The ABC of E-learning
How UEG E-learning fills a gap in Continuing Medical Education and how you can get the most out of our Online Education offer.
Mistakes in endoscopic retrograde cholangiopancreatography and how to avoid them
Endoscopic retrograde cholangiopancreatography (ERCP) is a widespread technique used for the treatment of different diseases of the bile and pancreatic ducts.
Endoscopic retrograde cholangiopancreatography (ERCP) is a widespread technique used for the treatment of different diseases of the bile and pancreatic ducts. The technique is, however, associated with rare but potentially severe morbidity.Some of the adverse events associated with ERCP are directly linked to commonly made mistakes and can, therefore, be prevented. Here, we discuss 10 common and/or high-impact mistakes that are made during ERCP and how they can be avoided.
Updates on calprotectin and IBD—where to look?
Endoscopy with biopsy is the gold standard for detection and monitoring of intestinal inflammation.
Endoscopy with biopsy is the gold standard for detection and monitoring of intestinal inflammation. Meanwhile, the use of surrogate markers (biomarkers) enables gastroenterologists to reduce costs and inconvenience in the management of intestinal disorders by eliminating the need for invasive procedures. Hence, efficient application of biomarkers for disease detection and assessment of treatment response is critical to cost-effective control of gastrointestinal disease. In this setting, elevated levels of C-reactive protein are a general sign of inflammation and widely used in combination with faecal calprotectin for the detection and monitoring of inflammatory bowel disease (IBD).Calprotectin is a protein found particularly in neutrophils but also in monocytes. Neutrophil disruption results in the release of calprotectin, although some of it is actively secreted.1 Detection of calprotectin in stool indicates neutrophil migration and infiltration in the intestinal tract, including the gut mucosa. Resisting enzymatic degradation, calprotectin is highly stable and can be detected in stool kept at room temperature for at least 7 days.2 Calprotectin levels in stool (usually expressed as µg/g of faeces) correlate well with endoscopic scoring systems for IBD, such as the ulcerative colitis endoscopic index of severity (UCEIS) and Crohn’s disease endoscopic index of severity (CDEIS), and may even perform better than the Crohn’s Disease Activity Index (CDAI).2 In his comprehensive Gastroenterology review on biomarkers of inflammation in IBD, Bruce Sands summarized the applicability and relevance of using faecal calprotectin to distinguish between IBD and irritable bowel syndrome, and also for categorizing IBD activity, ascertaining response to treatment and predicting clinical relapse.3 Reviews in leading journals are, of course, an excellent tool for updating yourself on state-of-the-art knowledge within a given area; however, the plethora of material present in the UEG Education Library may also prove highly useful. For example, searching the library for calprotectin currently returns no fewer than 338 hits, including 214 conference abstracts, 64 presentations, 55 posters, and 4 syllabus contributions submitted by leading gastroenterologists and rising stars. Among the four syllabus contributions, there is one specifically focused on calprotectin by Christoph Beglinger; for this particular syllabus contribution you have the option to read the pdf or view the associated presentation from UEG Week 2013.4 If you’re looking for the latest progress on the use of calprotectin, filtering your 338 hits by year narrows the results to 59 items for 2015. Among these hits, there are three abstracts from UEG Week 2015 on a smartphone-based calprotectin home test—a technology that was developed to try to eliminate the need for patients to bring stool samples to the clinic for analysis and to allow them to play a more active role in their disease management. Another great place to search for relevant information is in the ‘Standards and Guidelines’ that are also now available via the UEG Education Library. There are currently 17 IBD standards and guidelines available for you to access. One of these articles is “Second European evidence-based consensus on the diagnosis and management of ulcerative colitis Part 1: Definitions and diagnosis”, which you can use to update yourself on consensus opinion on the application of calprotectin.5 Finally, the UEG 24/7 pathway gives you access to all core scientific lectures from UEG Week 2015 in Barcelona. Here, you have the option to select the IBD pathway or you can narrow the results by entering the word biomarker in the filter by title’ search box. Any interesting hits? References:
- Ikhtaire S, et al. Fecal calprotectin: its scope and utility in the management of inflammatory bowel disease. J Gastroenterol 2016; 51: 434–446.
