queen Elizabeth Hospital, Birmingham, United Kingdom, between June 2000 and September 2010. In June 2000, the liver transplant unit in Birminghamintroduced a new protocol for managing biliary anastamotic strictures complicating orthotopic liver transplantation. The new protocol entailed a sequence of clearly defined clearly defined endoscopic interventions including balloon dilatations and stent insertions at regular intervals. A total of 1414 adult patients underwent liver transplantation. 81 (6%) patients were diagnosed with biliary anastomotic strictures during this period. Results Endoscopic therapy was successful in 61% of patients referred with anastomotic strictures with a median intervention/stent free follow-up of 54 months. Patients required a median of 3 endoscopic procedures and two 24 F balloon dilatations to adequately treat the stricture. Three patients (3%) had recurrent stricture and two of these were successfully retreated with endotherapy. A total of 261 endoscopic procedures were undertaken and complications included mild to moderate pancreatitis (n = 9), Cholangitis (n = 4) and stent migration (n = 2). The rate of pancreatitis per endoscopic procedure was 3%. Severe pancreatitis or death were not reported. Twenty patients underwent biliary reconstruction. Conclusion We report one of the very few prospective studies looking at the long-term efficacy and safety of endoscopic therapy in the management of anastamotic biliary strictures. Endoscopic balloon dilatation and stenting is a safe and efficacious means of treating biliary anastomotic strictures complicating liver transplantation.

Fatigue is probably the most intriguing symptom affecting patients with chronic cholestatic disorders, in particular those with primary biliary cirrhosis.It is postulated that fatigue in patients with primary biliary cirrhosis may be associated with morphological abnormalities of the central nervous system secondary to accumulation of manganese.However, we are still far from understanding this complex issue.. . . . . .

Background and Aim: The present study determined the pattern of cytokine secretion (interleukin [IL]-1beta, tumor necrosis factor [TNF]-alpha, interferon [IFN]-gamma and IL-10) and their cellular sources in mononuclear cells isolated from colonic mucosa from normal and ulcerative colitis (UC) in response to probiotic and pathogenic bacteria.Methods: Mononuclear cells were extracted from normal and active UC colonic mucosa and incubated with pure sonicates of probiotic, commensal, and pathogenic bacteria. Cytokine secretion was measured in culture supernatant and intracellular cytokine staining measured using fluorescent-activated cytometry.Results: In mononuclear cells isolated from normal mucosa, significant increases in mean IL-1beta were observed with enteropathogenic Escherichia coli (286.3 +/- 138.7 pg/mL P < 0.05) and E. coli (440.5 +/- 194.0 pg/mL P < 0.01) compared with unstimulated control cells (16.7 +/- 4.8 pg/mL). In contrast, mononuclear cells isolated from active UC mucosa produced significant increases in mean IL-1beta in response to stimulation with Salmonella dublin (230.5 +/- 38.8 pg/mL P < 0.05). enteropathogenic E. coli (231.7 +/- 45.3 pg/mL P < 0.05) and E. coli (465.4 +/- 60.2 pg/mL P < 0.001) compared with unstimulated control cells (60.7 +/- 17.1 pg/mL). Escherichia coli also produced significant mean increases of TNF-alpha and IFN-gamma compared with unstimulated control cells. No significant increases in IL-1beta, TNF-alpha or IFN-gamma were observed with Lactobacillus plantarum in cells derived from normal or inflamed mucosa. Strikingly, incubation of L. plantarum with mononuclear cells isolated from active UC mucosa resulted in significant increases of mean IL-10 (327 +/- 53.5 pg/mL, P < 0.05) compared with unstimulated control cells (29.7 +/- 13.2 pg/mL). Intracellular cytokine staining confirmed T-cell and macrophage IL-10 production after L. plantarum stimulation.Conclusions Lactobacillus plantarum demonstrates beneficial immunomodulatory activity by increasing IL-10 synthesis and secretion in macrophages and T-cells derived from the inflamed colon. This may provide a mechanism through which probiotic bacteria ameliorate inappropriate inflammation and induce tolerance. (C) 2004 Blackwell Publishing Asia Pty Ltd.

Objectives. To assess the prevalence and potential benefits of attitudes towards nurse endoscopy in the United Kingdom (UK).Design. Postal questionnaire.Subjects. All hospitals in the UK with accident and emergency, general medical and general surgical services in October 2000.Main outcome measures. Number of teaching or district general hospitals employing nurse endoscopists, range of diagnostic and therapeutic endoscopic skills and potential benefits to the endoscopy unit and patients.Results. Seventy-six hospitals employed 102 nurse endoscopists. Forty-four nurse endoscopists performed both oesophago-gastroduodenoscopy (OGD) and flexible sigmoidoscopy with solitary OGD and flexible sigmoidoscopy performed by 17 and 31, respectively. Three performed full colonoscopy while seven could perform all three procedures. Nurse endoscopists were found to provide good patient care in the majority of endoscopy units with no compromise in safety. Lead clinicians were keen to restrict nurse endoscopy to diagnostic OGD and flexible sigmoidoscopy only in the majority of units.Conclusions. Nurse endoscopy is widely practised in the UK and is not limited to one procedure or solely for diagnostic purposes. Benefits include good patient acceptability, improved care and safety. Most clinicians predict an important but restricted role for nurse endoscopy in contributing to endoscopic services.