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The European Society of Gastrointestinal Endoscopy and United European Gastroenterology have defined performance measures for upper and lower gastrointestinal, pancreaticobiliary, and small-bowel endoscopy. Quality indicators to guide endoscopists in the growing field of advanced endoscopy are also underway. We propose that equal attention is given to developing the entire advanced endoscopy team and not the individual endoscopist alone.We suggest that the practice of teams intending to deliver high quality advanced endoscopy is underpinned by six crucial principles concerning: selection, acceptance, complications, reconnaissance, envelopment, and documentation (SACRED).

ObjectiveTo assess the risks and benefits of reverse mentoring of consultants by junior doctors.DesignA feasibility study divided into two phases: first a semistructured interview where performance of participating consultants was assessed by junior doctors and then a second phase allowing for feedback to be given on a one-to-one basis. Data collected through questionnaires with free text questions and Likert scores.SettingTertiary teaching hospital in the UK.ParticipantsSix junior doctors (66.6% male, age range 31–40 years) and five consultants (80% male, age range 35–65 years and consultants for 5–20 years).InterventionReverse mentoring session.Main outcome measureThe concerns and/or benefits of the process of reverse mentoring. Confidence was assessed in 7 domains: clinical practice, approach to juniors, approachability, use of technology, time management, strengths and areas for improvement using Likert scales giving a total out of 35.ResultsThe most common concerns cited were overcoming the hierarchical difference and a selection bias in both mentors and mentees. However, no participant experienced this hierarchical difference through the reverse mentoring process and no relationships were negatively affected. Mentors became more confident in feeding back to seniors (23 vs 29 out of 35, p=0.04) most evident in clinical practice and areas to improve (3 vs 4 out of 5, p=0.041 and 3 vs 5 out of 5, p=0.041, respectively).ConclusionWe present the first study of reverse mentoring in an NHS clinical setting. Initial concerns with regard to damaged relationships and hierarchical gradients were not experienced and all participants perceived that they benefited from the process. Reverse mentoring can play a role in engaging and training future leaders at junior stages and provide a means for consultants to receive valuable feedback from junior colleagues.

Background and aims Capsule endoscopy (CE) interpretation requires the review of many thousands of images, with lesions often limited to just a few frames. In this study we aim to determine whether lesion detection declines according to the number of capsule videos read. Methods 32 participants, 16 of which were novices (NR) and 16 experienced (ER) capsule readers took part in this prospective evaluation study. Participants read six capsule cases with a variety of lesions, in a randomly assigned order during a single sitting. Psychomotor Vigilance Tests and Fatigue Scores were recorded prior to commencing and then after every two capsules read. Changes in lesion detection and measures of fatigue were assessed across the duration of the study. Results Mean agreement with the predefined lesions was 48.3% (SD:16.1), and 21.3% (SD:15.1) for the experienced and novice readers respectively. Lesion detection declined amongst experienced reader after the first study (p = 0.01), but remained stable after subsequent capsules read, while NR accuracy was unaffected by capsule numbers read. Objective measures of fatigue did not correlate with reading accuracy. Conclusion This study demonstrates that reader accuracy declines after reading just one capsule study. Subjective and objective measures of fatigue were not sufficient to predict the onset of the effects of fatigue.

Background and study aims Oropharyngeal intubation during Esophagogastroduodenoscopy (EGD) is uncomfortable, associated with aerosol generation and transmission of airborne microbes. Less-invasive alternatives may be better tolerated. In this study, patient tolerance and acceptability of EGD and transnasal endoscopy (TNE) have been compared with magnet-controlled capsule endoscopy (MACE). Patients and methods A comparison of MACE with EGD and TNE in the investigation of dyspepsia was performed. Factors affecting patient tolerance and acceptability were examined using the Endoscopy Concerns Scale (ECS) and Universal Patient Centeredness Questionnaire (UPC-Q). Results Patients were significantly more distressed (scoring least to most distress: 1–10) by gagging (6 vs 1), choking (5 vs 1), bloating (2 vs 1), instrumentation (4 vs 1), discomfort during (5 vs 1) and after (2 vs 1) EGD compared to MACE (all P Conclusions Gagging and choking during instrumentation, the main causes of patient distress during EGD, occurred less during TNE but tolerance, acceptability and patient experience favored MACE.