- Dhar A. Faecal calprotectin—ready for prime time? Frontline Gastroenterol 2015; 6: 11–13.
- Sands BE. Biomarkers of inflammation in inflammatory bowel disease. Gastroenterology 2015; 149: 1275–1285.
- “Utility of faecal markers in IBD clinical practice” syllabus contribution at UEG Week 2013
- Dignass A, et al. Second European evidence-based consensus on the diagnosis and management of ulcerative colitis Part 1: Definitions and diagnosis. J Crohn’s Colitis 2012; 6: 965–990.
Recordings covering hot topics in experimental GI cancer
Highlight recordings from the Basic Science Course 2016 in Munich are now online.
Mistakes in IBD and reproduction and how to avoid them
Find out more about the major mistakes and misperceptions!
Inflammatory bowel disease (IBD) is a chronic relapsing gastrointestinal disease, often affecting young people during their fertile years. The chronic character of IBD means that lifelong medical treatment is often required. As such, it is not surprising that questions often arise about fertility and pregnancy in patients with IBD.The most important risk factor for adverse pregnancy outcomes in IBD patients is the presence of disease activity during pregnancy. Indeed, negative pregnancy outcomes (e.g. spontaneous abortion, preterm delivery and low birth weight) are associated with disease activity at the time of conception and during pregnancy.1–4 The majority of pregnancies in women with quiescent IBD are uncomplicated. This demonstrates the importance of maintaining remission by continuing medication during pregnancy. Counselling patients before pregnancy on the effects of IBD drugs and disease activity on the child in utero is, therefore, of utmost importance. Although much is known about reproduction and IBD, misbeliefs regarding pregnancy and IBD still persist. Here, we present 10 major mistakes and misperceptions that are made when treating IBD patients who wish to reproduce. The list and discussion are evidence based and integrated in our clinical practice.
Get access to recorded lectures
This intense course for trainees and early career medical professionals can now be attended from home.
Find out more
Get access to recorded lectures from Summer School Prague 2016.This intense clinical-based weekend course is perfect for trainees and early career medical professionals and can now be attended from home.
EDS Surgery Course Recordings
Discover the highlights of the 10th EDS Postgraduate Course featuring a large variety of surgical state-of-the-art lectures.
Mistakes in upper gastrointestinal bleeding and how to avoid them
Discover more about the most frequent mistakes!
Faecal microbiota transplantation
Learn about FMT—the transfer of gut microbiota from a healthy donor to a recipient.
Primer in capsule endoscopy
Discover more about the procedure, indications, potential complications and how to use capsule reporting software.
Understand the role of liver biopsy in diagnosis and indications, contraindications, different techniques and steps involved.
Mistakes in mouse models of IBD and how to avoid them
Learn how to get the most from experimental colitis models!
In general, mouse models of colitis are used to study its pathophysiology and for the development of new treatment modalities for inflammatory bowel disease (IBD). For the latter it is essential to select a mouse model that has many overlapping features with human IBD.More than 50 experimental colitis models have been developed and they have provided us with very useful insights into IBD physiology, as reviewed by Bouma and Strober1 and others,2–4 but they have limited use in predicting the clinical relevance of therapeutic targets in IBD.5 Experimental colitis models broadly fit into four different groups. First is spontaneous colitis, resulting from a naturally occurring genetic abnormality. Second is induced colitis occurring as a consequence of a targeted mutation or the introduction of a transgene. Third is induced colitis resulting from administration of different exogenous causative agents. Fourth is induction of colitis by manipulation of the immune system. We have learned a great deal from these models about the involvement of genetics, the microbiota and the role of different cells and the mucus layer in the development of IBD. Here we discuss the major mistakes that are made using experimental colitis models, based on our own experience and the scientific literature. Recently increased awareness has developed for the necessity to improve the methodological quality of animal studies.
