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We recently published in GUT the outcomes of acute pancreatitis (AP) and coexisting SARS-CoV-2 infection.1 A number of patients who were SARS-CoV-2 positive had AP of unknown aetiology (25%) speculating SARS-CoV-2 as a cause for AP similar to other viruses.2 However, most patients did not complete investigations to exclude other causes of AP. In addition, SARS-CoV-2 infection may cause aberrant glycometabolic control,3 however it is unknown if this increases the risk of long-term diabetes mellitus (DM). The follow-up data were collected 12 months from the date of recruitment for 1476 patients (118 patients who were SARS-CoV-2 positive and 1358 patients who were negative) to establish an aetiology for AP and development of DM. Among the 118 patients who were SARS-CoV-2 positive, 35 patients had idiopathic or unknown aetiology AP. Sixteen patients underwent either MRCP (n=13) or EUS (n=4) and the remaining patients underwent biochemical investigations to exclude other causes of AP. The final aetiology of AP was available for 83 (70.3%) patients and included gallstones (56, 47.4%), alcohol (19, 16.1%), post ERCP (2, 1.7%) and other (6, 5.1%). Overall, 23 patients had a change of aetiology, and in 35 (29.7%) patients AP was considered idiopathic. Patients who were SARS-CoV-2 positive were more likely to have idiopathic AP (34.7% vs 13.9%, p

Pancreatic cystic lesions (PCLs) can present complex diagnostic and management challenges with uncertainty as to the most appropriate investigations, interventions and surveillance. Guidelines have been developed to aid decision making, including the European Study Group, American College of Gastroenterology and International Study Group guidelines. This paper presents issues relating to risk stratification and the appropriate management of patients with PCLs, reviewing these recently published guidelines. While there are similarities across these expert guidelines, there are notable differences in terms of features associated with increased risk of malignant transformation, the most appropriate imaging modality and timing of interval imaging. Where variations exist, this reflects differing interpretations of a limited evidence base, and decision making will likely evolve further as experience with these guidelines develops.

Endoscopic ultrasound (EUS) is now firmly established as one of the essential tools for diagnosis in most gastrointestinal MDTs across the UK. However, the ability to provide therapy with EUS has resulted in a significant impact on the management of the patients. These include drainage of peripancreatic collections, EUS-guided endoscopic retrograde cholangiopancreatogram, EUS-guided coeliac plexus blocks, etc. The rapid development of this area in endoscopy is a combination of newer tools and increasing expertise by endosonographers to push the boundaries of intervention with EUS. However, the indications are limited and we are at the start of the learning curve for these high-risk procedures. These therapies should, therefore, be confined to centres with a robust multidisciplinary team, including interventional endoscopists, radiologists and surgeons.

Introduction Endoscopic retrograde cholangiopancreatography (ERCP) is used as the first-line modality for biliary drainage in patients with obstructive jaundice. However, anatomical or technical factors may preclude conventional trans-papillary biliary access in less than 10% of cases. Endoscopic ultrasound-guided biliary drainage (EUS-BD) has recently emerged as an alternative method to percutaneous transhepatic biliary drainage (PTBD) or surgical biliary bypass after unsuccessful ERCP in patients with inoperable pancreatobiliary malignancies. We present initial experience of EUS-BD in our unit. Methods A prospectively collected database, of consecutive patients undergoing EUS-BD in our unit, was analysed. Data was retrieved from electronic, clinical and endoscopy records. All EUS-BD procedures were undertaken in the endoscopy department, under conscious sedation, using Pentax echoendoscopes and Hitachi ultrasound workstations. In all cases, conventional diagnostic EUS procedure was performed followed by trans-luminal EUS-guided placement of metal stents. One of three endoscopists (KO/MN/MD) performed the procedures. The primary outcome measurements were technical success, clinical success and adverse events. Results 4 EUS-BD procedures were performed in 4 patients – ¾ were female (75%) with median age 70 years (range 51–79). The primary indication in all patients was malignant biliary obstruction, which was not amenable to either PTBD or surgery. One patient had symptomatic cystic duct obstruction with gallbladder empyema. 1 patient received a Hot AXIOS™ covered lumen apposing metal stent (cLAMS), 1 had a Wallflex™ biliary fully covered self-expanding metal stent (fcSEMS) and the others had NAGI™ covered self-expanding metal stents (cSEMS) inserted. Technical and clinical success was 100% across all procedures with symptomatic improvement noted in all patients. Serum bilirubin measurements decremented post EUS-BD by median 89% (range 85–98%). No procedure related complications were seen. During follow up, 3/4 patients have died (median 7 months (range 3–8) from date of EUS-BD) of end-stage disease (unrelated to the EUS-BD procedure). The 4th patient remains clinically stable on follow-up (2 months after EUS-BD) with no evidence of further biliary symptoms. Conclusion Our early experience of EUS-BD confirms that it is a safe and effective palliative procedure in patients with malignant biliary tract obstruction, in whom surgery and/or PTBD are less favourable. We recommend that EUS-BD is performed after multidisciplinary team discussion and by experienced therapeutic endosonographers. Disclosure of Interest None Declared