Background and Aims Acute upper GI bleeding is common and requires investigation with EGD, but endotherapy is not always necessary. Magnetically assisted capsule endoscopy (MACE) uses a capsule steerable by an external magnet and allows examination of the upper GI tract and small bowel, but its role in acute upper GI bleeding has not been assessed. Methods We conducted a prospective cohort study comparing the diagnostic yield of MACE and EGD in patients with suspected acute upper GI bleeding. Patient tolerance, mucosal visibility by MACE, and frequency of small-bowel bleeding were assessed. Whether or not MACE could safely predict discharge of patients was also determined. Results Thirty-three patients were included for analysis (median age, 60 years; 75.8% male). MACE detected more focal lesions (peptic, vascular, and fresh/altered blood without a clear source) than EGD (40 versus 25, respectively, P = .02) but statistical significance was not reached for significant lesions (considered to be the bleeding source; 14 vs 13, respectively, P = 1). Capsule endoscopy identified an additional cause for bleeding in the small bowel in 18%. Visualization by MACE was excellent in most areas; views of the esophagus, gastroesophageal junction, fundus, and duodenal bulb were suboptimal. MACE was better tolerated than unsedated EGD and correctly identified patients who were safe for discharge. Conclusions MACE had higher diagnostic yield for focal lesions and was better tolerated than EGD. It also correctly predicted safe discharge for patients with acute upper GI bleeding. (Clinical trials registration number: NCT02690376.)

Background: Accelerated induction regimens of infliximab have been proposed to improve response rates in patients with steroid refractory acute severe colitis. Aims: We aimed to determine differences in outcome for acute severe ulcerative colitis between accelerated and standard-dose infliximab. Methods: We collected data on hospitalised patients receiving differing regimens of rescue therapy for steroid refractory Acute Severe Ulcerative Colitis. Our primary outcome was 30-day colectomy rate. Secondary outcomes were colectomy within index admission, 90 days and 12 months. We used propensity score analysis with optimal calliper matching using a priori defined high-risk covariates to reduce potential provider selection bias. Results: We included 131 patients receiving infliximab rescue therapy; 102 patients received standard induction and 29 received accelerated induction. In the unmatched cohort, there was no difference by type of induction in 30-day colectomy rates (18% vs. 20%, p=0.45), colectomy during index admission (13% vs. 20%, p = 0.26) or overall colectomy (20% vs. 24%, p= 0.38). In the propensity score-matched cohort of 52 patients, 30-day colectomy (57% vs. 27%, p = 0.048) and index admission colectomy (53% vs. 23%,p =0.045) rates were higher in those receiving standard induction compared to accelerated induction but there was no difference in overall colectomy rates between the 2 groups (57% vs. 31%, p =0.09). There was no significant difference in length of stay or in complication and infection rates. Conclusion: In a propensity score matched cohort, steroid refractory Acute Severe Ulcerative Colitis patients, short-term, but not long-term, colectomy rates appear to be lower in those receiving accelerated induction regimen.

