The Value of Quantitative Faecal Immunochemical Testing as a Prioritisation Tool for the Endoscopic Investigation of Patients With Iron Deficiency

Difficulty in providing endoscopy for patients with iron deficiency anaemia (IDA) during the COVID-19 pandemic has highlighted the requirement for a prioritisation tool. We aimed to test the validity of qFIT as a prioritisation tool in patients with iron deficiency and its ability to identify patients with advanced neoplastic lesions (ANLs). Data collected from patients referred with biochemically proven iron deficiency (ferritin ≤ 15 μg/L) and synchronous qFIT who underwent full gastrointestinal investigation within NHS Greater Glasgow and Clyde was analysed retrospectively. Patients who did not undergo full investigation, defined as gastroscopy and colonoscopy or CT colonography, were excluded. ANLs were defined as defined as upper GI cancer, colorectal adenoma ≥ 1 cm or colorectal cancer. Area under the curve (AUC) analysis was performed on qFIT results and outcome, defined as the presence of an ANL. AUC analysis guided cut-off scores for qFIT. Patients with a qFIT of <10, 10–200, >200, were allocated a score of 1, 2, and 3, respectively. A total of 575 patients met criteria for inclusion into the study. Overall, qFIT results strongly predicted the presence of ANLs (AUC 0.87, CI 0.81–0.92; P < 0.001). The prevalence of ANLs in patients with scores 1–3 was 1.2, 13.5, and 38.9% respectfully. When controlled for other significant variables, patients with a higher qFIT score were statistically more likely to have an ANL (qFIT score = 2; OR 12.8; P < 0.001, qFIT score = 3, OR 50.0; P < 0.001). A negative qFIT had a high NPV for the presence of ANLs (98.8%, CI 97.0–99.5%). These results strongly suggest that qFIT has validity as a prioritisation tool in patients with iron deficiency; both allowing for a more informed decision of investigation of patients with very low risk of malignancy, and in identifying higher risk patients who may benefit from more urgent endoscopy.

472 A PILOT COLORECTAL AND GERIATRIC MEDICINE (CGM) CLINIC FOR OLDER, FRAIL PATIENTS REFERRED VIA A 2 WEEK WAIT PATHWAY

Introduction The two week wait (2ww) colorectal referral pathway was introduced to expedite referrals where cancer is suspected, facilitating prompt diagnosis +/− intervention. Older frail patients are referred via this 2ww pathway even when invasive testing and intervention may not be appropriate. These patients may benefit more from holistic assessment than a universally surgical approach. A Colorectal and Geriatric Medicine (CGM) 2ww referral clinic was piloted, delivered by an urgent referral colorectal specialist nurse and an advanced clinical practitioner in geriatric medicine. Method Patients >65 years with a Clinical Frailty Scale (CFS) score of 5 or more at referral were directed to the CGM clinic. A telephone consultation was undertaken, incorporating both 2ww assessment and aspects of comprehensive geriatric assessment. Results 42-patients were reviewed in the clinic. Mean age was 86.1 years and mean CFS 6. 12-patients underwent CT, and 2 CT virtual colonoscopy. No patients underwent endoscopic investigation and 28-patients declined any investigation. Of those who underwent investigation, no cancers were identified. 1 patient was referred on for endosocpic mucosal resection of polyps. 5-patients had severe diverticular disease, which accounted for their symptoms. Medication recommendations were made for 30-patients, some of which led to symptom cessation. Onward referrals were made to a community geriatrician, diabetes and continence teams, and palliative care specialists. 9-patients were identified as meeting criteria for advance care planning. This was commenced during the consultation and communicated back to the referring clinician for further action. Conclusion Older, frail patients are often not able, nor wish to undergo, invasive investigations but should not be disadvantaged or delayed in their pathway. Further work is needed to determine the most appropriate referral pathway for this group of patients. Holistic assessment that leads to improvement in symptoms and future planning may not be achievable through a solely surgical assessment.

