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Summary Background There is a paucity of evidence to support safe and effective management of patients with acute severe ulcerative colitis during the COVID-19 pandemic. We sought to identify alterations to established conventional evidence-based management of acute severe ulcerative colitis during the early COVID-19 pandemic, the effect on outcomes, and any associations with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and severe COVID-19 outcomes. Methods The PROTECT-ASUC study was a multicentre, observational, case-control study in 60 acute secondary care hospitals throughout the UK. We included adults (≥18 years) with either ulcerative colitis or inflammatory bowel disease unclassified, who presented with acute severe ulcerative colitis and fulfilled the Truelove and Witts criteria. Cases and controls were identified as either admitted or managed in emergency ambulatory care settings between March 1, 2020, and June 30, 2020 (COVID-19 pandemic period cohort), or between Jan 1, 2019, and June 30, 2019 (historical control cohort), respectively. The primary outcome was the proportion of patients with acute severe ulcerative colitis receiving rescue therapy (including primary induction) or colectomy. The study is registered with ClinicalTrials.gov , NCT04411784 . Findings We included 782 patients (398 in the pandemic period cohort and 384 in the historical control cohort) who met the Truelove and Witts criteria for acute severe ulcerative colitis. The proportion of patients receiving rescue therapy (including primary induction) or surgery was higher during the pandemic period than in the historical period (217 [55%] of 393 patients vs 159 [42%] of 380 patients; p=0·00024) and the time to rescue therapy was shorter in the pandemic cohort than in the historical cohort (p=0·0026). This difference was driven by a greater use of rescue and primary induction therapies with biologicals, ciclosporin, or tofacitinib in the COVID-19 pandemic period cohort than in the historical control period cohort (177 [46%] of 387 patients in the COVID-19 cohort vs 134 [36%] of 373 patients in the historical cohort; p=0·0064). During the pandemic, more patients received ambulatory (outpatient) intravenous steroids (51 [13%] of 385 patients vs 19 [5%] of 360 patients; p=0·00023). Fewer patients received thiopurines (29 [7%] of 398 patients vs 46 [12%] of 384; p=0·029) and 5-aminosalicylic acids (67 [17%] of 398 patients vs 98 [26%] of 384; p=0·0037) during the pandemic than in the historical control period. Colectomy rates were similar between the pandemic and historical control groups (64 [16%] of 389 vs 50 [13%] of 375; p=0·26); however, laparoscopic surgery was less frequently performed during the pandemic period (34 [53%] of 64] vs 38 [76%] of 50; p=0·018). Five (2%) of 253 patients tested positive for SARS-CoV-2 during hospital treatment. Two (2%) of 103 patients re-tested for SARS-CoV-2 during the 3-month follow-up were positive 5 days and 12 days, respectively, after discharge from index admission. Both recovered without serious outcomes. Interpretation The COVID-19 pandemic altered practice patterns of gastroenterologists and colorectal surgeons in the management of acute severe ulcerative colitis but was associated with similar outcomes to a historical cohort. Despite continued use of high-dose corticosteroids and biologicals, the incidence of COVID-19 within 3 months was low and not associated with adverse COVID-19 outcomes. Funding None.

OBJECTIVE: The objective was to study hospitalised COVID-19 patients’ mortality and intensive care unit (ICU) admission with covariates of interest (age, gender, ethnicity, clinical presentation, comorbidities and admission laboratory findings). METHODS: Logistic regression analyses were performed for patients admitted to University Hospital, University Hospitals Coventry and Warwickshire NHS Trust, between 24 January 2020 – 13 April 2020. RESULTS: There were 321 patients hospitalised. Median age was 73 years and 189 (59%) were male. Ethnicity was divided between Caucasian (77%), and black, Asian, and minority ethnic (BAME) groups (23%). Commonest symptoms were dyspnoea (62.9%), fever (59.1%) and cough (56%). Gastrointestinal symptoms amounted to 11.8%. Forty-four patients (13.7%) received ICU care. ICU male to female ratio was 3:1 (p=0.027; odds ratio (OR) 2.3; 95% confidence interval (CI) 1.1–4.9), BAME (p=0.008; OR 2.5; 95% CI 1.3–4.9), age >65 years (p=0.026; OR 0.28; 95% CI 0.09–0.93), heart disease (p=0.009; OR 0.2; 95% CI 0.1–0.6) and elevated C-reactive protein (CRP; p65 years (p=0.011; OR 5; 95% CI 1.6–21.9), neutrophils (p=0.047), neutrophil:lymphocyte ratio (NLR; p=0.028), CRP (p

