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Alcohol is inextricably linked with the digestive system. It is absorbed through the gut and metabolised by hepatocytes within the liver. Excessive alcohol use results in alterations to the gut microbiome and gut epithelial integrity. It contributes to important micronutrient deficiencies including short-chain fatty acids and trace elements that can influence immune function and lead to liver damage. In some people, long-term alcohol misuse results in liver disease progressing from fatty liver to cirrhosis and hepatocellular carcinoma, and results in over half of all deaths from chronic liver disease, over half a million globally per year. In this review, we will describe the effect of alcohol on the gut, the gut microbiome and liver function and structure, with a specific focus on micronutrients and areas for future research.

Objective Opsoclonus-myoclonus syndrome (OMS) is a serious, often disabling neurological illness of early childhood which is frequently associated with occult neuroblastoma. As investigation methods vary significantly, the authors assessed the usefulness of imaging and metabolic studies in tumour detection. Methods Retrospective case note review of 101 OMS patients from two paediatric neurology centres over 53 years. Results The prevalence of neuroblastoma in OMS was 8% in the 1970s, 16% in the 1980s, 38% in the 1990s and 43% in the 2000s, with tumours being mainly low grade. CT/MR imaging of the chest and abdomen was the most accurate test to detect occult neuroblastoma. Poorer sensitivities were noted for metaiodobenzylguanidine scintigraphy and urine catecholamines, reflecting the low metabolic activity of these tumours. Conclusion CT/MR imaging has the highest detection rate of neuroblastoma and this should be reflected in investigation protocols to achieve the best possible outcome for children with OMS.

Objective: To assess the role of transcranial Doppler (TCD) scanning in assessing the risk of stroke in children with haemoglobin SC (HbSC) disease. TCD scanning has an established role in primary stroke prevention in sickle cell anaemia but its value in HbSC is unknown.Design: A retrospective audit of routinely performed TCD scans and routinely collected clinical data.Setting: A paediatric sickle cell clinic in a teaching hospital in south London, UK.Patients: 46 children with HbSC disease who have undergone routinely performed TCD scans and steady-state blood tests.Main outcome measures:The time-averaged mean of the maximum velocity (TAMMV) in the middle cerebral artery circulation correlated with clinical and laboratory data.Results:The mean TAMMV was 94 cm/s, with a 98th centile of 128 cm/s. This is significantly less than the published ranges for HbSS, with a mean reading of 129 cm/s. One child had a stroke at the age of 5 years, when her TAMMV was measured at 146 cm/s.Conclusions:Further studies are needed to assess stroke risk in HbSC disease, but we suggest that TCD measurements are potentially useful in this condition, and that readings greater than 128 cm/s are abnormally high and warrant further investigation.

IntroductionThis study aimed to utilise data from the second iteration of the National Endoscopy Database (NEDi2) to assess endoscopy quality across the UK.MethodsData uploads to NEDi2 for endoscopic procedures (Gastroscopy, ERCP, Colonoscopy) conducted over a one-month period (November 2023) were analysed. Quality was assessed by calculating key performance indicators (KPIs) according to British Society of Gastroenterology (BSG) guidelines.ResultsA total of 46,042 endoscopies were analysed: 23,107 gastroscopies (50.2%), 1,001 ERCPs (2.2%), and 21,934 colonoscopies (47.6%).The 23,107 gastroscopies were performed across 173 sites by 1,905 endoscopists. Most (57.0%) were conducted under conscious sedation, with 40.5% without sedation, and 2.5% using deep sedation or general anesthesia. Patient discomfort was reported as moderate or severe in 3.1% of cases. Intubation to the second part of the duodenum was achieved in 93.4%, and the J-maneuver was completed in 92.2% of procedures.The 1,001 ERCPs were performed across 65 sites by 187 endoscopists. Cannulation at first ERCP was successful in 89.0% of cases, with an initial stone clearance rate of 83.9%. The majority (81.2%) of ERCPs were performed under conscious sedation, 16.9% under deep sedation or general anesthesia, and 1.9% without sedation. Discomfort was recorded as moderate to severe in 3.6% of cases.The 21,934 colonoscopies were performed across 173 units by 1,880 endoscopists. Caecal intubation was achieved in 94.4% of cases, rectal retroversion in 91.8%, and the polyp detection rate was 44.1%. Mean withdrawal time in completed negative colonoscopies was 8.7 minutes. Most procedures (66.6%) were performed under conscious sedation, with 31.9% conducted without sedation and 1.4% under deep sedation or general anesthesia. Intubation methods included water alone (22.7%), a combination of gas and water (33.2%), and gas alone (44.0%). Discomfort was rated as moderate or severe in 4.5% of cases.ConclusionsThe NEDi2 enables near real-time monitoring of endoscopy quality across the UK, providing valuable insights into performance and identifying areas for improvement. November 2023 data highlights an increased use of deep sedation for ERCPs compared to 2020, combined with reduction in discomfort rates. It also revealed that nearly half of colonoscopies still used gas insufflation, despite the documented benefits of water-assisted techniques.

