Type 1 and type 2 diabetes mellitus (DM) are often accompanied by mild forms of pancreatic exocrine insufficiency (PEI). The prevalence rates of PEI in diabetic patients are unclear and variable depending on the testing modality and the studies published. The clinical consequences of PEI in diabetics are also not well defined. We aimed to determine the prevalence of PEI in a diabetic cohort using the faecal elastase-1 (FE-1) assay as a screening test and to validate a patient-reported symptom-based scoring system, the (PEI-S) for diagnosing PEI within this patient population. Two hundred and three diabetic patients attending diabetic and gastroenterology outpatients of a university hospital without previously known PEI were recruited for the study. Demographic parameters, PEI score (PEI-S), and glycated hemoglobin (HBA1c) were documented in standardized data sheets, and a stool sample was obtained. A FE-1 value < 200 μg/g and or a PEIS of > 0.6 was used as the screening cut-off for PEI. One hundred sixty-six patients returned faecal samples. The prevalence of PEI, as measured by low FE-1, was 12

Aims Assess the impact of nurse-led clinical review and the application of guidelines (European Society of Gastroenterology and National GI Endoscopy Quality Improvement Programme) to endoscopy lists to see if this will result in an increase in capacity within the system.

Aims To assess clinical value of EUS-guided pancreatic cystic lesion FNA performed in TUH from 2012-2019.

Aims To determine the completeness of polyp resection (i.e. achieving an R0 margin) and its relation with Endoscopists, histopathologist, size, location and technique of polypectomy in an NSS cohort. The definition of R0 margin is complete macroscopic resection with a negative microscopic margin at polypectomy. Method NCCS (National Colon Cancer Screening) colonoscopies are offered to bowel cancer screening patients after a positive faecal immunochemical test (FIT) test in a Joint Advisory Group (JAG) accredited Gastrointestinal Endoscopy centre. We histologically evaluated the polyp margins for complete resection, which was defined as the absence of adenomatous or hyperplastic tissue in the resected polyp margins in a cohort of faecal immunochemical test positive patients. Results A total of 186 consecutive NCCS colonoscopies out of a total of 542 performed between 2013 and 2017 were included in this study. Of the polyps excised 152(27%) had a R0 margin histologically, and 30(5%) had involvement of the margin. Surprisingly in 373(67%) of polyps pathologists were unable to assess the margin. Conclusion Achieving an R0 margin should be a key performance indicator for endoscopists performing polypectomy. At the same time more studies on polyp margins are recommended.

Aims This study aimed to characterize the value of Endoscopic Ultrasound (EUS)-guided drainage of Pancreatic Fluid collections (PFCs) with either plastic or Lumen Apposing Metal Stents (LAMS).

Aims To investigate factors that are associated with positive findings at EUS in patients with dilated ducts and correlation with LFTs.

Aims Our aim were to review our surveillance and intervention of pancreatic cystic lesions in our cohort from 2005–2019.

Vedolizumab (VDZ) is a monoclonal antibody designed to inhibit α4β7 integrin and result in gut-selective anti-inflammatory activity. Randomised control trials have shown VDZ to be safe and effective in treating patients with ulcerative colitis (UC). However, real-world data describing the outcome of VDZ therapy in routine clinical practice are limited. We aimed to evaluate the safety and efficacy of VDZ in routine clinical practice. A multicentre, retrospective study across seven Irish academic hospitals in the INITIATIVE Network was conducted. N = 68 eligible UC patients were identified with n = 39 having at least 6 months of follow-up included in the final study cohort. Demographics and disease characteristics were collected at baseline, and 3 and 6 months following VDZ initiation. VDZ was administered as per standard protocol. Primary endpoints were 3-month clinical response and 6-month steroid-free remission. Clinical response was defined as a decrease from baseline in clinical Mayo subscore of ≥3 points, with ongoing receipt of VDZ. Clinical remission was defined as a clinical Mayo subscore of ≤1, the absence of corticosteroid use and continuing receipt of VDZ. Secondary endpoints were baseline variables associated with VDZ induction outcome and rates of adverse events. Thirty-nine patients were included in the final study cohort. Baseline characteristics included (median [range]): age 44 [17–79]; gender 58% male; 61% extensive and 39% left-sided colitis; median clinical Mayo subscore at initiation 6 [2–9]; CRP 8mg/l [0.8–85mg/l) and median albumin 37g/l (20–47g/l). At VDZ initiation proportions receiving 5-aminosalicylates; thiopurines and systemic corticosteroids were 67%, 48%, and 50%, respectively. 24%, 35%, and 41% had been exposed to no, 1 and 2 anti-TNF agents, respectively. Three-month clinical response and 6-month steroid-free clinical remission rates were 47% and 46% respectively. Comparing anti-TNF naïve and exposed individuals; 3 months response rates was similar (40% vs. 48% respectively, p = 0.73); however, there was a trend toward increased 6 months steroid-free remission rates (75% vs. 35%, respectively, p = 0.10). Regression analysis demonstrated no baseline clinical or biochemical variable to be associated with 3-month clinical response or 6-month steroid-free remission. The rate of adverse events was 6.1%, none requiring hospitalisation. These data support the efficacy and safety of VDZ as an induction and maintenance agent in UC. Consistent with published literature the long-term outcome of VDZ therapy appears improved in anti-TNF naïve cohorts.