Introduction Risk scoring for acute upper gastrointestinal bleeding (AUGIB) is key when assessing patients for requiring OGD. The Rockall score utilises age, comorbidities and shock. The Glasgow-Blatchford score (GBS), in addition, utilises haemoglobin, melaena, and blood urea levels. Raised blood urea levels can represent digestion of blood from the upper gastrointestinal tract giving rise to melaena; the presence of both gives a high GBS. However, inexperienced health care professionals can misinterpret the absence/presence of melaena, raised urea levels may be due to kidney injury. Nevertheless, Gastroenterologists may use urea to diagnose AUGIB if patients haven’t had overt/witnessed/reliably reported haematemesis or melaena. It has been shown that a raised urea:creatinine ratio (URCR) can be associated with AUGIB and may be superior to urea alone as it mitigates for kidney injury.1 However, URCR is not widely used in the UK in the assessment of AUGIB. We aim to assess the association of urea and URCR levels with AUGIB. Methods A retrospective review at three UK centres (Kettering General Hospital, Queen Elizabeth Hospital Birmingham, and University Hospital Coventry & Warwickshire) was undertaken. Endoscopy reports and blood tests were reviewed of patients undergoing inpatient OGD for suspected AUGIB within 2017/8, data were recorded in an Excel spreadsheet. URCR was calculated by dividing Urea by creatinine, and multiplying by 1000 (abnormal = ≥100). Statistics were analysed using SPSS. Results 357 patients’ records were reviewed (median age = 68), 179 had a plausible AUGIB (50.1%). Receiver operator characteristic (ROC) curves for Urea gave an area under the curve (AUC) = 0.733. For URCR, AUC = 0.789. Binary logistic regression modelling was performed using age, urea, and URCR. χ2 (3, n = 357) = 102.92, p The model URCR value of 97.7 can be used to predict AUGIB, applying this to our data set correctly identifies 124/179 patients with AUGIB (69.3%), and is predicted to correctly identify 74.5%. Conclusion This pilot study has limitations as bleeding lesions may have not been identified at OGD. Urea and URCR have AUCs of 0.733, & 0.789. Logistic regression modelling suggests a URCR level of 100 would correctly identify ∼70% of AUGIB in patients with suggestive symptoms. Outside of firm indications for OGD in suspected AUGIB (shock, previous/suspected variceal bleed), a raised URCR appears to be a useful marker to predict AUGIB: a larger study would be able to test this robustly. Reference Srygley FD, Gerardo CI, Tran T, Fisher DA. Does this patient have a severe upper gastrointestinal bleed?JAMA 2012;307(10):1072–9.

ObjectiveAcademic medical training was overhauled in 2005 after the Walport report and Modernising Medical Careers to create a more attractive and transparent training pathway. In 2007 and 2016, national web-based surveys of gastroenterology trainees were undertaken to determine experiences, perceptions of and perceived barriers to out-of-programme research experience (OOP-R).Design, setting and patientsProspective, national web-based surveys of UK gastroenterology trainees in 2007 and 2016.Main outcome measureAttitudes to OOP-R of two cohorts of gastroenterology trainees.ResultsResponse rates were lower in 2016 (25.8% vs 56.7%) (p50% having already undertaken it. Doctor of Philosophy/medical doctorate remained the most popular OOP-R in both cohorts. Successful fellowship applications increased in 2016, and evidence of gender inequality in 2007 was no longer evident in 2016. In the 2016 cohort, 91.1% (n=144) felt the development of trainee-led research networks was important, with 74.7% (n=118) keen to get involved.ConclusionsThe majority of gastroenterology trainees who responded expressed a desire to undertake OOP-R, and participation rates in OOP-R remain high. Despite smaller absolute numbers responding than in 2007, 2016 trainees achieved higher successful fellowship application rates. Reassuringly more trainees in 2016 felt that OOP-R would be important in the future. Efforts are needed to tackle potential barriers to OOP-R and support trainees to pursue research-active careers.