Background The BSG offers a mentorship programme aimed at those in transitional phases of their career and less at experienced consultants. Reverse mentoring, the act of junior persons mentoring seniors, has gained traction in non-healthcare settings as a means of closing the gap between Boomers and Millennials. There is no data on applying this to a medical workforce. We present the first data of real clinical experience. Methods A mixed-methods feasibility study on the practicalities of reverse mentoring complete in two phases. Phase 1: all clinical fellows in a teaching hospital were invited to provide feedback in a group semi structured interview on their supervisors in 7 domains: use of technology, clinical practice, approach to juniors, time management, approachability, strengths and areas for improvement. Phase 2: information was fed back to consultants on a 1-2-1 basis with the opportunity to discuss the points raised. Pre and post mentoring questionnaires were collected. Likert scales were used to assess several aspects on a scale from 0 to 35 and thematic analysis to record participants thoughts. Results A total of 6 clinical fellows participated in the phase 1 feedback session (66.6% male, age range 31–40 years) and agreed to be mentors. All supervising consultants invited agreed to being mentees (80% male, age range 35–65 years) and have been consultants for 5–20 years. Mentoring sessions lasted 45 minutes (range 28–180 minutes) and all felt the time devoted was about right. Both mentors and mentees reported a good or excellent experience. Juniors became more confident in feeding back to seniors after the session (21vs 31, p=0.008) and had a greater understanding of their role as reverse mentors (2.5/5 vs 4/5, p=0.024). Seniors became more aware of how they were viewed after mentoring (25vs 32, p=0.04). All seniors felt this was a useful experience that will change their clinical practice and 80% reported less concern about reverse mentoring afterwards. All participants believed that feedback was important both prior to and after the study (31 vs 33, p=0.196) Common themes highlighted included the benefit of a different perspective to the norm and new ideas which can be implemented. There were concerns raised of the power gradient preventing effective mentoring and risks to relationships, however these were expressed as potential concerns and not experienced. Conclusion The experience of all participants in this feasibility study were positive supporting the benefits of reverse mentoring in a healthcare setting. Junior doctors became better equipped to be future mentors. Consultants were given a new perspective which inspired them to improve their clinical practice and work environment.

Background and Aims Since 2008, a plethora of research studies has compared the efficacy of water-assisted (aided) colonoscopy (WAC) and underwater resection (UWR) of colorectal lesions with standard colonoscopy. We reviewed and graded the research evidence with potential clinical application. We conducted a modified Delphi consensus among experienced colonoscopists on definitions and practice of water immersion (WI), water exchange (WE), and UWR. Methods Major databases were searched to obtain research reports that could potentially shape clinical practice related to WAC and UWR. Pertinent references were graded (Grading of Recommendations, Assessment, Development and Evaluation). Extracted data supporting evidence-based statements were tabulated and provided to respondents. We received responses from 55 (85% surveyed) experienced colonoscopists (37 experts and 18 nonexperts in WAC) from 16 countries in 3 rounds. Voting was conducted anonymously in the second and third round, with ≥80% agreement defined as consensus. We aimed to obtain consensus in all statements. Results In the first and the second modified Delphi rounds, 20 proposed statements were decreased to 14 and then 11 statements. After the third round, the combined responses from all respondents depicted the consensus in 11 statements (S): definitions of WI (S1) and WE (S2), procedural features (S3-S5), impact on bowel cleanliness (S6), adenoma detection (S7), pain score (S8), and UWR (S9-S11). Conclusions The most important consensus statements are that WI and WE are not the same in implementation and outcomes. Because studies that could potentially shape clinical practice of WAC and UWR were chosen for review, this modified Delphi consensus supports recommendations for the use of WAC in clinical practice.

ObjectiveTo evaluate the diagnostic yield of investigating dyspepsia with oesophagogastroduodenoscopy (OGD) with or without mucosal biopsy.DesignRetrospective service evaluation study.SettingTwo teaching hospitals: The Royal Hallamshire Hospital and Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, UK.Patients500 patients, 55 years of age and over, who underwent OGD to investigate dyspepsia were included. The study period included a 3-month window. All OGDs were performed on an outpatient basis.InterventionsData were extracted from electronic OGD records within the study period.Main outcome measuresDiagnostic yield provided by endoscopic examination and histological assessment.Results378 patients (75.6%) were reported to have some form of endoscopic abnormality, and 417 patients (83.4%) had biopsies taken. The most common findings at OGD were gastritis (47.2%) and oesophagitis (24.4%). Oesophagogastric malignancy was seen in 1%. Diagnoses made endoscopically or histologically that would not have been appropriately managed by empirical therapies were seen in 16.2%.ConclusionOGD in dyspepsia influences patient management in approximately one-sixth of cases. However, the majority of patients are sufficiently managed withHelicobacter pyloritesting and eradication and/or a trial of proton pump inhibitor therapy. Further non-invasive approaches are needed to identify patients who need endoscopy for biopsy or therapy.

