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Key points The first #FGDebates of 2021 tackled ‘Controversies in liver transplantation’ in a double-header inspired by the recent liver transplantation guidelines.1 2 The debates stimulated much discussion with nearly 900 tweets from over 100 participants across the two debates. This fantastic interaction generated a cumulative 3.7 million impressions worldwide with both debates ranking in the top 5 #FGDebates of all time for total impressions made. In this article, we aim to discuss the key discussion points from each of the #FGDebates. Liver transplantation for patients with alcohol use disorders (AUDs) has historically been viewed as a controversial area for both the general public and healthcare profession. This was largely due to the perceived ‘self-inflicted’ component and the risk of recidivism post-transplant.3 However, the majority of our attendees felt that it was the correct time to assess our patient with an AUD (figure 1) and alcohol-related liver disease remains the most common aetiology at registration for liver transplantation in the UK with good long-term outcomes.4 A common misconception is that patients require a period of 6 months abstinence prior to referral for assessment. While a period of 3 months abstinence may demonstrate the potential for recompensation, there is no absolute rule for abstinence duration prior to assessment in the UK other than patients must be abstinent.1 However, these patients should be assessed for their individual risk of return to drinking and should …

Over many years the liver transplant community has faced innumerable challenges which have been overcome, leading to increased donor utilization and improved recipient survival[1]. The coronavirus disease (COVID-19) pandemic has generated a set of unique obstacles for organ transplantation with significant reductions in organ donation as well as critical care capacity to facilitate transplantation[2]. Whilst transplant activity internationally continues to increase, ongoing efforts to maximize donor utilization remains vital in addressing the backlog of patients awaiting liver transplantation.

ObjectiveThe COVID-19 pandemic has placed increased strain on healthcare systems worldwide with enormous reorganisation undertaken to support ‘COVID-centric’ services. Non-COVID-19 admissions reduced secondary to public health measures to halt viral transmission. We aimed to understand the impact of the response to COVID-19 on the outcomes of upper gastrointestinal (UGI) bleeds.Design/methodsA retrospective observational multicentre study comparing outcomes following endoscopy for UGI bleeds from 24 March 2020 to 20 April 2020 to the corresponding dates in 2019. The primary outcome was in-hospital survival at 30 days with secondary outcomes of major rebleeding within 30 days postprocedure and intervention at the time of endoscopy.Results224 endoscopies for 203 patients with UGI bleeds were included within this study. 19 patients were diagnosed with COVID-19. There was a 44.4% reduction in the number of procedures performed between 2019 and 2020. Endoscopies performed for UGI bleeds in the COVID-19 era were associated with an adjusted reduced 30-day survival (OR 0.25, 95% CI 0.08–0.67). There was no increased risk of major rebleeding or interventions during this era. Patients with COVID-19 did not have reduced survival or increased complication rates.ConclusionEndoscopy for UGI bleeds in the COVID-19 era is associated with reduced survival. No clear cause has been identified but we suspect that this is a secondary effect of the response to the COVID-19 pandemic. Urgent work is required to encourage the public to seek medical help if required and to optimise patient pathways to ensure that the best possible care is provided.

Introduction: Anxiety and depression in patients awaiting liver transplantation are associated with worse clinical outcomes. However, optimising patient mental health is not routinely addressed in pre-transplant care. Aims: To understand the prevalence of anxiety and depression in patients awaiting transplantation and their access to pharmacological and psychological therapies. Methods: Patients awaiting transplantation were offered screening for anxiety and depression using the Hospital Anxiety and Depression Screening (HADS) tool. Data pertaining to patient demographics and previous treatment for anxiety and depression were recorded and analysed. Findings: Over 50% of patients recorded abnormal scores for anxiety and depression. Of the 19 patients screened, 42% had received treatment for either disorder, and most found the intervention unhelpful due to lack of follow-up appointments and limited understanding of their underlying chronic liver disease. There was a significant association between female sex and screening positive for depression. Conclusion: Anxiety and depression are prevalent in patients awaiting liver transplantation. The integration of a psychologist into the transplantation multidisciplinary team may improve patient outcomes.