Risk scoring for acute upper gastrointestinal bleeding (AUGIB) is key when assessing patients for requiring oesophagogastroduodenoscopy (OGD). The Rockall score utilises age, comorbidities and shock. The Glasgow-Blatchford score (GBS), in addition, utilises haemoglobin, melaena and blood urea levels

We are writing with regard to the recently published British Society of Gastroenterology (BSG) lower GI bleeding (LGIB) guidelines.1 We have significant concerns about some of the recommendations. The quick reference flowchart suggests that patients with stable LGIB (shock index

An 83-year-old man presented with an acute history of weight loss and jaundice. He had a history of type 2 diabetes mellitus and hypertension. He consumed 30 units of alcohol per week. The patient was cachectic and jaundiced with non-tender hepatomegaly and no evidence of chronic liver disease. There was evidence of hypoalbuminaemia (albumin 25 g/L, reference 34–51 g/L), hyperbilirubinaemia (bilirubin 188 μmol/L, reference

An 81-year-old woman presented with a history of severe chronic diarrhoea resulting in an admission with syncope and electrolyte abnormalities. Imaging studies of the bowel were normal. However, biopsies taken during colonoscopy enabled a diagnosis to be made and effective treatment to be initiated. This case report details the presentation, diagnosis and management of a rare injury pattern affecting the bowel: pseudomembranous collagenous colitis.

We describe a case of a 43-year-old man presenting to the gastroenterology outpatient department with exudative ascites. Mediastinal lymphadenopathy, pericardial effusion and pleural effusion were detected on further imaging. Further clinical examination revealed subcutaneous nodules on the left arm, which were confirmed to be rheumatoid nodules on histology. Inflammatory markers were elevated with positive serology for rheumatoid factor and anticyclic citrullinated protein antibody. Our investigations excluded tuberculosis, pancreatitis and malignancy in the patient. Following review by a rheumatologist, a diagnosis of systemic rheumatoid arthritis (RA) was made. Pleuritis and pericarditis are well recognised as extra-articular manifestation of RA. Ascites, however, is rarely recognised as a manifestation of RA. Our literature search revealed two other cases of ascites due to RA disease activity, and both patients had long-standing known RA. This case adds to the discussion on whether ascites and peritonitis should be classified as extra-articular manifestations of RA.

Introduction The rate of tuberculosis has remained relatively stable over the past decade. However, the proportion of cases with extra-pulmonary disease has increased from 40.9% to 47.9%. Multiple studies have shown that diagnosis of abdominal tuberculosis (ATB) is often delayed due to non-specific symptoms in patients. The aim of this study was to examine a selection of patients from a UK district general hospital with a diagnosis of ATB and the process in which that diagnosis was reached. Method We performed a retrospective review of all patients at Russells Hall Hospital, Dudley, who had a diagnosis of ATB between 2004 and 2014. Demographic, clinical, laboratory and radiographical findings were collated including the time delay between hospital presentation and diagnosis. Results Sixteen cases of ATB were identified with a median age of 38.5 years at time of diagnosis (range 22–73 years) with a male gender of 56%. The majority (87.5%) were of non-white background; South Asian (69%), Afrocaribbean (19%) and White British (12%). The commonest features were abdominal pain (62.5%), weight loss (50%) and fevers (50%). The time between first presentation to hospital and diagnosis ranged from 2 days to 3 years. Basic investigations revealed mean haemoglobin of 11.9 ± 1.7 g/dL, CRP of 109 ± 92 mg/L, alkaline phosphatase of 200 ± 160 IU/L, and albumin of 37.1 ± 6.5 g/L. The chest x-ray was normal in 11 patients; abnormalities seen were consolidation in 3 patients and a cavitating lesion in 1 patient. One patient did not have an x-ray. There was a wide range of sites of disease including small bowel (25%), peritoneum (25%), lymph nodes (18.75%), appendix (12.5%), liver (12.5%) and omentum (6.25%). Tuberculin test was only performed in three patients and all of which were positive. Diagnosis was based on histology (43.75%), imaging (31.25%), microbiology (6.25%), or a combination of clinical suspicion and imaging or appearances at surgery (18.75%). The majority who received treatment (9/14) were given Rifater plus ethambutol. The remaining five patients all received a different combination of antituberculous treatment (Rifater alone, Rifinah ± Pyrazinamide and Ethambutol, Rifampicin/Isoniazid/Pyrazinamide ± Ethambutol). Two patients did not receive treatment as their diagnosis was made post-mortem. Of the sixteen patients, ten were treated and discharged, three died, two have on-going review and one was lost to follow up. Conclusion ATB is a difficult diagnosis to make and there can be a significant time delay between symptom onset and diagnosis as the symptoms can be varied and insidious in nature. It is an easily treatable condition and a combination of abdominal pain, fevers and weight loss in a non-Caucasian patient should raise suspicion and warrants further investigation. Disclosure of interest None Declared.