The breakthrough success of capsule endoscopy and device-assisted enteroscopy has inspired researchers to test and push the boundary of these technologies. The authors herein summarize the latest and most significant studies with clinical impact.Competing capsule endoscopy models have enriched the platform of this wireless device. The role of capsule endoscopy in Crohn's disease is expanding as we learn more of the significance of disease distribution and response to treatment. The benefit of capsule endoscopy in abdominal pain has previously been sceptical, but may have a role. Device-assisted enteroscopy demonstrates significant benefit in the management of patients with Crohn's disease and Peutz-Jeghers syndrome. On the contrary, long-term data suggest that endotherapy to small bowel angioectasia may not be as beneficial to patients as we once thought. The role of device-assisted enteroscopy in novel territory, including coeliac disease and endoscopic retrograde cholangiopancreatography, continues to be tested.The limit of capsule endoscopy and enteroscopy is yet to be reached. Accumulating long-term data alludes to the benefits of our current practice while spawning novel indications for small bowel endoscopy.

Introduction Oesophagogastro duodenoscopy (OGD) is undertaken by 1% of UK population per year but is often poorly tolerated. Capsule endoscopy is well tolerated. Robot controlled magnet assisted capsule endoscopy (MACE) allows control of a capsule endoscope within a pool of swallowed water resulting in a non-invasive endoscopic examination of the upper GI tract. We examine whether there is a difference in the endoscopic views between MACE and OGD. Methods Patients referred for the endoscopic investigation of dyspepsia were recruited. Upper GI MACE examinations were performed followed by OGD. Endoscopic views of upper GI landmarks on MACE and video recordings of tandem OGDs are graded (0- no views, 1- Poor:>75% obscured, 2- Suboptimal:>50% obscured, 3- Reasonable: Results Sixteen (peroral n=15, transnasal n=2) patients (median age of 49, female 76%) were included. Mean examination time for MACE was longer at 46.4 minutes compared to conventional gastroscopy of 4.7 minutes (p Conclusions Unblinded comparisons suggest gastric landmark views are excellent and compared to swifter gastroscopy studies, may better visualise the body and fundus of the stomach. On the other hand, oesophageal and D1 views are superior with OGD and active transpyloric passage into the duodenum using the magnetic fields was limited. This endoscopic view score needs validation by blinded independent parties. Further work is required to develop oesophageal examination techniques using MACE.

Background Small-bowel capsule endoscopy is advocated and repeat upper gastrointestinal (GI) endoscopy should be considered for evaluation of recurrent or refractory iron deficiency anemia (IDA). A new device that allows magnetic steering of the capsule around the stomach (magnetically assisted capsule endoscopy [MACE]), followed by passive small-bowel examination might satisfy both requirements in a single procedure. Methods In this prospective cohort study, MACE and esophagogastroduodenoscopy (EGD) were performed in patients with recurrent or refractory IDA. Comparisons of total (upper GI and small bowel) and upper GI diagnostic yields, gastric mucosal visibility, and patient comfort scores were the primary end points. Results 49 patients were recruited (median age 64 years; 39 % male). Combined upper and small-bowel examination using the new capsule yielded more pathology than EGD alone (113 vs. 52; P Conclusion Combined examination of the upper GI tract and small bowel using the MACE capsule detected more pathology than EGD alone in patients with recurrent or refractory IDA. MACE also had a higher diagnostic yield than EGD in the upper GI tract and was better tolerated by patients.