IntroductionJAG accreditation is a supportive process of evaluating the quality of clinical services. A voluntary process, accreditation promotes quality improvement through highlighting areas of best practice and areas for change.19 individual standards are assessed through a combination of evidence submission and an on-site visit. All must be met in order to gain accreditation. Re-accreditation occurs every 5 years.We aim to evaluate what factors influence success in accreditation, and if any difference is seen between the NHS and private sectors.MethodsData on all assessments from 2023 and 2024 was extracted from the JAG accreditation database. Data is presented descriptively, and Fisher’s exact test was used to identify differences in categorical data between the private and NHS sectors.ResultsThere were 26 new applicant assessments. 53.8% (n=14) were for NHS sites, and 46.2% (n=12) for private. 42.3% met criteria on the first attempt (n=11). All sites that were deferred met criteria after remote evidence re-assessment. Private-sector sites were significantly more likely to meet criteria at the initial assessment (p=0.0043).There were 96 re-accreditation assessments. 55.2% met criteria on the first attempt. Of the deferrals, 2 were not awarded after reassessment. 63.2% of re-accreditations were for NHS sites, with the remainder private. Private-sector sites were significantly more likely to meet criteria at the initial assessment (p=0.0355).Across all assessments, 857 actions were generated from standards that were not met. The most commonly ‘triggered’ standard in both the NHS and private sector was 9.3: ‘The facilities and environment support service delivery’, making up 13.1% and 6.0% of actions respectively. The remainder of the top 5 most commonly triggered standards in the NHS were around confidentiality and privacy, waiting times, maintenance and flow in facilities and decontamination. In comparison, the private sector triggered most on key performance indicator (KPI) feedback to endoscopists, comfort score feedback to endoscopists, safety feedback to endoscopists and the presence of operational, nursing and governance meetings.ConclusionsPrivate-sector sites are more likely to succeed in accreditation at the first time of asking, but almost all applications are successful following re-assessment. All services most commonly trigger actions based on the physical endoscopy environment. Beyond this there is a difference between the NHS and private sectors as to where services do not meet standards. The independent sector most commonly triggers on issues surrounding clinical leadership and governance, whereas the NHS perhaps predictably does not meet standards for waiting times, maintenance and patient flow. 5.7% of the actions generated in NHS assessments were for issues in confidentiality and privacy. This is concerning and requires further evaluation.

IntroductionTo date there has been no formalised training programme for GPs working within Gastroenterology. In 2023 the first GP cohort was enrolled onto a 2-year GPwER-G programme endorsed by the BSG. The programme comprises weekly supervised clinics, webinars, case-studies and quality improvement projects (QIP). GPs are formally assessed before and after each online module (Upper GI, Lower GI & Hepato-pancreaticobiliary). We present their feedback and outcomes after year 1 and discuss the cost-effectiveness and potential impact of the programme.MethodsAll GPs who had completed year 1 (and their supervisors (CS)) were invited to participate in an interview and consented for analysis of their assessment scores and feedback. Interviews were subjected to thematic analysis. Interview and feedback data is presented qualitatively. A paired student T-test was used to identify differences in pre and post module test scores. An external health economics company analysed the cost-effectiveness of the programme.ResultsFour GPs completed year 1. 100% found the e-portal easy to use and praised the webinars. CSs were unanimously positive about hosting a GP, despite occasional clinic delays (ave 20-40 mins discussion/clinic). Each GP had the capacity to see 258 patients per annum in parallel clinics. All GPs felt they would be confident to work independently after 2 years.A paired t-test demonstrates that both Lower and Upper GI assessment scores significantly increased after completion of the modules (LGI=63%-86% [t=3.5, p<0.05, df=3], UGI=49%-82% [t=4.6, p<0.01, df=4]). QIPs are ongoing but one has significantly reduced local straight to test colonoscopy referrals.All GPs aspired to develop an interface pathway between primary and secondary care upon programme completion. 100% felt more motivated for their concurrent GP work.Cost analysis demonstrated that upon completion of the programme, each GPwER would need to reduce onward secondary care referrals by only 59/annum over 5 years for the programme to be cost-effective. Costs would reduce if the programme was adopted nationally.ConclusionsThis shows that the GPwER-G programme is implementable, effective and cost-effective. It allows quality assurance of GPwERs which did not previously exist. Lord Darzi’s report1 into the state of the NHS highlighted long secondary care waiting times and placed an emphasis on the primary-secondary care interface. During the programme, GPs provide outpatient care, thus alleviating waiting lists. After training, alumni have the potential to set up community Gastroenterology pathways which will improve patient experience and reduce the burden on secondary care GI services. We recommend that the GPwER-G programme is adopted nationally with support from regional Integrated Care Boards.ReferenceDarzi. Independent Investigation of the NHS in England 2024.