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

Introduction A new core biopsy needle (SharkCore) with a novel design has recently been introduced for endoscopic ultrasound guided biopsy. There is as yet no data on how its diagnostic performance compares to the existing core biopsy needle (Procore) in the diagnosis of pancreatic masses. The aim of this study was to compare the diagnostic performance and yield of the two core biopsy needles i.e. the ProCore and the Sharkcore needles in the biopsy of solid pancreatic lesions. This is the first study in literature to compare 2 core biopsy needles. Methods A retrospective comparison of a prospectively maintained database. Consecutive patients who had EUS guided fine needle biopsy with Procore (100) and Sharkcore (101) were included in the study. Demographic details, site of lesion, number of passes and histological diagnosis. Final diagnosis was based on positive histology or at least 6 months follow up in cases with a benign pathology. Primary outcome was to compare the diagnostic accuracy of the two needles using only samples graded as definitely malignant as diagnostic for malignancy. The secondary outcome was to compare the diagnostic yield for both needles. Results The sensitivity, specificity, negative predictive value and accuracy between the groups were - Procore =71%, 100%, 28% and 74% vs. Sharkcore =91%, 100%, 53% and 94%. There was a significant difference in sensitivity (p = 0.0003) and accuracy (p = 0.006). The proportion of samples classified as adequate for histological analysis was 87% for Procore and 99% for Sharkcore - this was significantly different (p = 0.0009). There were no complications in either group. Conclusion In this study the SharkCore biopsy needle demonstrated significantly better diagnostic accuracy and tissue yield. Prospective randomised studies are required. Disclosure of Interest None Declared

Introduction EUS-guided FNA is the standard of care for tissue sampling of pancreatic lesions. The new Echo Tip ProCore biopsy needle (Cook Medical) was developed to obtain core tissue specimens for histological analysis improving the diagnostic yield and potentially obviating the need for onsite cytopathologist. Our aim was to compare the standard Echo tip ultra FNAC needle with the new Echo Tip Ultra ProCore FNAB needle in the sampling of solid pancreatic lesions. Method Randomised multicenter trial (REC Ref 12/EM/0189). All patients referred for EUS-guided tissue sampling of a solid pancreatic mass were invited to participate. Linear EUS (Aloka-Olympus/Hitachi-Pentax) was performed and patients were randomised to either FNAC or FNAB. Due to the nature of the study the endoscopist could not be blinded. A 22G needle was used when sampling from the stomach and a 25G from the duodenum. A maximum of 5 passes were allowed. Sampling time from first insertion of the needle into the lesion to the time the last tissue sample is transferred into the histology pot, number of passes and adequacy for diagnosis were recorded and included for analysis. Immediate and delayed complications were also recorded. Results 266 patients were recruited (median age 67 years, 52% men); 142 randomised to the FNAC group and 124 to the FNAB group. Two patients were excluded after randomization; no mass lesion was seen in 1 patient randomised to FNAC and the needle failed in 1 patient in the FNAB group and FNAC was performed. 264 patients were analysed, 141 in the FNAC group (22G=83 and 25G=58. Median max diameter of the lesion 34 mm, range 10–87 mm) and 123 in the FNAB group (22G=53 and 25G=71. Median max diameter 33 mm, range 8–85 mm). There was no statistical significant difference between groups in number of passes (median 4, range 1–5 in the FNAC group vs. median 3, range 1–5 in the FNAB group, p = 0.12), sampling time (median 13 min, range 1–32 min vs. median 13 min, range 2–42 min, p = 0.63) and adequacy of the specimen for diagnosis (90.8% vs. 87%, p = 0.33). Three technical failures were observed in the FNAB group and none in the FNAC cohort (1.6% vs. 0%, p = 0.99). No complications reported in either group. Conclusion FNAC and FNAB needles were comparable in terms of sampling time, number of passes, sample adequacy for diagnosis and safety. Technical failure was higher in the FNAB arm but not statistically significant. Disclosure of interest None Declared.