Introduction Capsule endoscopy may have a role in triaging patients with suspected acute upper gastrointestinal (GI) bleeding who need further invasive investigation. Method The Mirocam Navi (Intromedic Ltd., Korea) is a single camera capsule endoscope steerable by a handheld magnet. Magnetically assisted capsule endoscopy (MACE) was performed in stable patients with suspected acute upper GI bleeding and a decision made as to whether same day discharge was appropriate, prior to gastroscopy (OGD) performed by a different, blinded endoscopist followed by standard care by the admitting team during which small bowel capsule endoscopy was completed. Diagnostic yield and comfort were compared. Potential impact on hospital stay was examined and MACE mucosal visualisation quality was assessed. Results A total of 90 upper GI lesions were detected in 30 patients (80% male, median age 57 years (IQR=26)): 21 (23%) concomitantly identified by MACE and OGD, 49 (54%) by MACE alone and 20 (22%) by OGD alone (CI 0.05–0.58; p=0.0007). MACE and OGD concomitantly detected 50% of major pathologies (gastric and duodenal ulcers and oesophageal and gastric varices (n=2 each)). MACE alone identified 31% (D1 ulcers (n=4) and varices (n=1)) whereas OGD alone identified three D1 ulcers (19%; p=0.7). Ulcers (all classified as Forest class III at OGD) missed by MACE were due to rapid D1 transit and insufficient imaging. Review of small bowel images identified additional causes for GI bleeding distal to D2 in five cases: small bowel lymphoma (n=1), angioectasia (n=2), fresh bleeding in the proximal and distal small bowel with no culprit lesion seen (n=1 for each). MACE correctly suggested safe discharge for 21/21 patients. The median hospital stay of uncomplicated admissions where MACE suggested discharge was 53 (range 14–103) hours. Pain, discomfort and distress scores were lower with MACE than OGD (p 2 =133 (p Conclusions MACE has better diagnostic yield than OGD in suspected upper GI bleeding (with both modalities missing lesions), is better tolerated and used ‘at the front door’ might allow immediate discharge for two thirds of patients saving a median hospital stay for each of over two days. In addition, it suggests that about 10% of suspected upper GI bleeding may have a small bowel source.

Introduction Confirmed (visual) passage of an intact Agile (Medtronic Ltd) patency device (which contains a radiofrequency (RF) tag), absence of an RF signal or failure to identify the patency device on radiological imaging 30 hours post-ingestion predicts safe capsule endoscopy. [Hererrias et al., Gastrointest Endosc 2008] Premature dissolution of the device would give false reassurance that capsule endoscopy could be performed safely. Methods Retrospective review of 2017 patency capsule database. Results RF scan was performed on 490 patients 30 hours after swallowing an Agile patency device and, if an RF signal was present, patients went for a scout film and, where indicated, limited CT scan. Premature dissolution occurred in four cases (0.8%). All had normal colonoscopies and symptoms of Crohn’s disease (two of whom had abnormal, one normal and one no prior small bowel imaging). In two, the scout films were reported normal, but a persistent RF signal prompted re-examination of the films and the identification of the RF tags. In the two later cases, the RF tag alone or with adjacent high density material (consistent with barium) was recognised as demonstrating premature dissolution. Conclusions This is the first report of premature dissolution of the Agile patency device which occurred in about 1:100 cases. If the RF signal remains 30 hours post ingestion, care should be taken to look for the RF device on radiological imaging when the intact patency device (see figure 1) is not evident. The tags may be confused with surgical clips, IUCDs, metallic items of clothing and jewellery.

Introduction Gastroscopy (OGD) is invasive and not always well tolerated. The NaviCam® (Ankon Technologies Co. Ltd., Shanghai, China) combines capsule endoscopy technology with external robot magnetic control. Operator joysticks command the robot to steer the capsule within the stomach. Real-time visualisation is displayed on two workstation monitors. When compared to OGD, the NaviCam® has already demonstrated high sensitivity and specificity for identifying focal gastric lesions.1 The focus of this study was to grade imaging quality and patient tolerance of the NaviCam®. Method Patients with dyspepsia were recruited. Patients swallowed 100 mls of water (containing 10 mls simethicone) 15 min prior to 1L of water followed by the NaviCam®. Clarity of views and adequacy of gastric distension were assessed (1, poor; 2, reasonable; 3, good), as was completeness of views of the oesophagogastric mucosa (1,>75% obscured; 2,>50% obscured; 3, Results Eighteen participants were included (mean age 53±16.1 years, 27.8% male). The NaviCam could be held stationary within the stomach (resisting peristaltic waves) and could cartwheel over rugal folds to a chosen proximal location using a preset programme activated by a ‘shoot’ button on the joystick. Mean examination duration was 25±3.4 mins. Mean clarity (2.3±0.7) and distension scores (2.9±0.3) were good. Complete views (5±0) for all areas of the gastric body (greater and lesser curvature, anterior and posterior wall) and distal stomach (antrum and pylorus) were achieved. Views of the oesophagus (4.3±1.3) and proximal stomach (cardia, 4.9±0.2; fundus 4.8±0.3) were also good. Duodenal images were not assessed real-time (but are provided after the capsule traverses the pylorus). Tolerance scores for anxiety, discomfort and pain were all lower with MACE compared to OGD (2.2±1.4 vs 5.8±3, 1.3±1 vs 4.9±3, 2.4±2.4 vs 3.4±2.5, respectively; p Conclusion The NaviCam® demonstrates excellent oesophagogastric views. The NaviCam® is extremely well tolerated compared to OGD and patients experience significantly fewer undesirable symptoms associated with upper GI endoscopy. Reference . Liao Z, et al. Clin Gastroenterol Hepatol2016;14(9):1266–73.e1.

