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Giant lipomas of the stomach are very rare, accounting for less than 3% of all benign tumors of the stomach. A clear-cut endoscopic differentiation between gastric lipomas and other submucosal neoplasms is not feasible, because routine endoscopic gastric biopsies do not reach the submucosal layer. Gastric submucosal lipomas can cause gastric ulceration as in the case presented below and in rare instances this may in turn promote gastric cancer. Therefore, complete pretreatment diagnostic evaluation is needed. We present a 52-year-old man with a 6-month history of epigastric discomfort, early satiety, decreased appetite, and dyspepsia. His weight was noted to be stable and he was iron deficient (hemoglobin 11.5 g/dl and ferritin of 5 g/dl). His past history included a gastric ulcer found on endoscopy 5 years ago for which he was on omeprazole 40 mg once a day, hypertension, hypercholesterolemia, and diabetes. Clinical examination revealed central obesity with divarification of recti muscles. He underwent a colonoscopy that was normal, and an oesophago-gastro-duodenoscopy that revealed a smooth extrinsic indentation of the anterior aspect of the distal stomach at around 50 cm. Biopsies of this were normal. A computed tomography scan was obtained () that demonstrated a 14 by 15-cm fatty tumor arising from the distal stomach with a couple of 5-mm nodes adjacent to tumor and no distant metastasis representing either a lipoma, liposarcoma or gastrointestinal stromal tumours. He subsequently underwent a subtotal gastrectomy. Macroscopically, the antrum was distorted by a huge submucosal intramural tumor mass. The antral mucosa was stretched over its surface and bore a central 15-mm ulcer surrounded by a raised border (). Microscopic examination confirmed an ulcerated benign submucosal lipoma. Our patient was symptomatic with a large gastric lipoma that necessitated surgical excision. Following surgery his postoperative recovery was uneventful, and he was asymptomatic when reviewed 4 weeks later. This case demonstrates a rare case of gastric lipoma causing gastric epithelial ulceration leading to iron deficiency.

Introduction Initial data from the UK BCSP demonstrated variation in referrals to surgery and management for complex polyps encountered in colonoscopy. Associated factors included local availability of operator skills and expertise with endoscopic resection, lack of a structure for discussion and standardised management at the Local assessment centres (LAC). Inappropriately high incomplete resection rates at colonoscopy was noted for such polyps at local units. We hence established a National Clinical Network of specialist expert advisors, meeting every fortnight via videoconference to review endoscopy, radiology, pathology and clinical data of cases referred through specific criteria for complex lesions. We also established a National referral centre (NRC) at Llandough with the requisite skills and expertise in complex Endoscopic Mucosal Resection and Dissection (EMR, ESD) where appropriate polyps that met the referral criteria after a Network Multidisciplinary Team meeting discussion (NMDT) could undergo advanced therapy. An NMDT and NRC pilot was established in Oct 2011 to offer the opportunity to access expert opinion and discussion of therapeutic options for Welsh participants of the BCSP. We present our preliminary results. Methods Referral criteria for complex polyps were agreed based on a composite of site, size, morphology and accessibility. Polyps satisfying the criteria were referred to the NMDT electronically along with relevant images and video. Depending on outcomes of NMDT discussion participants were given the option of accessing local surgery or travelling to the NRC for therapeutic endoscopy. Over a 2 year period, 140 referrals were made from 14 different welsh BCS centres to the NMDT. Results The various management decisions taken in 126 benign complex polyps and the 14 cancers detected is illustrated in fig 1. Polyps that had incomplete resection (22) often had piecemeal EMR or repeated attempts at EMR at LAC causing failure of lifting in polyps. It is noteworthy that in the first 1 year of NMDT and NRC establishment;16 such cases were referred in contrast to 6 in the subsequent year with most cases in the 1st year needing surgery. This is an encouraging trend as awareness through discussion in the NMDT has streamlined management and decreased the incidence of incomplete resections allowing definitive management in the first instance and reduction in inappropriate referral to surgery for benign disease. Conclusion Establishing a clinical network for standardised decision making for complex polyps appears to have a significant effect on clinical outcomes. Disclosure of Interest None Declared.