We previously demonstrated a distinct hepatic microRNA (miRNA) signature (down-regulation of miRNA-23a, -150, - 200b, -503, and -663 and up-regulation of miRNA-20a) is associated with successful regeneration in auxiliary liver transplantation (ALT). This study aimed to evaluate whether the serum expression of this regeneration-linked miRNA signature is associated with clinical outcomes in acute and chronic liver disease. These were represented by patients with acetaminophen-induced acute liver failure (ALF; n = 18) and patients with hepatitis C virus (HCV) undergoing treatment with direct-acting antivirals (n = 56), respectively. Patients were grouped depending on their clinical outcome. Global serum miRNA expression was analyzed using polymerase chain reaction (PCR) arrays and selected miRNA expression using targeted PCR. We demonstrate that specific regeneration-linked miRNAs discriminate outcomes in both clinical scenarios. We further show that miRNA-20a, -23a, -150, -200b, -503, and -663 undergo concordant changes in expression in 3 distinct clinical settings: liver regeneration accompanying successful ALT, clinical recovery after ALF, and clinical recompensation after cure of HCV. This miRNA signature represents a potentially novel biomarker to predict outcome and optimize patient selection for liver transplantation in both acute and chronic liver disease.

IntroductionLiver transplantation (LT) remains integral to the management of end-stage chronic liver disease (CLD). However, referral thresholds and assessment pathways remain poorly defined. Distance from LT centre has been demonstrated to impact negatively on patient outcomes resulting in the development of satellite LT centres (SLTCs). We aimed to evaluate the impact of SLTCs on LT assessment in patients with CLD and hepatocellular carcinoma (HCC).MethodsA retrospective cohort study was undertaken including all patients with CLD or HCC assessed for LT at King’s College Hospital (KCH) between October 2014 and October 2019. Referral location, social, demographic, clinical and laboratory data were collected. Univariable and multivariable analyses (MVA) were performed to assess the impact of SLTCs on patients being accepted as LT candidates and contraindications being identified.Results1102 and 240 LT assessments were included for patients with CLD and HCC, respectively. MVA demonstrated significant associations with; patients living greater than 60 min from KCH/SLTCs and LT candidacy acceptance in CLD, and less deprived patients and LT candidacy acceptance in HCC. However, neither variable was associated with identification of LT contraindications. MVA demonstrated that referrals from SLTCs were more likely to result in acceptance of LT candidacy and less likely to result in a contraindication being identified in CLD. However, such associations were not demonstrated in HCC.ConclusionSLTCs improve LT assessment outcomes in CLD but not HCC reflecting the standardised HCC referral pathway. Developing a formal regional LT assessment pathway across the UK would improve equity of access to transplantation.

ObjectiveThe increasing prevalence of liver disease in the UK means there is a pressing need to expand the hepatology workforce. This survey aims to evaluate current hepatology training provision, and trainee attitudes towards future careers in hepatology.MethodAn electronic survey was distributed to higher specialty gastroenterology and hepatology trainees in the UK between March and May 2022.Results138 trainees completed the survey covering all training grades and regions of the UK. 73.7% reported receiving adequate hepatology training currently, with 55.6% intending to become future hepatologists. Trainee preference for future hepatology consultant posts in specialist liver centres were almost threefold higher compared with district general hospitals (60.9% vs 22.6%). All trainees, irrespective of training grade reported high confidence in managing decompensated cirrhosis in both inpatient and outpatient settings. Senior trainees (grade ST6 and higher), without advanced training programme (ATP) experience reported significantly lower confidence in managing viral hepatitis, hepatocellular carcinoma and post-transplant patients compared with equivalent trainees with ATP experience. For junior trainees (IMT3–ST5), remaining in their current deanery was the most important factor when considering future hepatology training application.ConclusionsThere is a significant need to deliver widely available training on the management of complex liver disease to improve non-ATP trainee confidence. Innovative job planning strategies are required to encourage trainees to pursue careers outside of specialist liver centres. Expansion of hepatology training networks with wider geographical coverage are needed to address the growing need for more hepatologists around the UK.