Introduction There are a number of factors which can influence the accuracy of EUS FNA but the presence of an in-room cytotechnician (IRC) has been shown to be one of the important factors. The aim of this study was to establish if the introduction of an IRC improved the diagnostic accuracy of EUS guided FNA of solid pancreatico biliary lesions Methods This is a prospective study and includes all patients with solid pancreatico biliary lesions who underwent EUS FNA from April 2009 to September 2010. We have been performing EUS FNA since 2003 but did not have an IRC till this period. The IRC attended 2 of the 4 EUS lists and therefore there were two groups identified: Group 1 – Cytotechnician absent; Group 2 – Cytotechnician present. Final diagnosis was based on a positive diagnosis on cytology, other forms of tissue acquisition and/or a year9s follow up for the benign/indeterminate cases. Only patients with a final diagnosis were included in the study. Results The final results are shown in table 1. We compared our data to the 6 months prior to this study (October 2008–March 2009) when there was no IRC available. The accuracy, sensitivity, specificity, PPV and NPV during this period were 86%, 82%, 100%, 100% and 57.6% respectively. The inadequate aspirate rate during this period was 14.2%. There was no statistical difference when this data was compared to either Groups 1 or 2. Conclusion This study shows that the presence of an IRC does not necessarily improve the diagnostic accuracy of EUS FNA of pancreatobiliary lesions. There are a number of factors which influence the results but experience of the cytopathologist/cytotechnician has shown to be one of the important factors. By keeping the number of inadequate aspirates low and reducing the number of highly suspicious samples the accuracy of the test can be improved. Large studies may be required to show a significant difference. Cost effectiveness and experience of the cytopathologist/cytotechnician should be taken into consideration when setting up this service.

Introduction Secretin enhanced magnetic resonance cholangio-pancreatography (S-MRCP) has been used as part of the diagnostic algorithm for the diagnosis of patients presenting with acalculous biliary type abdominal pain (ABAP); the exact role of this diagnostic modality is unclear. The aim of this study was to assess the diagnostic yield of S-MRCP in a large HPB tertiary referral centre in the investigation of patients with ABAP. Methods Retrospective analysis of a prospectively maintained database of all patients presenting with ABAP in whom a S-MRCP was requested from June 2008 to May 2013. The findings of S-MRCP were compared with those of MRCP and EUS (performed prior to S MRCP) and the diagnostic yield of S-MRCP in the work up of a patient presenting with ABAP was estimated. Results Of the 117 patients with ABAP [28 males and 89 female; mean age 48 yrs] were referred for S-MRCP, 114 (97.4%) patients successfully completed the scan. Of these 37 patients who had a normal MRCP, S-MRCP identified significant findings in 8 (22%) patients (Table 1). In the present study 78 (67%) patients had EUS. Out of the 41 patients who had a normal EUS, S-MRCP was able to identify significant pathology in 21 (54%) patients (Table 1). Conclusion This study suggests that S-MRCP has a 22 and 54% additional diagnostic yield in ABAP patients who have a normal MRCP and a normal EUS respectively. The commonest abnormality identified in these patients on S-MRCP was obstruction at ampulla or proximal PD. S-MRCP should be considered in the diagnostic algorithm of patients with ABAP. References 1 Mariani A, Arcidiacono PG, Curioni S, et al . Diagnostic yield of ERCP and secretin-enhanced MRCP and EUS in patients with acute recurrent pancreatitis of unknown aetiology. Dig Liver Dis 2009 Oct;41(10):753-8 2 Matos C, Metens T, Deviere J, et al . Pancreas divisum: evaluation with secretin-enhanced magnetic resonance cholangiopancreatography. Gastrointest Endosc 2001 Jun;53(7):728-33 Disclosure of Interest None Declared.