Introduction High amylase does not always signify acute pancreatitis and it can occur due to focal areas of ischaemia in the pancreas due to mechanical stress during double balloon enteroscopy (DBE). The use of rectal NSAIDs to prevent post DBE pancreatitis has never been explored unlike in ERCP where patients receiving rectal NSAIDs have a lower incidence of pancreatitis. Methods Patients who received rectal indomethacin (100 mg) 30 min prior to antegrade DBE were compared to a control group who did not receive indomethacin before the above protocol was implemented. Serum amylase and CRP 3 hours before and after DBE were compared. Results 240 patients (56 indomethacin, 184 controls; 50% males; mean age 58.5±SD14.0) were included. Indications included IDA (37.5%), obscure overt gastrointestinal bleeding (17.1%), suspected crohn’s disease and strictures (17.9%), complication of coeliac disease (1.3%), small bowel (SB) tumours/polyps (17.9%), others (8.3%). Patients had a median of 13.0±SD13.0 passes, 65.0±SD25.0 min, 170±SD52.0 cm of SB examined. 36.3% underwent a therapeutic procedure during DBE: APC/adrenaline/clips (27.5%), foreign body removal (0.4%), polypectomy (8.3%). Only 4 (1.67%; 2 females) patients developed pancreatitis, all prior to implementation of indomethacin into the local protocol. They had a median age of 47.0±SD3.20 years, 11±SD29.4 passes, 90±SD52.0 min, 150 cm ±SD64.2 cm of SB examined and median hospital stay of 14±SD3.70 days. 3 had polypectomies. 2 episodes occurred in the same patient. All had evidence of pancreatitis on CT scan. None of the patients received indomethacin before DBE. Mean amylase (51.6±SD22.7 vs 143.0±SD143.9 IU/L p=0.0001) and CRP (13.0±SD46.1 vs 17.3±SD81.7 mg/L p=0.0001) after the procedure were significantly higher than before the procedure. Females had a significantly higher amylase than males post procedure (155.2 vs 130.7 IU/L p=0.017). Mean amylase 3 hours after DBE was significantly lower in patients who received indomethacin (114 vs 152) (p=0.044). 83.9% had a rise in amylase in the indomethacin group compared to 92.2% controls.(p=0.064). Whilst there was no correlation between post-procedure amylase (p=0.552), CRP (p=0.058) and duration of the procedure, there was a significant association between amylase post procedure and length of SB examined.(Spearman’s rho 0.186; p=0.005) Conclusions This study identifies a role for rectal indomethacin in patients undergoing antegrade DBE. We have demonstrated that rectal indomethacin reduces amylase post DBE and no patients given indomethacin experienced pancreatitis. Larger studies are required to assess if this also transforms into lowering risk or severity of pancreatitis.