ERCP & EUS Symposium
Recordings from the last Quality in Endoscopy series cover topics including “Conquering the papilla”, “Diagnostic EUS” and “Pancreatitis”.
Scientific writing practice
32 aspiring researchers met at the House of European Gastroenterology to practice how to craft research papers and abstracts.
Mistakes in colorectal cancer and how to avoid them
Specialist tips on diagnosis, prevention and treatment!
Colorectal cancer (CRC) is one of the most common malignancies and the second leading cause of cancer death in both sexes in developed countries. Over the past 30 years, a great advance in the understanding of this disease has occurred, from colorectal carcinogenesis to diagnosis, prevention and treatment.Although the majority of CRCs are related to environmental factors, up to 25% of cases have a familial component and potential genetic basis, and highly penetrant monogenic germline mutations account for up to 5% of all CRC cases1. Identification and characterization of these hereditary disorders have allowed modification of their natural history, with a substantial decrease in morbidity and mortality among high-risk patients1. Nonetheless, the majority of patients who are at high risk of CRC remain undiagnosed due to lack of suspicion. On the other hand, studies from the past two decades have suggested that besides adenomas, serrated polyps are also precursors of CRC, responsible for up to 15–30% of all malignancies.2 Several studies have demonstrated that serrated polyps are common precursors of colonoscopy interval cancers (cancers diagnosed within the surveillance interval after a complete colonoscopy), mainly due to their challenging clinical management.2 Finally, strategies for CRC prevention have shown efficacy in reducing CRC incidence and mortality, and colonoscopy is an integral part of CRC screening strategies. The main objective of screening colonoscopy is the detection and removal of premalignant lesions or early CRC.3 However, colonoscopy is not perfect, and some lesions may be missed. Colonoscopy quality is an emerging concept, and some quality indicators have been demonstrated to be directly related to the development of interval CRC.3 Here we discuss the major mistakes that are made when gastroenterologists deal with CRC diagnosis, prevention and treatment, and how to avoid them. The list of mistakes and the discussion that follows is evidence based and integrated with our longstanding clinical experience.
Mistakes in dyspepsia and how to avoid them
Expert knowledge at your fingertips!
Dyspepsia refers to upper abdominal discomfort that is thought to arise from the upper gastrointestinal tract. Symptoms include epigastric pain or discomfort, bloating, early satiety and/or fullness after meals, repeated belching or regurgitation (often rumination), nausea and heartburn.1 The symptoms of dyspepsia are nonspecific, but most commonly result from one of four underlying disorders: functional (nonulcer) dyspepsia, gastro-oesophageal reflux disease (GORD; 10–20% erosive esophagitis), peptic ulcer disease (5–15%) and malignancy (~1%).2 Dyspeptic symptoms may also result from other problems, such as medication intolerance, pancreatitis, biliary tract disease or motility disorders (e.g. gastroparesis or gastric dumping).Clinical guidelines recommend that endoscopy is not always required for diagnosis; a positive diagnosis of GORD and functional dyspepsia can be based on clinical presentation in the absence of alarm symptoms or features (see below).3,4 In many cases symptoms are increased after meal ingestion (postprandial distress syndrome), being triggered by impaired gastric accommodation and visceral hypersensitivity to gastric distension.5 Other patients have an epigastric pain syndrome in which discomfort is independent of food intake and gastrointestinal function.6 There is an important overlap between functional dyspepsia and other functional gastrointestinal diseases (e.g. irritable bowel syndrome [IBS]) and chronic pain syndromes (e.g. fibromyalgia).7 Psychological disease (e.g. anxiety or somatization disorder) and/or psychosocial stress are also present in a significant proportion of patients who seek medical attention.8,9 Notwithstanding the constructive advice provided by published reviews and guidelines, the broad definition of dyspepsia, lack of diagnostic investigations, uncertain cause of disease, psychosocial issues and paucity of specific treatments make the management of dyspepsia challenging. Here, I discuss 10 common and/or high-impact mistakes that are made in the diagnosis and treatment of patients with dyspeptic symptoms: five related to diagnosis, five related to treatment.