Introduction Water assisted colonoscopy [WAC] is known to reduce patient discomfort and improve the adenoma detection rate [ADR]. 1 In this retrospective observational study, we compared water assisted colonoscopy against standard colonoscopy[SC] using CO 2 in a bowel cancer screening positive population. Method This was a retrospective review of prospectively collected data. The population studied was undergoing colonoscopies following a positive faecal occult blood test as part of the bowel cancer screening programme [BCSP]. Endoscopist A preferred to intubate the caecum using the water exchange method and endoscopist B would insufflate the bowel using carbon dioxide. Sedation and analgesic use was at the discretion of the endoscopist. The primary outcome was the adenoma detection rate and the comfort scores in the two groups. Secondary outcomes included caecal intubation rate, mean withdrawal time, sedation use and polyp retrieval rate. Results Data from two hundred and seven colonoscopies performed from April 2014 to December 2014 [9 months] were analysed. 102 colonoscopies were performed using the water exchange method [group A] and 105 colonoscopies were performed using CO 2 [group B]. Primary outcomes: Adenoma detection rate [ADR] in group A was 53% compared to of 36% in group B. This was statistically significant [difference in rate = -0.1868 [95% CI 0.0052–0.3685 p = 0.0438]. The proportion of patients experiencing none [score 1] or minimal [score2] discomfort [based on modified Gloucester comfort score] were more in group A [n = 74] compared to group B [n = 62]. This was found to be statistically significant [Z = 2.046, p = 0.0408] Secondary outcomes: Conclusion Our finding of a significant improvement in ADR and better tolerability in the WAC group supports similar conclusions by Hsieh e t al. This may have potential implications for the bowel cancer screening programme since the perception of colonoscopy can influence public participation and improve uptake in the BCSP. Improved ADR may be due to combination of factors like improved bowel preparation, flattening of mucosal folds and floating effect of polyps with water irrigation. We hope our findings are validated in the future through randomised trials. Disclosure of interest None Declared. Reference Hsieh YH, Koo M, Leung FW. A patient blinded randomized, controlled trial comparing air insufflation, water immersion and water exchange during minimally sedated colonoscopy. Am J Gastroenterol. 2014;109(9):1390–400

A 43-year-old lady with a known history of ulcerative colitis (UC) was admitted with a 2-day history of profuse bloody diarrhoea and generalised abdominal tenderness. On examination, the patient looked unwell with a temperature of 38.7°C, pulse rate of 98 beats per min and blood pressure 138/68 mmHg. Blood testing showed white blood cell count of 11.6 x 109/l with a differential neutrophil count of 9.65 x 109/l. Haemoglobin, platelets, renal function and liver …

