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IntroductionWe audited intravenous (IV) iron prescribing in Gastroenterology inpatients to assess whether patients received follow-up doses as outpatients to complete their calculated total iron requirement. We have used this information to change prescribing practice within our trust.MethodsElectronic inpatient prescribing data for ferric carboxymaltose prescriptions from June 2022 - May 2023 (Gastroenterology) were retrieved including patient ID, dose and date of administration. Patient records were accessed to assess three primary end-points - organisation of a second dose, delivery of a second dose, and requests for GPs to re-assess haemoglobin/iron studies after treatment.Results155 inpatient prescriptions were identified, of which 130 admission episodes were analysed where data were complete and inclusion criteria were met. There were 50 females (38%), and mean age was 68.6 years (interquartile range: 62–81). Indications for IV iron included 106 following UGI bleeds (82%), 3 PR bleeds (2.3%) and 21 patients with symptomatic anaemia. 50 (38%) patients received the full dose of ferric carboxymaltose. 80 (62%) patients did not receive the recommended full dose of IV iron. Of these, 64 (80%) did not have an MDC appointment arranged, with 16 (20%) failing to attend their organised appointment. Of the latter group, 5 were female (31%) and mean age was 64.4 years (interquartile range 51–81). A request to the GP to monitor haemoglobin/iron studies was included in only one immediate discharge letter (0.603%).ConclusionsA significant proportion of patients who receive ferric carboxymaltose as inpatients are not receiving a full dose of iron. Given the constraints on infusion units to allocate out-patient appointments, service optimisation is necessary to ensure patients receive iron supplementation to their needs, Switching to alternative IV iron preparations that enable greater doses to be given in a single sessions can be considered. Furthermore, education of trainees and improved communication between secondary and primary care can result in better iron infusion adherence and subsequent blood test monitoring.

Abstract Pilot of a Quantitative Faecal Immunochemical Test.pdf (could not be inserted)

IntroductionIn a palliative setting, oesophageal stent insertion has been the main approach in relieving dysphagia in oesophageal cancer.1 Our aim was to explore the effect of pre-stent prognostic factors on clinical outcomes and mortality; and to identify patients that would most benefit from timely stent insertion. We examined the impact of the primary tumour location and pre-stent MUST score on morbidity and mortality post-stent insertion. We looked specifically at post-stent pain score, 30-day mortality, stent complication rate and re-admission rate.MethodsData were collected from 309 patients with oesophageal cancer who underwent palliative SX ELLA HV Plus (SEHP) endoscopic stent insertion from January 2020 to September 2024. Patient variables and clinical outcomes were recorded retrospectively including post-stent Edinburgh dysphagia score, pre-stent MUST score, tumour location, presence of new or worsening pain post-stent, death at 30 days, re-admission rate and stent complication rate. Data were recorded and analysed using Microsoft Excel.ResultsOf the 309 patients, 204 (66%) were male and mean age 72.6 (SD=11.37). There were 25 patients (8.1%) with an upper, 105 (34%) with a middle and 179 (57.9%) with a lower oesophageal tumour. 199 patients had a MUST-score available at time of stent insertion. Patients with a MUST-score of 2, or >2, accounted for 42.2% and 39.2%, respectively. 115 patients (37.2%) described a new, or worsening of pre-existing pain at 2 weeks post-stent insertion. A 30-day mortality rate of 14.2% was observed. 65.4% of patients were re-admitted post-stent insertion on at least one occasion. Of those admitted 24.8% were due to aspiration pneumonia and 18.3% due to stent complications. Stent complication rates included stent migration (8.4%), food bolus (1%), erosion (0.6%), fracture (0.3%) and replacement due to tumour progression (2.9%). The remainder of admissions were non-stent related.Tumour location had no statistically significant association with post-stent pain (chi sq p=0.6), stent complication rate (p=0.8), re-admission rate (p=0.8) or aspiration pneumonia (p=0.3). There was no statistically significant relationship between pre-stent MUST score and 30-day mortality (p=0.7), re-admission rate (p=0.4) or aspiration pneumonia (p=0.2). The presence of pain at 2-weeks post-stent insertion was not a statistically significant indicator for post-stent clinical outcomes (p=0.8).ConclusionTumour location, pre-stent nutritional status and post-stent pain score are not significantly associated with clinical outcomes and mortality for patients with Oesophageal cancer undergoing Palliative stent insertion.ReferenceBurstow M, Kelly T, Panchani S, Khan IM, Meek D, Memon B, et al. Outcome of palliative esophageal stenting for malignant dysphagia: a retrospective analysis. Diseases of the Esophagus 2009 Sep 1;22(6):519-525.