Introduction Management of type III sphincter of Oddi dysfunction (SOD) remains controversial. A recent large multi centre study of manometry and sphincterotomy in type III SOD (EPISOD) 1 found that sphincterotomy was no more effective than sham treatment. Botulinum toxin (botox) injection to the papilla has been shown to be safe and lead to improvement in symptoms, it may also predict response to sphincterotomy .2 This study reviewed use of botox in patients with type III within a single tertiary centre to guide decision making. Methods The endoscopy unit database was searched for cases between January 2008 to August 2013 who received botox for SOD. Records were reviewed to identify those who had type 3 SOD as per Rome 3 criteria. Response to botox was graded as no response, partial (reduction but not resolution of pain) or complete response. Complications, manometry and sphincterotomy results were recorded. Results 63 patients had botox injection for SOD 46 were classified as type III and formed the study group. All received 100IU of botox. Following the procedure 3 of 46 patients required overnight observation for abdominal pain, there were no cases of pancreatitis. 14 patients had no response to botox, 7 partial response, 24 a complete response, 1 did not attend follow up. Of those that had a complete response 14 patients proceeded to manometry; reasons not to proceed included failure to attend follow up (2) patient declined treatment (1) other co-morbidities (1). One underwent a second botox procedure with no relief in symptoms and was not offered further treatment, 5 patients (21%) were not offered manometry. Of those that proceeded to manometry, 10 (71%) had elevated pressures 8 biliary, 2 pancreatic. All proceeded to sphincterotomy with good response in 9 (64% of Botox responders). 3 of the 7 patients who partially responded proceeded to manometry; 1 of these had increased biliary pressures. 3 patients (18%)had an episode of pancreatitis following manometry. Conclusion Response to botox appears to show moderate correlation with abnormal manometry findings and response to sphincterotomy. ERCP and manometry was associated with a significant risk of pancreatitis. Randomised sham controlled studies are required to ascertain whether a response to botox can accurately select patients who benefit from a sustained response to sphincterotomy. References Cotton P et al. Results of the EPISOD Multicenter Sham-controlled Trial of Sphincterotomy in Patients with Suspected Sphincter of Oddi Dysfunction Type III presented at ACG San Diego October 2013 Bryce GJ, et al . Ampullary botulinum toxin injection in biliary sphincter of oddi dysfunction. Pancreatology 2013;13(1):e3 Disclosure of Interest None Declared.

Introduction Post-inflammatory peri-pancreatic fluid collections are frequent sequelae of severe acute pancreatitis. Collections are at risk of suppurative infection complicated by pancreatic necrosis. Over the last decade there has been an increasing emphasis on minimally invasive drainage procedures, including EUS-guided cyst-gastrostomy, and these approaches seem to be associated with lower morbidity and mortality. Access to the necrosis cavity has however been severely limited by having to maintain the tract with small diameter plastic stents. Recently, a novel flanged fully covered self-expanding metal stent (FCSEMS; NAGI stent, Taewoong Medical, Korea) has been developed to allow for better drainage of infected necrosis and easier endoscopic access into the cavity. Setting A non-randomised prospective multicentre phase II study to determine the safety and efficacy of FCSEMS endoscopic cyst-gastrostomy in the management of complex/infected pancreatic fluid collections. Methods Patients were included if they had evidence of a pancreatic fluid collection which was deemed to be amenable for EUS-guided drainage after discussion at a HPB multidisciplinary meeting. Patients selected for EUS-guided drainage had cross sectional imaging (MR or CT) performed within 2 weeks of the procedure and then an EUS assessment was made of the necrotic component. The collection was punctured using a cystotome and the FCSEMS inserted over a guidewire with fluoroscopic control. Repeat procedures were performed as necessary. Results A total of 11 patients (8 male, 3 female) were included in the study. Median age was 57.3 years. The aetiology of the collection was gallstones in 6 patients, idiopathic in 3, ischaemic in 1 and drug-induced in 1. Ten patients had evidence of at least 30% necrosis within the collection. Mean diameter of the collection was 15 cm and EUS-guided puncture was initially performed in all patients. The tract was dilated with a balloon in 6 patients. Stent insertion was either with a 20 mm (7 patients) or 30 mm (4 patients) length FCSEMS. Ten patients underwent endoscopic necrosectomy, with a median of 3 procedures (range 1–10). Significant reduction in the size of collection was achieved in all patients. Adverse events included stent migration in 3 (2 spontaneously and 1 during necrosectomy). Two patients died of complications of severe acute pancreatitis. Conclusion FCSEMS insertion is feasible and safe for drainage of pancreatic fluid collections. It allows repeated through the stent necrosectomy procedures and appears to be a major advance in the management of infected pancreatic necrosis. Disclosure of Interest None Declared.

Introduction The detection and diagnosis of pNETs remains challenging. EUS and EUS-FNA has a significant role in the detection, precise localisation and cytological confirmation of pNETs. Methods A retrospective review of all pNET patients undergoing EUS-FNA between April 2003 and September 2011 was carried out to determine the efficacy of EUS-FNA in confirming pNETs and compare performance over two consecutive 4 year period. Results 10 patients (3% of EUS procedures for cystic lesions) with cystic pNETs and 44 (4% of EUS procedures for solid lesions) with solid pNETs were identified. Table 1 compares the size, demographics and diagnostic performance of radiology, EUS & cytology in solid and cystic pNETs. 17 and 5 solid and cystic pNETs respectively were diagnosed between 2003 and 2007 while 27 and 5 solid and cystic pNETs were diagnosed between 2008 and 2011. EUS-FNA diagnosis of cystic and solid pNETs has improved from 20% and 59% respectively between 2003 and 2007 to 100% and 81% respectively between 2008 and 2011. Overall, sensitivity of EUS cytology has improved from 50% to 84.4% (p = 0.015) during this period. Malignant potential of solid pNETs was higher (54.5% vs 20%) compared to cystic pNETs. Curative resection was higher in patients with cystic pNETs (80% vs 68%) compared to solid pNETs. Conclusion EUS & EUS-FNA is a useful test in diagnosing pNETs. Overall, the sensitivity of combined EUS imaging and cytology was significantly better compared to CT/MRI (p Disclosure of Interest None Declared.