IntroductionImmersion training programmes (intensive blocks of training), were first offered by select training academies in 2022. In 2022, colonoscopy certification changed from two stages: 200 (provisional) and 300 (full) procedures, to a single stage: 280 procedures. We evaluate the impact of this on training time.MethodsThe National Endoscopy Database was interrogated. Excluding users who submitted baseline procedures, the median time from first procedure to certification, and training lists per week, procedure and role in 2021 and 2024 were calculated. Year of training at certification was sought.ResultsMedian times to certification are seen in table 1. The overall time to OGD certification has fallen (p=0.012). By role, only clinical endoscopists (p=0.015) and gastroenterology trainees (p=0.027) have seen a reduction in OGD training time.Overall time to full colonoscopy certification has significantly shortened (p=<0.001). By role, both gastroenterology and clinical endoscopist trainees have seen a shortened colonoscopy training time (p<0.001), however surgical trainees have not seen a significant reduction, although training time has trended downwards (p=0.108). All roles have seen a significant increase in the number of training lists provided per week.Abstract P118 Table 1Median time to certification by role Median time to certification (IQR) 2021 2024 OGD Colon (provisional) 200 procedures Colon (full) 300 procedures OGD Colon (full) 280 procedures Overall 738 (546-1125) 1318 (888-2131) 1905 (1447-2818) 656 (382-1157) 1314 (806-2312) Clinical endoscopists 547 (291-894) 951 (714-1570) 1675 (957-2602) 335 (261-520) 534 (404-919) Gastroenterology trainees 684 (554-955) 1219 (927-1838) 1865 (1507-2498) 621 (435-914) 1383 (1064-2023) Surgical trainees 1591 (878-2623) 2258 (1464-2947) 3078 (1924-3580) 1642 (920-2403) 2371 (1244-3293) Gastroenterology trainees are certified in a lower year of training in 2024 for both OGD (median year 1 vs. 3 in 2021, p=<0.001) and colonoscopy (4 vs. 5 in 2021, p=<0.001). This is not seen in surgical trainees: OGD - year 5 in 2021 vs. 4 in 2024, p=0.067; colonoscopy - year 6 in both periods, p=0.351.ConclusionsBoth clinical endoscopists and gastroenterology trainees are certifying in OGD in a shorter period of time and earlier year of training. This is allowing gastroenterology trainees to enter colonoscopy training earlier. Both clinical endoscopists and gastroenterology trainees have experienced shortened colonoscopy training times, despite the number of required procedures only reducing by 20. Surgical trainees are not achieving full certification any faster.Our findings are evidence of early benefit from the advent of training academies and immersion training, for which capacity continues to expand. Surgical training requires significant further investment, particularly in colonoscopy where trainees are still only gaining certification in their last year of training.

IntroductionDespite making up only 12% of the endoscopist workforce, Clinical Endoscopists (CEs) undertake almost a quarter of endoscopies nationwide. April 2023 saw the end of the Health Education England (HEE) nationally co-ordinated clinical endoscopist training programme, with funding diverted to individual training academies.The South West Endoscopy Training Academy (SWETA) supports CEs in acute trusts across the South West of England in both their training and continued professional development. SWETA also funds a regional training programme for General Practitioners (GPs) with Extended Roles (GPwER), which is currently training 5 GPs. Alongside their clinical training, the GPs complete a comprehensive online educational programme. To enhance their knowledge base and clinical decision making, this online educational programme has been offered to qualified CEs. We present their feedback and knowledge attainment from the programme.MethodsClinical endoscopists from across the SW were invited to join the GPwER Upper and Lower GI online modules. Each module consists of a pre-module assessment to gauge knowledge, live online lectures, interactive case-studies, written assignments and an end-of-module assessment.Data collected from delegates includes pre- and post- module assessment scores, module completion rates, and subjective feedback from delegates on the online platform, course organisation and the impact of the training on knowledge and confidence.Wilcoxon rank test is used to identify significant differences in assessment scores from before and after each module. Feedback data is presented narratively.Results10 CEs joined the Upper GI module, and 12 joined the Lower GI module. 80% (n=8) completed the Upper GI, and 83% (n=10) completed the Lower GI module.The mean pre-module assessment score among the CEs was 52.38% in the Upper GI module and 45.20% in the lower GI module. The online training led to significantly improved mean scores of 74.13% (p=0.014) and 70.80% (p=0.009) respectively.Both modules received unanimously positive feedback, with all elements rated at least 4.5 out of 5. In particular, candidates felt that the modules had increased their knowledge of common presentations and conditions, and that the knowledge gained would directly enhance their daily clinical practice. The online platform and course organisation was also unanimously praised.ConclusionsClinical endoscopists provide an essential service, performing high-quality endoscopy across the UK. We describe a novel way of enhancing their clinical knowledge and decision-making by utilising an existing training programme for GPwERs. By allowing CEs to complete elements of this programme we have demonstrated objective and subjective improvements in their clinical knowledge without any additional cost or time outlay. Furthermore our online platform is highlighted as an accessible and easy way of accessing training.