Introduction Repeat upper gastrointestinal (GI) examination and small bowel capsule endoscopy should be considered in iron deficiency anaemia (IDA) when recurrent/refractory. Magnetically assisted capsule endoscopy (MACE) using a handheld magnet to steer the MiroCam Navi (Intromedic Ltd., Korea) capsule around the stomach followed by passive small bowel transit might satisfy both requirements as a single procedure. Methods MACE was performed in patients with recurrent/refractory IDA who were due gastroscopy (OGD). Total (upper GI and small bowel) and upper GI diagnostic yields and patient tolerance of the two modalities were compared. Assuming a diagnostic yield of 25% and 55% for OGD and small bowel capsule endoscopy (SBCE) respectively in recurrent/refractory IDA, 41 patients were needed to achieve 80% power and 5% two-sided significance. McNemar’s test was used to measure differences in paired proportions. To allow for withdrawal, 50 patients were recruited. MACE mucosal visualisation was also assessed. Results OGD was performed within 2 days (IQR=13) of MACE in 49 patients (one failed to attend for OGD; median age 64 years (IQR=13), 39% male). Combined upper and mid-gut examination using MACE and passive SBCE yielded pathology in more patients than OGD alone (32 vs 6 (CI, 0.37 to 0.69); p Conclusions Combined upper GI and small bowel examination with the MiroCam Navi yields more pathology than OGD alone in patients with recurrent/refractory IDA. MACE also has better diagnostic yield than OGD in the upper GI tract and was better tolerated.

AIM To test the feasibility and performance of a novel upper gastrointestinal (GI) capsule endoscope using a nurse-led protocol. METHODS We conducted a prospective cohort analysis of patients who declined gastroscopy (oesophagogastroduodenoscopy, OGD) but who consented to upper GI capsule endoscopy. Patients swallowed the upper GI capsule following ingestion of 1 liter of water (containing simethicone). A series of positional changes were used to exploit the effects of water flow and move the upper GI capsule from one gravity-dependent area to another using a nurse-led protocol. Capsule transit time, video reading time, mucosal visualisation, pathology detection and patient tolerance was evaluated. RESULTS Fifty patients were included in the study. The mean capsule transit times in the oesophagus and stomach were 28 s and 68 min respectively. Visualisation of the following major anatomical landmarks was achieved (graded 1-5: Poor to excellent): Oesophagus, 4.8 (± 0.5); gastro-oesophageal junction (GOJ), 4.8 (± 0.8); cardia, 4.8 (± 0.8); fundus, 3.8 (± 1.2); body, 4.5 (± 1); antrum, 4.5 (± 1); pylorus, 4.7 (± 0.8); duodenal bulb, 4.7 (± 0.7); second part of the duodenum (D2), 4.7 (± 1). The upper GI capsule reached D2 in 64% of patients. The mean video reading time was 48 min with standard playback mode and 20 min using Quickview (P = 0.0001). No pathology was missed using Quickview. Procedural tolerance was excellent. No complications were seen with the upper GI capsule. CONCLUSION The upper GI capsule achieved excellent views of the upper GI tract. Future studies should compare the diagnostic accuracy between upper GI capsule and OGD.

Background and aims Magnetically controlled capsule endoscopy (MCE) is a novel technique for which there is no agreed gastric preparation. We aimed to determine an optimal standardized gastric preparation regimen. Methods 120 patients referred for MCE were randomly assigned to gastric preparation with either water alone (A), water with simethicone (B) or water, simethicone and pronase (C). Image quality was assessed using cleanliness and visualization scores, higher scores equating to better image quality. Results The total cleanliness scores were (mean ± SD) 15.83 ± 2.41 (A), 21.35 ± 1.23 (B), and 20.82 ± 1.90 (C). The total visualization scores (mean ± SD) were 10.75 ± 2.02 (A), 15.20 ± 1.32 (B), and 15.08 ± 1.86 (C). While the image quality of the whole stomach in groups B and C were significantly better than group A (P 0.05). MCE detected positive findings in 21 (52.5%), 27 (67.5%) and 21 (53.8%) patients in group A, B and C respectively, with no significant difference between groups (P > 0.5). Conclusions Simethicone swallowed with water prior to MCE produced the optimal gastric mucosal image quality. The addition of pronase had no demonstrable additional benefit.

ObjectiveEvaluate the safety of propofol-assisted double balloon enteroscopy (DBE) in elderly patients against a younger cohort.DesignProspective cohort studySettingAll patients undergoing DBE over a 30-month period were recruited at our tertiary centre.Patients215 procedures in 161 patients were performed. An age cut-off of 65 years and above was used to define those who were elderly.InterventionsPatients were subcategorised into four groups: elderly or young undergoing DBE with propofol or conventional sedation (with midazolam±fentanyl).Main outcome measuresPatient demographics, comorbidities, procedural data, complications, diagnostic and therapeutic yield were compared.ResultsCardiovascular disease and a higher American Society of Anaethesiologists (ASA) status were more prevalent in elderly patients undergoing DBE with propofol (pConclusionCompared with young patients, propofol-assisted DBE in the elderly is safe and has a high diagnostic yield.