Introduction The accurate diagnosis of solid pancreatic masses is important in directing appropriate management of patients. The methods commonly used are percutaneous, laparoscopic and EUS guided biopsy of these lesions. Laparoscopic guided biopsy consumes theatre time and space and can be more expensive than the alternatives. In our unit; laparoscopic guided biopsy is reserved for patients who have an inconclusive result from an EUS guided biopsy or are considered for trial resection. The aim of this study was to look at the diagnostic performance of endoscopic ultrasound (EUS) guided biopsy (fine needle aspiration (FNA) or pro-core biopsy) and laparoscopic (lap) guided biopsy of solid pancreatic masses in a large HPB referral centre. Methods Retrospective review of patients undergoing EUS or laparoscopic guided biopsy for solid lesions between January 2011 and March 2012. Data was obtained from a dedicated prospectively maintained database in the histopathology department. Final diagnosis was based on positive histology/cytology of pancreatic adenocarcinoma. Benign cases were followed up for a period of at least six months. Results 464 specimens from the pancreas (histology + cytology including pancreatic resections) were received by the histopathology department during this period. Of these 275/464 (59%) patients had tissue biopsy of solid lesions. These included: EUS guided biopsy = 253 and Laparoscopic guided biopsy = 22. In the latter group; 10/22(45%) had a previous EUS of which 8/10 had an accurate diagnosis. 12/22(54%) patients went straight for laparoscopic guided biopsy. For the purposes of this study; highly suspicious and malignant samples were categorised as malignant. The accuracy, sensitivity and negative predictive value for EUS guided biopsy and laparoscopic guided biopsy were 92%/96%; 90%/94% and 74%/89% respectively. The inadequate aspirate rate was 5% and 0% respectively. There was no significant difference between the two groups. The cost of performing these procedures in our trust were: EUS guided biopsy £1094 and lap guided biopsy £ 2164. Conclusion In our unit;EUS guided biopsy of solid pancreaticobiliary lesions provides high diagnostic accuracy with a low inadequate aspirate rate. Our data supports the role of EUS guided FNA as the first modality of tissue acquisition from the pancreas. Though this data also shows the cost effectiveness of EUS guided biopsy over lap guide biopsy; in units with lower diagnostic accuracy of EUS guided biopsy the cost benefit may not be realised. Disclosure of Interest None Declared.

Introduction The finding of dilated CBD or PD or both (double duct sign) on abdominal cross-sectional imaging (CT or MRI) in patients with normal LFTs frequently leads to further investigation by EUS if a clear cause is not demonstrated on imaging. There is limited literature on the yield of EUS in this setting. Methods A retrospective review of our prospectively maintained EUS database was carried out to identify patients who underwent EUS for dilated duct(s), normal LFTs and non-diagnostic cross-sectional imaging between January 2007 and August 2011. Our aim was to evaluate the yield of EUS in this setting. Minimum follow up was for 12 months. Results 83 patients (3% of pancreaticobiliary EUS procedures during this period) were identified. Mean age was 66.7 years (30 – 87). There was a female preponderance (73%). 40(48%) had dilated CBD only, 5(6%) had solitary PD dilatation and 38(46%) had both CBD and PD dilatation on prior imaging. EUS was concordant with prior imaging in 60(72%) patients and discordant in 23(28%) [partial agreement in 18, non-dilated ducts in 3 and different duct dilated in 2]. 16(19%) patients had a new finding on EUS [3 cbd stones, 3 cbd polyps, 4 microlithiasis, 1 ampullary adenoma, 3 chronic pancreatitis, 1 pancreatic duct adenocarcinoma (PDAC) and 1 portal vein compressing mid CBD]. Of these 11(13%) were felt to be the cause of duct dilatation. On subsequent MDT review, the PDAC was identified on the initial scan from the referring hospital. 45% (10/22) of males compared to 9.8% of (6/61) females had a new finding on EUS (p = 0.0008). Overall, more females had symptoms compared to males (p = 0.065). There was no significant association between symptoms and new finding on EUS (p = 0.24). 7(17.5%) of the isolated CBD dilatation, 3(60%) of the isolated PD dilatation and 1(2.5%) of the dilated CBD and PD had a causative diagnosis respectively. Follow up of patients with no cause of duct dilatation on EUS revealed that 18 patients (54.5%) in the dilated CBD cohort had prior cholecystectomy [one patient had peri-ampullary diverticulum and prior cholecystectomy] while 2 and 10 patients in the dilated CBD and PD cohort (n = 37) had ampullary stenosis and prior cholecystectomy respectively. Conclusion Our study shows that EUS has a significant yield in individuals with unexplained duct dilatation and normal LFT (13% had a causative diagnosis). The yield was highest in isolated PD dilatation. A new finding was significantly more likely in men then women. EUS should ideally follow review of original cross sectional imaging by a HPB radiologist. Disclosure of Interest None Declared.