Background: Inflammatory Bowel Disease (IBD) confers an increased risk of opportunistic infection. Chronic inflammation and the use of steroids, thiopurines and biologic medications contribute to immunosuppression state. Ecco guidelines recommend checking the vaccination status before starting immunosuppressive agents and actively vaccinate them. However many studies have shown poor uptake of recommended vaccinations despite the guidelines and education n provided to them by GI health care providers. In our department we have a dedicated IBD nurse specialist and we provide individual and quarterly group education sessions about different aspects of IBD for our patients. We provide written recommendations to the general practitioner and expect vaccines to be administered in the community. The aim of this study was to assess patient awareness regarding importance of vaccination and their vaccination status Methods: This is single centre observational study performed at a tertiary care centre in Dublin Ireland. A written questionnaire based on ECCO guidelines was developed with simple Yes/No answers. This was given to IBD patients at the outpatient clinics, Infusion suite and in the community. The data was analysed using microsoft excel Results: A total of eighty nine patients completed the survey, 45 (51%) were male. Fifty two percent (47) had Crohn's. Average duration of the disease was 11 years (range 6ms to 46 years). At least 64% of them were exposed to steroids and similar numbers were on thiopurines. Sixty six percent had been or were being treated with an anti-tnf. One patient was on a combination of anti-tnf and of methotrexate. Only 20% of patients responded that they knew about the vaccination recommendations and 18% responded that they were educated about the vaccination at some point in their disease course. Fifteen percent have their up-to-date Pneumococcal vaccination while influenza vaccination was approximately 48%. Twenty one percent have been vaccinated against their hepatitis B. Regular cervical smear check was significantly better as compared to the vaccination which was around 64% of females Figure 1. Vaccination status of the study group. Conclusions: Despite having regular education sessions about the awareness and the importance of vaccination, the uptake of vaccination is very poor. Our findings would suggest that despite education sessions and recommendations to GPs that uptake remains poor, therefore GI providers should take a more pro-active approach and offer vaccination as part of the ambulatory care management of our IBD patients

Background Compared with standard endoscopy, Endoscopic Retrograde Cholangio-Pancreatography(ERCP) is an uncomfortable, complex procedure that typically requires higher doses of sedative and analgesic medication. Our unit, like many throughout Ireland and the UK, performs the vast majority of ERCPs under conscious sedation. Challenges with appropriate sedation levels and patient compliance during ERCP are common. Aim To evaluate patient comfort (1-4) and sedation score (1–5) with conscious sedation using a scoring system based on the modified Gloucester score. Method We prospectively evaluated consecutive ERCPs performed under conscious sedation over a three-month period in a single, tertiary referral centre. Results 121 patients were evaluated. The median age was 73, and 60/121 (49.6%) were female. 46 patients (38%) were ≥75 years. 62 patients (51%) had a comfort score of ≤2, and 59 (49%) had a comfort score of ≥3. One patient required reversal of sedation due to respiratory compromise. Median doses of medication were: midazolam (4.27 mg), diazepam (7.5 mg), fentanyl (84 mcg), and pethidine (35.7 mg). 7 patients received more than one benzodiazepines, 7 with more than one opiates and 6 with all four medications. Conclusions There are limited data to define what is acceptable sedation practice for ERCP. The RCPI have recently recommended that>80% of colonoscopies should have a comfort score of 1 or 2. Though there are no validated comfort scores for ERCP, our data demonstrate that many patients undergoing ERCP with conscious sedation are subjected to an experience that would be considered unacceptable in general endoscopy.