IntroductionA local ‘gastric ulcer follow-up’ protocol was developed, externally validated and implemented locally in May 2021. Under the local protocol, patients with low ulcer risk scores based on ulcer size, location and patient age with benign biopsy results at index oesophagogastroduodenoscopy (OGD1), are not offered endoscopic follow-up to check healing (OGD2). We investigated the uptake of this protocol and its impact on patient outcomes.MethodsPatients diagnosed with a gastric ulcer at OGD1 in NHS Lothian from 24/5/21–16/1/22 were identified. OGD1 reports were reviewed and data were gathered, including the ulcer risk score components, score documentation, biopsy rates and if the decision to request an OGD2 or to discontinue surveillance was made in accordance with the protocol. Electronic patient records were reviewed at follow-up post OGD1 to assess for subsequent diagnoses of upper gastrointestinal (UGI) cancer.ResultsIn total 143 patients were diagnosed with a gastric ulcer at OGD1. The ulcer risk score could be calculated for 65.0% of patients but was documented in only 15.4% of OGD1 reports. The OGD1 biopsy rate was 65.0%. of the patients who did not have an OGD2 requested (n=81), 54.3% (44/81) of decisions followed the protocol; a cost saving of £24,640. There were no UGI cancers identified at review in patients who did not have an OGD2 performed in accordance with the protocol (median follow-up: 15 months, IQR 14–17 months).OGD2s were requested for 43.4% (n=62) of patients. of the patients with an OGD2, 62.9% (n=39) of requests followed the protocol, in three of these cases patients were diagnosed with cancer at OGD2 (dysplasia had been present at OGD1 in 2/3). None of the 16.1% (n=10) of requests which were made contrary to the protocol identified new pathology. Six patients underwent OGD2s for follow-up of concomitant pathology; protocol adherence could not be determined in seven patients as a component of the risk score was not documented.ConclusionsThe gastric ulcer protocol has been shown to be a safe and cost-effective method to tailor follow-up endoscopy for gastric ulcers. Protocol adherence has demonstrated no missed diagnoses of cancer at follow-up. Measures are currently being undertaken to improve uptake within Lothian.

IntroductionThere are no unified criteria to risk stratify patients under 50 with lower gastrointestinal bleed (LGIB) for endoscopic investigations. We evaluated this cohort to identify predictors for significant bowel disease (SBD), defined as malignancy, high risk adenoma (≥3 adenomas or any adenoma ≥1 cm) or new diagnosis of Inflammatory bowel disease (IBD).MethodsAll patients under 50 in NHS Lothian with no colorectal cancer or IBD history referred for endoscopy for LGIB in 2019 were identified through the endoscopy reporting system. Electronic patient records were reviewed to extract variables including LGIB history, diarrhoea, abdominal pain, weight loss, and diagnoses. Univariate analysis, with Chi-square or t-test/Wilcoxon test as appropriate, was used to identify significant associations with SBD. Normality was tested with Shapiro-Wilk test. Complete case analysis was used where data were missing.Results532 patients were included in the analysis, 223 and 309 patients underwent flexible sigmoidoscopy and colonoscopy respectively. Mean age was 38.0 years (IQR 32.0 to 45.6) and 57.4% were females. SBD were present in 17.3% of all cases (1.3% malignancy; 1.3% advanced adenoma; 14.7% IBD). Normal assessment was reported in 42.7% of endoscopies and haemorrhoids were the only finding in 29.5% of cases.A significant proportion of GP referrals contained missing data for duration (37.4%) and frequency (35.9%) of LGIB. In those with data for frequency (n=341), referrals that reported ‘frequent’ LGIB were more likely to have SBD than those with infrequent LGIB (28.0% vs 11.2%; p=0.002), but the duration was not associated with SBD (p=0.19). All other recorded symptoms in clinical history were insignificant, including diarrhoea (p=0.28), which was present in 58.5% of cases.83% of patients had full blood count measured before endoscopy. Faecal calprotectin (FC) was missing in over half of patients. Iron studies were performed in 12.4% of cases. Patients with SBD were more likely to be anaemic (24.7% vs 10.7%; p=0.004) or have raised FC (89.4% vs 44.3%; p<0.001) than those without SBD. Age and gender were not associated with SBD. LGIB frequency remained the only significant predictor of SBD (OR 2.34; IQR: 1.36-4.13) after multivariate stepwise regression using age, gender, and haemoglobin as covariates.ConclusionsDetermining appropriate investigations for LGIB in under 50 can be hampered by limited referral details. A dedicated GP referral proforma may improve risk stratification. In a limited dataset, our study identifies LGIB frequency, anaemia and raised FC as factors that could be used to prioritise endoscopy referrals.