Introduction IgG4 related disease is now well recognised as a multisystem disease. This condition, originally discovered in Japan in 1995 is now being increasingly recognised in the Western World. Apart from diagnosis, treatment can also present as a challenge in a small group of patients. We report our experience from a tertiary referral hospital in North-East England. Methods Data were obtained from retrospective case note review from 2005 to 2011. Only patients diagnosed with AIP and IgG4 disease based on accepted international criteria were included in the study. 1 Results 16 patients were identified during this period. Mean age group was 64 years (Range 43–83 yrs). Male=15, Female=1. Abnormal LFTs were present in 62.5% of patients. Mean bilirubin was 97 mmols/l (range 4–354). Mean total IgG was 15.9 g/l (range 7.5–26.7). Mean IgG4 subclass levels was 6.4 g/l (Range 0.27–24.6). Pancreas was affected in 88% (15) and biliary abnormalities were seen in 62.5% (10) of the cases. Other organs noted to be involved were pericardium (1), retroperitoneum (2), gall bladder (2). Two patients had duodenal obstruction due to inflammation of the duodenum, stomach, peripancreatic area and the gall bladder bed. CT scan revealed enlarged head of pancreas (HOP) in nine patients (57%), extra-pancreatic mass in 4 (25%), extra hepatic bile duct involvement in 10 (62.5 %) and intrahepatic bile duct involvement in 9 (37.5%). 3 (18.75%) patients underwent ERCP and two had stenting of biliary strictures. EUS was performed in nine patients—showed enlarged HOP in 4 (44 %) and changes of chronic pancreatitis—4 (44 %). Nine patients (56%) had a raised serum IgG4. Diagnosis was made at surgery or by laparoscopic biopsy in 7 (44%) patients. Final diagnosis: Type I AIP in 15 patients (88%), Type II AIP in 1 (6%) and IgG4 cholangiopathy with no pancreatic involvement in 1 (6%). Other autoimmune diseases that were associated were Raynauds disease (1) and Sjogren9s syndrome (1). Steroids were initiated in 12 (75%) patients (mean dose 37.5 mg). Disease relapsed in three patients (25%). Azathioprine was started on five patients. One patient was switched to 6MP due to side effects. Conclusion Extrapancreatic disease, especially biliary structuring appears to be common. As this condition mimics malignancy, a combination of modalities were needed to arrive at a diagnosis. Relapse in not uncommon and a small group of patients will require additional immunosuppression for control of the disease. Competing interests None declared. Reference 1. Okazaki K , Kawa S, Kamisawa T, et al. Clinical diagnostic criteria of autoimmune pancreatitis: revised proposal. J Gastroenterol 2006; 41 :626–31.

Introduction The Differentiation of mucinous (MCA, IPMN) from non-mucinous pancreatic cysts is important because of the malignant potential of the former. Cyst fluid amylase is known to be elevated in cysts with overt communication with the pancreatic duct (Pseudocysts and IPMN) recent data has also suggested it may be elevated in MCA and that malignant mucinous cysts have a significantly lower level than benign. 1 We aimed to assess the diagnostic performance of cyst fluid amylase in a large cohort of histologically confirmed pancreatic cysts. Methods The study population comprised all patients with suspected neoplastic pancreatic cysts who underwent EUS-FNA between June 2003 and October 2011.The study group consisted of all patients with a definitive diagnosis (resection histology, biopsy histology or malignant cytology) in whom a cyst amylase value had been recorded. Test performance was compared using Mann–Whitney U test and an ROC curve was generated to characterise the diagnostic performance of cyst fluid amylase to differentiate pseudocyst from non pseudocyst. Results During the study period 334 cyst EUS-FNA procedures were performed. A definitive diagnosis was available for 93 individuals, an amylase level was available for 59/93 (63.4%) of cases. 37 mucinous cyst (24 benign, 13 malignant), 22 non-mucinous (eight pseudocysts). Median values (IU/L) and IQR for differing categories of cyst were IPMN 9188 (IQR, 587–20 105), MCA 1291 (IQR, 469–85 100), benign mucinous 6385 (IQR, 372–23 050), malignant mucinous 115 (IQR, 36.5–5123) pseudocysts 31 762 (IQR 20 051–53 610) non-pseudocysts 200 (IQR, 53.2–9710). There was a significant difference (p Conclusion Cyst fluid amylase while significantly elevated in pseudocycts cannot be solely relied upon to distinguish from mucinous cysts and cannot be used to differentiate between IPMN and MCA. Competing interests None declared. Reference 1. Park WG , et al. Diagnostic performance of cyst fluid carcinoembryonic antigen and amylase in histologically confirmed pancreatic cysts. Pancreas 2011; 40 :42–5.