Introduction With the advent of the Bowel cancer screening programme (BCSP) in the UK participants who have positive FOB tests are generally offered optical colonoscopy (OC) if considered safe, for early detection and prevention of CRC. In our study we undertook Computed Tomographic Colonography (CTC) in our hospital as the investigation of choice in those FOBt positive individuals with an American Society of Anesthesiology (ASA)grade > = 3 and analysed outcomes. Methods Cases were prospectively discussed with screening practitioners carrying out assessments prior to OC and on the basis of hospital records and liaison with primary care physicians were assigned to CTC/OC with majority proceeding to OC as per standard practise. Patient data was accessed from our database in radiology, endoscopy and histology retrospectively and ASA grade assigned on the basis of the above information.44/69 cases that were referred for CTC from the BCSP between Feb 2009 and Nov 2011, were considered to have an ASA > = 3.CTC results were analysed and correlated with endoscopic and histological findings. Results Out of 44 cases (17 female,27 male, mean age 65.4) with positive FOBt referred for CTC in the BCSP,50%(22) of patients had positive findings i.e.18 polyps and 4 suspected CRC.3/44 cases had a normal Flexible Sigmoidoscopy (FS) before CTC. Hence 41 of the above were considered to have had a primary CTC.44% (18/41) of patients referred for primary CTC had an endoscopy (20% OC,24% FS), of which 61% had a polypectomy.41 primary CTCs detected 32 polyps in 18 cases and 4 cancers.18 cases (4 diminutive polyps on CTC not requiring OC/FS) underwent endoscopy as a result of the above (OC 8, FS 10) detecting 36 polyps (35 removed) in 11 patients.86% of polyps were detected on the left side and the majority of this (83%) were histologically confirmed to be adenomas. In addition to this 2 left sided cancers was confirmed endoscopically. Conclusion In this small cohort CTC seems comparable to colonoscopy for detection of polyps and cancers1.In the patient group selected almost 44% of cases thought to have significant comorbidity who had primary CTC ended up having a lower GI endoscopy along with a need for therapy. It is also noted that the majority of significant polyps and all cancers were located in the left colon. We suggest that in this group a larger study evaluating a combination of CTC with FS (with no or minimal sedation) would be most appropriate in the context of the BCSP. It may also be useful to have evidence based criteria on fitness for colonoscopy in order to inform individuals and programmes on the appropriateness of screening in the context of comorbidity and the risk to benefit ratio. Disclosure of Interest None Declared. Reference Laghi, A et al . Current status on performance of CTC and clinical indications. EJR.doi:10.1016/j.ejrad.2012.05.026

Introduction It is well known that CO2 insufflation reduces pain during and after colonoscopy. However air insufflation is more popular probably due to limited randomised studies.1 This study compares the effects of air and CO2 insufflation on pain during and after colonoscopy. Methods The study was conducted over a 3-month period and 126 patients were randomly assigned into CO2 or air insufflation groups. Discomfort scores during and after colonoscopy was recorded using the modified gloucester discomfort score and factors influencing outcome such as sex, endoscopist grade, previous surgery and sedation were also considered. Results Of 126 in the study, air was used in 36 and CO2 in 90. The caecal intubation rate in CO2 was 95% versus 91% in the air group. Patients in the CO2 group had lower pain scores during the procedure compared to air. During the procedure, 51.6% CO2 versus 36.11% (Air) had no discomfort at all (score 1). Patients who had a score of 2, 3 were 46% Air versus 40% CO2. There was a higher pain score (4, 5) noted at 7% versus 2.7% (Air) noted mainly in females (83.3%). Postprocedure discomfort scores were almost equal noted to be 1.19 Air versus 1.06 at 1 h and 1.08 versus 1.00 CO2 at 2 h. A number of factors were taken into consideration to see whether this influenced discomfort scores. (1) Sex : 57 males and 69 females were in the study. Females had higher pain scores 31.34% versus 15.52% (males). However this was not statistically significant using the Mann–Whitney test. (2) Sedation : Average sedation used, midazolam (M) 1.93 versus 0.67 mg CO2, Pethidine 9 versus 14 mg CO2, fentanyl 34 versus 17 mg CO2. Average top up sedation used was 0.02 versus 0.05 mg CO2 of M, Pethidine 0.69 versus 0.5 mg CO2 and fentanyl 2.5 mg top up for CO2 group versus no top up. (3) Previous surgery : Data for only 74 patients was available. Those patients who have had no previous surgery (n=50) appear to have lower discomfort levels, however data points for pelvic surgery were too few to come to a conclusion. (4) Endoscopist : Discomfort scores were higher in trainees (n=34) using CO2 than consultants (n=56). Using Mann–Whitney test this was statistically significant with a CI of 95.1%. There was no difference in scores in air group. In the consultant group, using CO2 lowered patient discomfort compared to air (p=0.06) that was statistically significant. Conclusion Though CO2 insufflation is said to be effective in reducing postprocedural discomfort there was not much difference in both groups however pain was reduced during procedure in the C02 group. Caecal intubation rate was slightly higher in the CO2 group and endoscopist grade, sex and previous surgery influenced outcome.