Background: Golimumab (GLB) is a subcutaneous anti-tumour necrosis factor alpha (anti-TNF) therapy. Randomised controlled trials have demonstrated GLB efficacy in the induction and maintenance of remission in ulcerative colitis (UC). Data are few on the outcome of GLB therapy for UC in routine clinical practice. Aims: To describe the outcome of GLB therapy for UC in routine clinical practice in Ireland. Methods: Patients receiving GLB as therapy for UC were identified (n=77) from six Irish Medical centers. Only ambulatory outpatients, with 6 months of follow up post GLB initiation were included (n=69). Baseline clinical, demographic and laboratory data were collected. The primary endpoints were factors associated with durability of GLB response measured by time to drug discontinuation; 3-month clinical response; and 6-month corticosteroid free remission rates. Clinical response was defined as a decrease from baseline in partial Mayo score of at least 3 points and ongoing receipt of GLB. Clinical remission was defined as a partial Mayo score of less than or equal to 2 and continuing receipt of GLB. Secondary endpoints included rates of dose optimisation, dose intervention strategy and adverse events. Raw p values are reported with p values <0.006 (Bonferroni correction) considered significant Results: The study cohort comprised n=69 UC patients. Baseline characteristics were as follows (continuous variables, median [range]): Age 41.4 years [20.3–76.8]; 55% male; disease duration 6.5 years [0–29.9]; clinical Mayo subscore 6 [0–9]; proctitis, left-sided and extensive colitis in 8%, 54% and 38% respectively; baseline CRP 4.4 mg/L [0.2–134.6]; baseline albumin 42 g/L (16–51). Proportions on concomitant medications at GLB initiation were as follows: 5-aminosalicylate therapy 78%, concomitant immunomodulator 45%, systemic corticosteroids 40% (prednisolone dose, 35mg [5–40]). 36% of subjects were anti-TNF naive. Proportions receiving 50mg and 100mg 4-weekly maintenance regimes were 44% and 56% respectively. 3-month clinical response and 6-month corticosteroid free clinical remission rates were 42% and 42% respectively. 41% of patients required GLB dose optimisation (median [95% CI] time to dose optimisation: 6.5 months [1.4–11.6]); 44% dose increase and 56% interval shortening. Baseline CRP of ≥5mg/L is associated with a shorter time to GLB discontinuation, hazard ratio 3.1 (95% CI 1.4–6.7], p=0.005. Significant adverse events occurred in 3% of patients. Conclusions: These real world clinical data demonstrate GLB is an effective and safe induction and maintenance agent for UC. GLB dose optimisation is frequently required. A high baseline CRP, likely reflective of increased inflammatory burden, is associated with a less durable GLB response.

Background The differential diagnosis of a mediastinal mass is a common challenge in clinical practice, with a wide range of differential diagnosis to be considered. One of the rarer causes is tuberculosis. Atypical presentations of tuberculosis are well documented in immunocompromised patients, but should also be considered in the immunocompetent. Case presentation This case outlines a previously healthy 22 year-old immunocompetent male presenting with worsening chest pain, positional dyspnea, dry cough and dysphagia. Chest x-ray showed evidence of an isolated anterior mediastinal mass, which was confirmed on computed tomography. A mediastinoscopy was diagnostic as histology revealed necrotizing granulomatous inflammation and the presence of acid-fast bacilli, indicating mediastinal tuberculosis. Conclusion Typically the underlying presentation of mediastinal tuberculosis is mediastinal lymphadenitis. This case was unusual in that we detected an isolated large anterior mediastinal mass accompanied by a relatively small burden of mediastinal lymphadenitis. Cases similar to this have been documented in immunosuppressed patients however in our case no evidence of immunosuppression was found. This case report emphasizes the importance that a detailed and logical pathway of investigation is pursued when encountering a mediastinal mass.

Introduction Pancreatic fluid collections (PFC) are a common local complication of pancreatitis with incidences of 5–16% and 20–40% in acute and chronic pancreatitis, respectively.1 Classification of PFC includes acute peripancreatic fluid collection, pancreatic pseudocyst, acute necrotic collection and walled-off necrosis (WON). A new lumen-apposing, covered self-expanding metal stent on a catheter-based delivery system (Hot AXIOS, Boston Scientific) may have higher technical success rates, easier deployment and lower migration than plastic stents. We present the first multicentre prospective case series from the UK and Ireland to assess success and complication rates associated with Hot AXIOS stent for the drainage of PFC. Methods All adult patients who had Hot AXIOS stent placement for PFC from July 2015-February 2016 were included. Eight centres participated (London, Glasgow, Edinburgh, Newcastle, Cambridge, Manchester, Dublin and Leeds). All patients had CT of the PFC prior to placement. Data including technical success, resolution of collection, complications and stent migration were collected. Results Forty patients were treated with a single Hot AXIOS stent in each case. The median age was 57 years (range 31–78). 25 were male and 15 female. Indications were WON (24), pseudocyst (15) and abscess.1 The median size of the PFC was 11 cm (4–20 cm). Thirty-eight patients (95%) had trans-gastric stents, 1 had trans-duodenal and 1 had a trans-oesophageal stent. Procedures were technically successful in all patients. Of 22 patients with available follow-up data to date, the collection resolved in 19 (86%) and reduced in size in 3 (14%). The median time to resolution was 36 (7–208) days. Twelve patients (30%) had 33 necrosectomies and/or endoscopic lavage following stent insertion. Stents migrated out in 2 patients and was displaced during necrosectomy in 1. Serious adverse events occurred in 1/40 (2.5%): a small bowel obstruction resulting from stent migration, managed surgically. There was no procedure related or 30 day mortality (data available in 27 patients). Conclusion This multicentre case series demonstrates that the Hot AXIOS system is safe and effective in draining PFC with a technical success rate of 100% and low serious adverse event rate. Reference 1 Banks PA, Bollen TL, Dervenis C, et al. Classification of acute pancreatitis—2012: Revision of the Atlanta classification and definitions by international consensus. Gut 2013. Disclosure of Interest None Declared