Introduction Imaging morphology alone does not currently have high enough accuracy to determine the nature of pancreatic cystic lesions and therefore sampling of cyst fluid for biochemical markers via endoscopic ultrasound (EUS) has value. There is little data showing whether these markers are stable over time in an individual cyst. The aim of this study was to determine the variability of these markers. Methods Patients are prospectively added to the EUS FNA database when attending for EUS and the period April 2003–April 2010 was examined with reference to patients undergoing repeat EUS and aspiration of cystic lesions. These individuals had either declined surgery or there was clinical doubt concerning the neoplastic potential of the cyst. Results During the study period 267 EUS and cyst aspiration were performed. 28 individuals had 61 repeat procedures (24 had 2 procedures, 3 had 3 procedures and 1 had 4 procedures). Complete data was available on 13 individuals. Mean CEA at first aspiration was 74.8 compared to 121.0 at second aspiration (p=0.32) with a mean difference of −46.2. Mean amylase at first aspiration was 7142.4 compared to 7344.1 at second aspiration (p=0.98) with a mean difference of −186.2. There were no changes in CEA from normal to abnormal between aspirations. In two individuals there was a significant change in amylase level from normal to abnormal, both of whom were subsequently found to have undergone malignant change at surgery. Conclusion In this small study, biochemical markers appear relatively constant. Major changes in amylase may be associated with malignant change. Further study on a larger cohort is required.

Introduction The differentiation of mucinous from non-mucinous pancreatic cysts is important because of the malignant potential of the latter. EUS-FNA allows for high resolution imaging of pancreatic cysts as well as sampling for markers (CEA), cytology and a visual assessment of cyst content. The Cooperative cyst study found an elevated fluid CEA (>192 ng/ml) to be the single most accurate test in correctly predicting mucinous cysts with a sensitivity of 73%. The CEA value of 192ng/ml has subsequently been widely adopted as a definitive cut-off value. Methods The aims of the present study were to assess the utility of a cut-off value of 192 ng/ml in differentiating mucinous from non-mucinous pancreatic cysts and to compare this to general EUS assessment. IPMN and mucinous cyst adenoma/adenocarcinoma (MCA and MCAC) were considered separately. The study population comprised all the patients undergoing EUS-FNA at a tertiary centre for assessment of suspected pancreatic neoplastic cysts between June 2003 and April 2010. Results During this period 267 procedures were performed on 235 individuals, of whom 71 had a definitive diagnosis (60 resection histology, 5 histology, 6 malignant cytology), cystic degeneration of pancreatic adenocarcinoma (3) being excluded. 68 patients (51 females), (78 procedures) formed the study group. There were 25 mucinous cyst adenomas (11 MCA, 14 MCAC). There were 22 IPMN (2 malignant) and 21 non-mucinous cysts. For MCA/MCAC using a cut-off of 192 ng/ml the sensitivity, specificity, accuracy and NPV of detecting a mucinous lesion were 62.5%, 94.4%, 79.4%, 73.9%. Combining EUS morphology, cytology and visual assessment of aspirate (mucoid/non-mucoid) gave figures of 100%, 70.8%, 86%, 100%. The combination was significantly more sensitive p=0.007, but no significant difference in specificity. ROC area under the curve was numerically greater 0.861 versus 0.785 (not significant). For the IPMN patients the cut-off 192 ng/ml showed a sensitivity of 20% in the diagnosis of IPMN. EUS diagnosis had a sensitivity of 85%. Sensitivity of aspirate appearance: 87%, cytology: 50%; combining fluid appearance, EUS and cytology: 93%. Comparing the performance of CEA 192 versus combination in differentiating IPMN from non-mucinous cyst, ROC curve area was 0.864 versus 0.623 p =0.02. Conclusion A CEA cut-off of 192 ng/ml demonstrated good specificity and moderate sensitivity in the diagnosis of MCA, however it performed poorly in the diagnosis of IPMN. Combining EUS, aspirate appearance and cytology was significantly more sensitive in diagnosing mucinous cysts with a very high NPV.