Introduction The case for methotrexate (MTX) therapy has been comprehensively compiled in Crohn’s disease, with trials showing its efficacy in both induction and maintenance of remission. By contrast, the evidence remains patchy for ulcerative colitis (UC). BSG guidelines recommend its trial as a second-line agent in those patients intolerant of, or resistant to, azathioprine (AZA) or mercaptopurine (MP). Previous studies show conflicting results for MTX in UC; with response rates between 22–33%, with a high rate of colectomy, 44%, in one of the studies. We aimed to review the clinical effectiveness of MTX in our cohort of UC patients who had previously tried, or failed, with thiopurine therapy. Methods A retrospective analysis of patients taking MTX for UC was carried out. Subjects were identified from our inflammatory bowel disease database. All patients had trialled thiopurine therapy prior to MTX. Their outcomes on these treatments, including reasons for discontinuation, were recorded. It is current policy within our department to start with oral MTX (plus folate supplementation), initially 15 mg once weekly, increasing to 20mg or 25mg as necessary. Clinical response at 12 weeks and 12 months was used to assess efficacy of MTX treatment. The primary endpoint was steroid-free remission. Results A total of 21 UC patients (male = 62%) were identified. Median age was 61 years (range 21–82). Disease pattern was extensive (43%), left-sided (19%), and recto-sigmoid (38%). Reasons for AZA/MP discontinuation were intolerance to therapy (38%), and failure of therapy (62%) despite dose optimisation. Steroid-free remission was achieved in 11 patients (52%), and this appears sustained at 12 months follow-up. A further 4 patients (19%) report improved symptoms with MTX, but remain dependent on low-dose steroids (although it is noted that 1 of these patients has co-existent rheumatoid arthritis which may explain this). MTX was discontinued in 4 patients (19%) because of a lack of clinical response (n = 1), side-effects (n = 2) or planned pregnancy (n = 1). Side-effects reported with MTX were liver toxicity and skin rashes. A final 2 patients (10%) have shown promising results with MTX but are not yet eligible for 12-month follow-up. Of the 21 patients included, 20 remain on oral therapy, and one has switched to parenteral MTX. Of note, none of the MTX patients have progressed to colectomy, in contrast to previous studies. Conclusion Our study has shown good efficacy with MTX, with approximately half of UC patients achieving steroid-free clinical remission at 12 months. In contrast to previous studies, our experience suggests it is a useful treatment option in patients previously failing or intolerant of optimised thiopurine therapy. Disclosure of Interest None Declared.

Introduction A national survey of UK gastroenterology trainees in 20071 identified high rates of participation in research and Out Of Programme Experience (OOPE). 49.6% of respondents were currently or had already undertaken OOPE. Trainees9 success at fellowship applications to the major funding bodies ranged from 23.5 to 29.9%. The changes in academic training pathways post Walport and the Modernising Medical Careers process will have implications for both academic and clinical trainees wishing to undertake a period of out-of-programme experience (OOPE), although the effects are currently unclear. Aims The aims were to determine: Trainees9 experience of OOPE Trainees9 success at research fellowship application The perceived barriers to undertaking a period of OOPE Methods A Web-based national survey of trainees in Gastroenterology in the UK was carried out in September 2009, supported by the British Society of Gastroenterology. Results 237 trainees completed the survey in 2009, 73% (n=173) male, 27% (n=64) female. All training years and regions were evenly represented. 89.9% (n=213) were in clinical training programmes, with 10.1% (n=24) in a Walport training programme. 88.7% of trainees expressed a wish to undertake OOPE/research. 55.7% (n=132) of respondents were currently in or had previously undertaken OOPE. 50% (n=61) of these had registered for a PhD and 34% (n=45) an MD. 47.7% (n=113) of trainees had completed their OOPE at the time of survey and of this group 15.9% (n=18) had received their degree. Trainees had success rates between 12.5% and 40.8% for clinical research fellowships. 94.9% (n=225) of trainees feel that attainment of a higher degree will make them more competitive at NHS consultant interviews. The most common reasons for not undertaking OOPE were related to competition for funding and personal financial implications. Conclusion The majority of trainees express a desire to undertake OOPE and rates of participation in research/OOPE remains high. UK gastroenterology trainees are competitive for major fellowship programmes. Further surveys will be needed to study the effects of MMC and Walport, as well as the effects of increasing student debt on participation in OOPE.