Mistakes in coeliac disease diagnosis and how to avoid them
Learn from leaders in the field!
Coeliac disease is regarded as an autoimmune disorder triggered by gluten, which activates an immune reaction against the autoantigen tissue transglutaminase (transglutaminase 2; TG2) in genetically predisposed subjects. Genetic susceptibility to coeliac disease has been proven by its close linkage with major histocompatibility complex (MHC) class II human leukocyte antigen (HLA) DQ2 and DQ8 haplotypes. The identification of biomarkers for coeliac disease (e.g. endomysial antibodies [EmA] and antibodies to TG2 [anti-TG2]) has changed the epidemiology of coeliac disease from being a rare to a frequent condition, with an expected prevalence of 1% in the worldwide population.1 Nonetheless, the majority of patients who have coeliac disease remain undiagnosed, leaving the coeliac ‘iceberg’ mostly submerged. Coeliac disease can be difficult to diagnose because symptoms vary from patient to patient. Indeed, the heterogeneity among the clinical signs and the lack of specificity of many of the presenting symptoms means that the diagnosis of coeliac disease can be a challenge even for experts.Despite substantial differences in the mode of presentation and the availability of new diagnostic tools, small intestinal biopsy, which shows different grades of mucosal damage, remains the gold standard for coeliac disease diagnosis. A delayed diagnosis of coeliac disease in the elderly can be considered a risk factor for complications including refractory coeliac disease, ulcerative jejunoileitis, collagenous sprue, small bowel carcinoma and enteropathy-associated T-cell lymphoma (EATL). Complicated coeliac disease is not so frequent, being found only in about 1–2% of the total number of coeliac disease patients, but for those who have it the prognosis is very poor, with a low rate of survival after 5 years.2 Here we discuss the major mistakes that are made when diagnosing coeliac disease and how to avoid them. The list of mistakes and the discussion that follows is evidence based and integrated with our clinical experience of more than 30 years in this field.
Advice on Christmas Dinners...
A factual but fun article for the festive period from Mark Fox based on a Q&A session for his local newspaper
Advice on Christmas Dinners and its after effects“A factual but fun article for the festive period from Mark Fox based on a Q&A session for his local newspaper. Merry Christmas!”
How have nurse endoscopists benefitted endoscopy services?
I remember the incredulity on the faces on my European colleagues 20 years ago when I told them that the UK was to start training nurse endoscopists. They doubted that it was desirable (or even possible!) to train nurses. Of course, by then the American Society for Gastrointestinal Endoscopy (ASGE) had for many years endorsed flexible sigmoidoscopy by ‘nonspecialists,’1,2 but little evidence of their effectiveness had been published.3Unsurprisingly, it was the relentlessly increasing demand for endoscopy that made the introduction of nurse endoscopists necessary in the UK. Some 20 years ago, the demand for gastroscopy approached 10 per 1,000 population per year and the demand for colonoscopy was expected to increase from an average of 2.5 to 10 colonoscopies per 1,000 population per year.4 In addition, the implementation of the NHS National Bowel Cancer Screening programme would further inflate the demand for endoscopy. For this reason, a British Society of Gastroenterology (BSG) Working Party5 gave the green light for nurse endoscopy, together with the United Kingdom Central Council (UKCC)6 and the General Medical Council (GMC). However, it was a cautious start because endoscopy was seen as a risky procedure that was associated with a 1:2,000 risk of death.7 The BSG, GMC and UKCC all agreed that nurse endoscopists were only to act as “technicians”. The responsibility for the patient’s management remained with “the supervising doctor” who had to be “immediately available within the hospital” (an oxymoron of course) in the event of complications or to give advice. Now we know that they were wrong and that the “interpretation of findings does not rely on the experience and training of an appropriately qualified doctor.”5 Endoscopy can be taught! Indeed, throughout