Introduction Sphincter of Oddi (SO) dysfunction (SOD) is a functional disorder that can cause severe morbidity. SO manometry (SOM) measures SO pressure (SOP) and is the definitive test for SOD.1 SOD can be treated with sphincterotomy.1 ERCP in patients with SOD increases risk of complications.23 Sphincterotomy can cause long-term complications.4 As such patient selection and pre-procedure counselling is paramount.5 SOM is not widely available (in UK) and commercial SOM equipment is expensive. Methods We retrospectively evaluated the first 18 months of a new SOM service. Patients were referred from Northern region clinicians. After careful selection those with type II SOD were offered SOM. An in-house manometric system was developed using a water-perfused system constructed from existing invasive BP measuring equipment and a standard SOM catheter. Before use it was evaluated and produced reliable and valid pressure measurements comparable with commercial systems. Results Between 1/2008 and 7/2009, 29 patients (25F:4M) underwent SOM (36 procedures), following MRCP in 26, endoscopic ultrasound in 24 and SO Botox injection in 11. SO hypertension (SOH) was diagnosed in 16 and 18 patients underwent sphincterotomy (16-SOH, 1-choledocholithiasis, 1-dilated CBD at MRCP). There were five episodes of pancreatitis (14%) and one episode of cholangitis (after 36 SOM procedures). Discharge was within 24 h of the procedure in 21 patients, within 1 week in 9 and after 1 week in 6, in 4 of whom the pain was felt to be functional, (range 0–36 days, mean 4, median 1). One patient needed HDU care and one NJ feeding. In 13 of the 36 procedures a prophylactic pancreatic duct (PD) stent was placed. Of 16/29 patients who were contactable by phone for long-term follow-up (average 280 days, SD 142 days), 9 (82%) out of 11 who had sphincterotomy described a sustained symptomatic improvement. Only 2 (40%) out of 5 with no sphincterotomy reported an improvement. Conclusion Over half (56%) of patients having SOM had SOD indicating appropriate patient selection. The pancreatitis rate for SOM was 10 times that of all other ERCP in our unit but in keeping with published series.23 The in-house equipment was effective and allowed the service to be delivered without commercial costs. Sphincterotomy provided long-term benefit to over 80% of patients. The service will be further developed in light of these findings, with earlier discharge of patients with functional post-procedure pain and an increase in PD stent placement rate.

Introduction Endoscopic retrograde cholangiopancreatography and endoscopic ultrasound (ERCP and EUS, respectively) are complex endoscopic procedures requiring highly skilled nursing assistants. For these procedures to be performed safely and efficiently; regular training and teaching is essential. Currently there are no mandatory training courses in the region for these procedures despite the recognised need. The aim of the course was to address the basic principles of these complex endoscopic procedures and highlight recent developments in the field. Methods Fifty nurses working in endoscopy units around the country attended the first Newcastle ERCP and Endoscopic Ultrasound course for nurses (The Newcastle Upon Tyne Hospitals NHS Foundation Trust). They were surveyed at the end of the course using a detailed questionnaire. Results 50 delegates attended from eight institutions around the UK. 49 (98%) delegates completed the questionnaire. The average experience of the staff working in endoscopy was 5.5 years (range 0–20 years). 13/49 (26.5%) had previously attended some form of ERCP±EUS training. 42 (85.7%) delegates thought all nurses should attend similar course. 38 (77.5%) thought their knowledge was either basic or moderate prior to attending the course. 47 (95.9%) said that their knowledge had improved after the course. 31 (63.2%) thought their ability to assist during an ERCP/EUS either basic or moderate before the course 45 (91.8%) thought their ability to assist during ERCP/EUS had improved after the course. Confidence in assisting the Endoscopist with therapeutic procedures increased from 28 (57.1%) to 41 (83.6%) of attendees after the course. 42 (85.7%) of attendees agree all nurses should undergo a training course within the first year in post in the Endoscopy unit. Conclusion 1. Less than a third of the endoscopy nurses attending the course had attended some form of formal training course for either ERCP or EUS, despite a medium time working in Endoscopy of 5.5 years. 2. This course not only improved the knowledge and ability to assist during a therapeutic ERCP/EUS list but also improved the nurse9s confidence about these complex procedures. 3. More prospective surveys are required to address training issues for nurse assistants involved in ERCP and EUS.