IntroductionThe COVID-19 pandemic has forced patients to rapidly adjust to virtual consultations in outpatients. A perceived benefit is reducing unnecessary travel. However, there is a paucity of literature describing acceptability of virtual consultations to gastroenterology patients.MethodsIn collaboration with the Patient Experience team, satisfaction surveys were disseminated in Gastroenterology and Hepatology clinics at Bristol Royal Infirmary electronically via SurveyMonkey® and paper format between June and August 2021. These consisted of multiple choice questions and Likert 5-scale ranking questions, ranging from ‘strongly agree’ to ‘strongly disagree’. Virtual clinics were defined as telephone or video consultations. Data was collected on patient demographic, travel method, satisfaction with virtual clinics, and preferences for service delivery.Results100 patients completed the survey (27% aged 55-64yrs; 21% aged 65-74 years). 50%, 27% and 23% of patients were from hepatology clinic, inflammatory bowel disease clinic and general gastroenterology clinic respectively. 84% were follow-up patients.56% of patients normally drove to appointments, with a further 30% taking public transport. 23% of patients were travelling over 10 miles to attend appointments. 38% of patients were in full-time employment of which 63.1% had to take annual leave to attend appointments (n=24/38). 82% of patients owned a laptop of which 19.5% (n=16/82) disagreed or strongly disagreed with feeling comfortable using their computer for an online appointment.Face-to-face (F2F) consultation was the preferred mode of appointments in almost half of patients (49%), followed by a mix of F2F and telephone consultations (19%). 54% of patients agreed or strongly agreed that clinicians could address their concerns virtually, with only 16% disagreeing or strongly disagreeing with this. 65% of patients agreed or strongly agreed they felt comfortable sharing personal information during a virtual consultation, with 14% of patients disagreeing or strongly disagreeing with this. 80% of patients stated they would want to receive bad news in a F2F consultations.ConclusionsVirtual consultations appear to be acceptable rather than preferable to gastroenterology patients. F2F consultations remain the overall preference, particularly when receiving bad news. Virtual consultations can provide flexibility in service delivery. This is important given almost two thirds of patients in full time employment had to take annual leave to attend an appointment. Furthermore, as services consider their carbon footprint, with half of patients driving to their appointments in Bristol, virtual consultations offer a genuine opportunity to provide a greener service.

Objective To report the clinical and investigative features of children with a clinical diagnosis of probable autoimmune encephalopathy, both with and without antibodies to central nervous system antigens. Method Patients with encephalopathy plus one or more of neuropsychiatric symptoms, seizures, movement disorder or cognitive dysfunction, were identified from 111 paediatric serum samples referred from five tertiary paediatric neurology centres to Oxford for antibody testing in 2007–2010. A blinded clinical review panel identified 48 patients with a diagnosis of probable autoimmune encephalitis whose features are described. All samples were tested/retested for antibodies to N-methyl-D-aspartate receptor (NMDAR), VGKC-complex, LGI1, CASPR2 and contactin-2, GlyR, D1R, D2R, AMPAR, GABA(B)R and glutamic acid decarboxylase. Results Seizures (83%), behavioural change (63%), confusion (50%), movement disorder (38%) and hallucinations (25%) were common. 52% required intensive care support for seizure control or profound encephalopathy. An acute infective organism (15%) or abnormal cerebrospinal fluid (32%), EEG (70%) or MRI (37%) abnormalities were found. One 14-year-old girl had an ovarian teratoma. Serum antibodies were detected in 21/48 (44%) patients: NMDAR 13/48 (27%), VGKC-complex 7/48(15%) and GlyR 1/48(2%). Antibody negative patients shared similar clinical features to those who had specific antibodies detected. 18/34 patients (52%) who received immunotherapy made a complete recovery compared to 4/14 (28%) who were not treated; reductions in modified Rankin Scale for children scores were more common following immunotherapies. Antibody status did not appear to influence the treatment effect. Conclusions Our study outlines the common clinical and paraclinical features of children and adolescents with probable autoimmune encephalopathies. These patients, irrespective of positivity for the known antibody targets, appeared to benefit from immunotherapies and further antibody targets may be defined in the future.