the UK, nurse endoscopists now work independently, interpreting findings without the immediate supervision of a clinician. The uptake of nurse endoscopy has been steady in the past 20 years. In Leeds we have seven nurse endoscopists who undertake about 22% of our gastroscopies, 27% of our colonoscopies and all of our flexible sigmoidoscopies. ERCP, enteroscopy, EUS and most therapeutic endoscopy procedures that pose a significant risk of complications are carried out by consultants who are increasingly dedicating their time purely to endoscopy. Now we know more about the performance of nurse endoscopists. There is irrefutable evidence that the caecal intubation rate, adenoma detection rate, complication rate and patient satisfaction scores are comparable among nurses and doctors.8–10 In Leeds, the ‘raw’ caecal intubation rate for both our nurse endoscopists and consultants is 92% and the average polyp detection index (total number of polyps found/total number of patients) is also virtually identical (34.5 for nurses and 33.5 for consultants). In view of the reassuring published literature that has become available over the years, I was bemused to read a recent survey from New Zealand in which only 30% of doctors welcomed the introduction of nurse endoscopists.11 A huge majority believed that doctors would always deliver a better quality of endoscopy and that overall costs would spiral out of control if nurses were to be trained in endoscopy. Of course, endoscopy is a valued source of extra income for gastroenterologists in New Zealand, which makes me wonder if this may have had an influence on the outcome of the survey. Nevertheless, the statistics, reassuring as the may be, do not do nurse endoscopists justice. As a lead endoscopist, it is a relief to have a stable workforce that is fully committed to endoscopy. Most of my gastroenterology colleagues rush between ward rounds and outpatient clinics, phoning patients and their relatives in between. They have little time and energy to invest in endoscopy. By contrast, if an endoscopy list needs back filling, one of our nurse endoscopists will take it on. If an endoscopy audit is required, a nurse endoscopist can make the time. If there is an endoscopy-related problem, a nurse endoscopist will be willing to get involved. The truth is that without nurse endoscopists, endoscopy services will not be able to make the quantum leap from ‘Cinderella speciality’ to a core hospital service that is on an equal footing with radiology. My advice to any anxious colleagues who worry about the emergence of the nurse endoscopist is to welcome them, because with their help we can make endoscopy bloom! References
- Maule WF. Screening for colorectal cancer by nurse endoscopist. NEJM 1994; 330(3):183–187.
- DiSario JA and Sanowski RA. Sigmoidoscopy training for nurses and resident physicians. Gastrointest Endosc 1993; 39(1):29–32.
- Committee on Training, Gross GWW, Bozymski EM, et al. Guidelines for training non-specialists in screening flexible sigmoidoscopy. Gastrointest Endosc 2000;51(6):783–785.
- Barrison IG, Bramble MG, Wilkinson M, et al. Provision of endoscopy related services in district general hospitals: BSG Working Party Report 2001.
- British Society of Gastroenterology. Report of the British Society of Gastroenterology Working Party—The nurse endoscopist. 1994.
- UKCC. The Scope Of Professional Practice. London UKCC 1992.
- Quine MA, Bell GD, McCloy RF, et al. Prospective audit of upper gastrointestinal endoscopy in two regions of England: safety, staffing, and sedation methods. Gut 1995; 36(3):462–467.
- Hui AJ, Lau JY, Lam PPY, et al. Comparison of colonoscopic performance between medical and nurse endoscopists: a non-inferiority randomised controlled study in Asia. Gut 2015; 64(7): 1058–1062.
- Massl R, van Putten PG, Steyerberg EW, et al. Comparing quality, safety, and costs of colonoscopies performed by nurse vs physician trainees. Clin Gastroenterol Hepatol 2014; 12(3): 470–477.
- Schoenfeld P; Lipscomb S; Crook J; et al. Accuracy of polyp detection by gastroenterologists and nurse endoscopists during flexible sigmoidoscopy: a randomized trial. Gastroenterology 1999; 117(2): 312–318.
- Khan MI, Khan R and Owen W. Doctors and the nurse endoscopist issue in New Zealand. NZ Med J 2012; 125(1357): 88–97.