The Use of Clinical Parameters as Adjuncts to Endoscopic Evaluation of Mural Thickening on Conventional Computed Tomography in Diagnosing Malignancy

<b><i>Background:</i></b> Mural thickening (MT) on computed tomography (CT) poses a diagnostic dilemma in the absence of clear reporting guidelines. The aim of this study was to analyse CT reports, identifying patients in whom gastrointestinal wall MT was observed, and to correlate these reports with subsequent endoscopic evaluation. <b><i>Methods:</i></b> Patients with MT who had follow-up endoscopy were included in the study (<i>n</i> = 308). The cohort was subdivided into upper gastrointestinal mural thickening (UGIMT) &amp; lower gastrointestinal mural thickening (LGIMT). <b><i>Results:</i></b> In total, 55.71% (<i>n</i> = 122) of colonoscopies and 61.8% (<i>n</i> = 55) of gastroscopies were found to be normal. Haemoglobin (HB) level in combination with MT was a predictor of neoplasia in both arms (<i>p</i> = 0.04 UGIMT cohort, <i>p</i> &#x3c; 0.001 LGIMT cohort). In addition to this, age was a significant correlative parameter in both UGIMT and LGIMT cohorts (<i>p</i> = 0.003, <i>p</i> &#x3c; 0.001 respectively). Dysphagia and weight loss were associated with UGI malignancies (38 and 63% respectively) and rectal bleeding was correlative in 20% of patients with LGI malignancies. <b><i>Conclusion:</i></b> HB, advancing age, and red flag symptoms are potentially useful adjuncts to MT in predicting upper and lower gastrointestinal malignancies. We propose the adoption of a streamlined pathway to delineate patients who should undergo endoscopic investigation following CT identification of MT.

N05 IBDoc® Faecal calprotectin self-test retrospective audit in a District General Hospital (DGH)

Background In 2016, a DGH in England commenced the IBDoc® Faecal calprotectin test. Using smart phone technology, the test can provide results as quickly as 2 hrs. An audit of patients who trialled the test was presented at ECCO in 2017; this abstract looked at the value of the tests and helped to show the investigations worth to the DGH trust. The continued use of the test at the trust has recently been audited and these data are presented by the authors to help further understand the benefit. Methods A retrospective audit of patients enrolled on the IBDoc® between July 2017 and October 2019 was carried out by the IBD nursing team. Electronic patient records were searched and corresponding endoscopic assessments that had been carried out within 6 months of the most recent IBDoc® results, were documented for each patient. The terms normal/mild, moderate and severe were used to categorise inflammation seen at colonoscopy, flexible-sigmoidoscopy (C/FS) and/or histopathology (HP). The IBDoc® uses the categories normal (&lt;150) moderate (&lt;400), and high (&gt;400); these values have been set locally easy comparison of these data is possible due to the three levels of stratification. The reason for the endoscopic investigation was also documented. In the sample where no endoscopic investigation was recorded, outcomes were categorised into three groups; well (W), increase monitoring (IM), and treatment adjustment required (TAR). Results 134 patients are signed up to the IBDoc®, 23 patients failed to carry out the test successfully (CD 14 and UC 9). 6 did not accept a test in clinic due to changing their mind or failure in smart phone technology, 12 did not do the test before expiry* and 5 failed to give a result due to difficulties completing the test. *Myriad of reasons were given for not doing the test and another paper could be written to attempt to understand the persons motivation for not completing the test. Of the 111 patients’ (CD 55, UC 56, IBDU 2 and non-IBD 2), 80 patients did not undergo a C/FS, of the 31 that did, correlation between calprotectin, C/FS and/or HP result was 84%. at 100% best correlation was seen in the severe C/FS results and high IBDoc® results. C/FS were carried out for diagnosis (n =10) surveillance (n =4) and disease assessment (n = 17). In the 80 patients with no colonoscopy’s were assessed for outcomes and are: W. n = 39; IM. n = 19; TAR. n = 23. Conclusion The above data shows continuing value of the IBDoc® faecal calprotectin self-test, and there is correlation seen in the comparative results. This data also helps separate well from unwell patients, offering further opportunities to promote supported self-management in people with IBD and prioritisation of clinic appointments.