Learning point for clinicians We recommend Inflammatory Bowel Disease patients should have full viral serology testing prior to commencing immunosuppressive agents. While vaccinations are not available for all viruses, it highlights at-risk patients and may result in earlier detection and treatment. Primary infection with cytomegalovirus while immunosuppressed carries a significantly greater morbidity and mortality. In this case, had this patient’s CMV status been known, she would have flagged as high risk for primary CMV infection, possibly leading to earlier intervention. A 35-year old lady presented with a 1-week history of a febrile illness without localizing symptoms or signs. She was on azathioprine 200 mg monotherapy for treatment of terminal ileum Crohn’s Disease diagnosed 3 years previously. She attended for 3 monthly phlebotomy which document a baseline lymphopenia, averaging at 1.4. She was an active smoker, 20 pack years. She had no other medical history, …

Sir, A recent interesting case at our institution reminded us to remain cognisant of the oldest known venereal disease; known as ‚Aothe great imitator‚Ao, syphilis is a sexually transmitted infection caused by the spirochete Treponema pallidum. A 40-year-old Romanian man presented with weakness and paraesthesia in his left arm and leg, and an occipital headache. His wife noted he was disorientated and had slurred speech. He had no facial droop, gait or visual problems. He had no past medical or relevant family history. On presentation, within hours of symptom onset, he was asymptomatic and neurological exam was normal except for reduced power in the left upper limb (4+/5). Blood investigations were essentially normal but his CSF was cloudy with leukocytosis and an elevated protein (120mg/dl). CSF and serology was negative for all viruses tested, as well as paraneoplastic, vasculitic and autoimmune markers. Contrast CT Brain showed an ill-defined area of hypo-attenuation in the right temporal fossa and an area of low attenuation in the right thalamic region. A subsequent MRI Brain showed extensive highT2/FLAIR signal within the same region. Neuroradiology review of the imaging emphasized that the mesiotemporal T2 hyperintensity was ‚Ao‚Aovirtually pathognomonic‚Ao‚Ao for herpes encephalitis 1 . He was treated with IV acyclovir based on these clinical and radiological findings however repeat imaging and LP showed persistent abnormalities. After further discussion with the National Virus Reference Laboratory, his CSF was tested for syphilis and was positive. On questioning, he denied any prior history of syphilis. He was discharged to the Infectious Disease clinic and completed treatment with IM procaine penicillin/probenicid. Follow up serology showed a decline in RPR (Rapid Plasma Reagin) and repeat LPs showed a reduced protein count. Syphilis has various clinical, laboratory and imaging findings, all of which lack specificity, which can make diagnosis difficult. Of those who contract syphilis, 4-10% will develop neurosyphillis 2 . In the recent past the clinical manifestations have changed; this may be due to the routine use of penicillin antibiotics for non-syphilitic infections and the emergence of immunosuppression in HIV. There is no gold standard diagnostic test. The CDC advises that VDRL (Venereal Disease Research Laboratory test) and RPR (Rapid Plasma Reagin) should be used as screening tests. A positive screening test should lead to a treponemal test specific for syphilitic antibodies and subsequently have the titre results reported quantitatively. Neurosyphilis is diagnosed by a combination of CSF VDRL, cell count, and protein level 3 in the correct clinical setting. A single intramuscular injection of long acting Benzathine penicillin G is the treatment of choice for primary, secondary or early latent syphilis 3

Infliximab, a monoclonal antibody directed against tumour necrosis factor, is an effective therapy for moderate-to-severe ulcerative colitis and Crohn’s disease. Uncommonly, serious opportunistic infections have occurred in patients after infliximab administration. Here, we describe meningitis caused by Listeria monocytogenes developing in a 37-year-old man with ulcerative colitis refractory to intravenous corticosteroids 10 days after receiving his first infusion of infliximab. With the increasing use of tumour necrosis factor-α-neutralizing agents, clinicians should be aware of the risk of opportunistic infections caused by L. monocytogenes in patients with inflammatory bowel disease following infliximab treatment. The half-life of infliximab is 9.5 days; therefore, patients tend to be more susceptible in the immediate period following infusion. Patients receiving anti-TNF therapy should be advised to avoid foods such as soft cheeses and unpasteurized dairy products.

The effects of thiopurines on white cell count are well documented.