Capsule endoscopy (CE) is a first line small bowel investigative modality which provides more sensitive mucosal imaging than comparators. It is a non-invasive, non-irradiating tool well tolerated by patients. The risk of retention of the capsule can be minimised by ensuring luminal patency using the Agile patency device. Research continues into how to minimise missed pathology and variability in the identification of pathology or interpretation of images. The consensus is that bowel preparation using laxatives improves visibility and diagnostic yield. Research includes the development of image recognition software, both to eliminate sequentially identical images to improve viewing speed and to select or enhance images likely to represent pathology. However, careful reading by experienced capsule endoscopists remains the benchmark. This should be performed at a speed comfortable to the viewer, probably at a maximum of 15 frames per second. Some prior experience of endoscopy appears to be helpful for novice capsule endoscopists and formal training on a hands-on training course seems to improve pathology recognition, for novices and for those with CE experience.

Capsule endoscopy first captivated the medical world when it provided a means to visualize the small bowel, which was previously out of endoscopic reach. In the subsequent decade and a half we continue to learn of the true potential that capsule endoscopy has to offer. Of particular current interest is whether capsule endoscopy has any reliable investigative role in the upper gastrointestinal tract. Much research has already been dedicated to enhancing the diagnostic and indeed therapeutic properties of capsule endoscopy. Specific modifications to tackle the challenges of the gut have already been described in the current literature. In the upper gastrointestinal tract, the capacious anatomy of the stomach represents one of many challenges that capsule endoscopy must overcome. One solution to improving diagnostic yield is to utilize external magnetic steering of a magnetically receptive capsule endoscope. Notionally this would provide a navigation system to direct the capsule to different areas of the stomach and allow complete gastric mucosal examination. To date, several studies have presented promising data to support the feasibility of this endeavour. However the jury is still out as to whether this system will surpass conventional gastroscopy, which remains the gold standard diagnostic tool in the foregut. Nevertheless, a minimally invasive and patient-friendly alternative to gastroscopy remains irresistibly appealing, warranting further studies to test the potential of magnetically assisted capsule endoscopy. In this article the authors would like to share the current state of magnetically assisted capsule endoscopy and anticipate what is yet to come.

Dear Editor,We read with interest the review by Pasha et al on the use of various modalities including double balloon enteroscopy (DBE) in patients with obscure gastrointestinal bleeding (OGB) [1]....

Alpha synuclein can be phosphorylated at serine129 (P-S129), and the presence of highly phosphorylated alpha-synuclein in Lewy bodies suggests changes to its phosphorylation status has an important pathological role. We demonstrate that the kinase(s) responsible for alpha-synuclein S129 phosphorylation is constitutively active in SH-SY5Y cells and involves casein kinase 2 activity. Increased oxidative stress or proteasomal inhibition caused significant elevation of P-S129 alpha-synuclein levels. Under these conditions, similar increases in P-S129 alpha-synuclein were found in both sodium dodecyl sulphate lysates and Triton extracts indicating the phosphorylated protein was soluble and did not lead to aggregation. The rate of S129 phosphorylation was increased in response to proteasomal inhibition indicating a higher activity of the relevant kinase. Cells expressing the phosphorylation mimic, S129D alpha-synuclein increased cell death and enhanced sensitivity to epoxomycin exposure. Proteasomal inhibition markedly decreased S129D alpha-synuclein turnover suggesting proteasomal inhibition leads to the accumulation of P-S129 alpha-synuclein through an increase in the kinase activity and a decrease in protein turnover resulting in increased cell death. We conclude that S129 phosphorylation is toxic to dopaminergic cells and both the levels of S129 phosphorylated protein and its toxicity are increased with proteasomal inhibition emphasising the interdependence of these pathways in Parkinson's disease pathogenesis.