Routine Colonoscopy after Diverticulitis Should not be Performed to Rule Out Colorectal Cancer

Introduction: Diverticulitis is a clinical diagnosis generally confirmed by a radiological examination. Guidelines recommend routine screening for colorectal cancer after the acute phase. Aim: Patients diagnosed with diverticulitis were studied in order to gain more information on presence of concomitant abnormalities. Material and methods: Inclusion criterion was the radiologic diagnosis of diverticulitis. All consecutive requests for ultrasound and/ or CT-scan of the abdomen in a three year period, with Diverticulitis mentioned in application were included. If diverticulitis was diagnosed, than this specific investigation was included in the present study. Hospital records were searched for the presence of endoscopic investigation. Results: In the three year period 1410 consecutive ultrasound investigation and/or CT-scans of the abdomen were performed. After exclusions 198 patients remained with the radiological confirmed diagnosis of diverticulitis. Of these patients 127 (64%) underwent an additional endoscopy. Seventy one patients (36%) did not undergo a colonoscopy. There was no difference in gender or in age between both groups. Colonoscopy showed additional abnormalities in 22 (17.3%) of the patients. These were hyperplastic polyp(s) in six, adenomatous polyp(s) in nine, polyps without histological confirmation in three and segmental colitis in three. Two male patients were diagnosed with sigmoid cancer. Both had non-subsiding diverticulitis with abscess formation at the location of the tumor. Conclusion: It is safe to omit colonoscopy after an episode of uncomplicated diverticulitis. Only in cases of complications or persistent complaints cancer should be part of the differential diagnosis and a subsequent colonoscopy should be performed.

Prescribing Warfarin to a Patient with Oesophageal Varices—A Case Report and Review of the Literature

We describe the case of a 42-year old man who presented with melaena. He was found to have bleeding varices during endoscopic investigation. Subsequent investigation revealed the aetiology to be a portal vein thrombosis (PVT) due to an underlying pro-coagulable state (Factor V Leiden). He was managed with cautious anticoagulation but suffered a life-threatening upper gastrointestinal bleed that was not amenable to endoscopic treatment or transjugular intrahepatic portosystemic shunting (TIPS). As such, the only therapeutic option involved the pursuit of surgical shunt operations. We review the literature regarding this atypical cause of GI-bleeding and discuss medical and surgical considerations for the management of such patients.

Clinic-morphological diagnosis of Barrett’s esophagus

Objective. Determination of efficacy of morphological diagnosis of the Barrett’s esophagus (BE). Маterials and methods. Diagnosis of BE in accordance to data obtained during screening endoscopic investigation with biopsy and morphological verification in 2014 - 2016 yrs, basing on Medical Centre «University Clinic «Оberig», Kyiv, was analyzed. Results. BE was diagnosed in 841 (36.8%) patients (95% of confidence interval (CІ) 36.02 – 39.76) among 2405 patients, in whom esophagogastroscopy was conducted. Histologically cardiac metaplasia was revealed in 48 (5.71%) patients, fundic - in 136 (16.19%), intestinal specialized - in 625 (72.28%), and the mixed - in 32 (3.81%) patients. Dysplasia of high and low grades was diagnosed in 32 (3.81%) (95% CІ 2.04 – 4.62), including: in 24 (75.0%) - low, and in 8 (25.0%) – high. Аdenocarcinoma was revealed in 4 (0.47%) patients (95% CІ 0.20 – 1.36). Conclusion. Мorphological verdict constitutes the main and objective criterion for the BE verification, what is important for selection of the treatment tactics and certainly help to determine the disease prognosis.