Liver transplantation (LT) is a life-saving treatment for patients with end-stage chronic liver disease. Given the negative impact of distance from transplant centre on patient outcomes,1 2 King’s College Hospital (KCH) developed a network of satellite liver transplant centres (SLTCs) in Plymouth and Belfast to optimise access to LT.3 These centres deliver transplant assessment and comparable post-LT care to conventional LT centres.4 However, patients are still required to complete their assessments at KCH prior to listing. The COVID-19 pandemic has caused unprecedented strain on health services globally. The UK LT programme was affected with transplantation and assessment occurring only in patients with urgent need.5 However, patients at SLTCs were also subject to travel restrictions which further disadvantaged them compared with local patients. A virtual transplant assessment (VTA) pathway was developed to allow SLTCs to assess their patients for LT locally and to discuss listing without attendance at KCH. Here, we describe our first experiences with this novel pathway. We retrospectively included all patients from both SLTCs who completed an LT assessment between April 2020 and April 2021. The decision for a VTA was made by consensus decision from the …

Like many across the world, in January we tend to contemplate what we hope to achieve in the upcoming year. Of course, these are not hard and fast objectives due to a combination of overambition (which frequently leads to my gym goals being modified) and unforeseen circumstance. It would be an understatement to say that 2020 was affected by unforeseen circumstance. Nevertheless, as healthcare professionals we have united in our response to the COVID-19 pandemic and in our attempts to continue to provide a quality service for our patients. Here, we look back over the past year and review what we have learnt about COVID-19 and its effects on how we work as gastroenterologists as well as what questions remain unanswered. The pandemic was initially accompanied with an explosion of case reports. Flicking through Twitter on the commute, one learnt that ‘COVID-19 causes pancreatitis1 ’, ’COVID-19 causes encephalitis2 ’ and ‘COVID-19 causes orchitis3 ’ which left you wondering what inflammatory condition the disease was not associated with. It soon became apparent that gastrointestinal symptoms were not uncommon and that they may be associated with a more severe disease phenotype.4 5 Abnormal liver function tests are frequently observed and may be associated with a more severe disease phenotype.6 7 Whether or not this represents a direct effect of SARS-CoV-2 infection is …

Background The development of delirium has been previously demonstrated to be associated with an increased risk of mortality and length of stay post liver transplant (LTx) with multiple risk factors being identified in previous studies. In this study, we have aimed to identify the most important variables associated with the onset of post-LTx delirium and understand the effect on length of stay (LOS). Methods All liver transplants for chronic liver disease between 1 August 2012 and 1 August 2017 were included (n = 793). Data were collected for analysis retrospectively from electronic patient records. Results Delirium is associated with an overall increased hospital and ICU LOS but not one-year mortality. The risk of developing post-LTx delirium was the greatest among patients: with post-LTx sepsis, who required renal sparing immunosuppression, who received donation after cardiac death (DCD) grafts and who were older. Patients with autoimmune hepatitis, primary biliary cholangitis or primary sclerosing cholangitis seemed to be at lower risk of post-LTx delirium. However, global patient LOS was only prolonged in patients with sepsis and renal failure. Conclusion Many of the risk factors previously described to be associated with the development of post-LTx delirium were not demonstrated to be significant in this study. Sepsis, renal failure, older age and DCD use are associated with delirium post-LTx. It is unclear if this syndrome is an independent risk factor for increased LOS or if it is a symptom of well established syndromes associated with increased LOS. The role for prophylactic strategies to reduce the incidence of post-LTx delirium is therefore unclear.

Acute liver failure (ALF) is a rare but life-threatening clinical syndrome with a broad range of causes. Significant improvements in outcome have occurred over the last 50 years, resulting not only from incremental improvements in specialist critical care and a step-change following the introduction of transplantation for this indication, but also better and more effective treatment started early at the site of first presentation.1 2 Emergency liver transplantation (LTx) remains an important intervention and the decision regarding the need for LTx remains key to management, though non-transplant therapies now appear effective for many causes of the condition. In this short review, we will outline issues in the recognition and management of ALF and ongoing challenges in its treatment.

Despite concerns that patients with liver transplants might be at increased risk of adverse outcomes from COVID-19 because of coexisting comorbidities and use of immunosuppressants, the effect of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection on this patient group remains unclear. We aimed to assess the clinical outcomes in these patients.In this multicentre cohort study, we collected data on patients with laboratory-confirmed SARS-CoV-2 infection, who were older than 18 years, who had previously received a liver transplant, and for whom data had been submitted by clinicians to one of two international registries (COVID-Hep and SECURE-Cirrhosis) at the end of the patient's disease course. Patients without a known hospitalisation status or mortality outcome were excluded. For comparison, data from a contemporaneous cohort of consecutive patients with SARS-CoV-2 infection who had not received a liver transplant were collected from the electronic patient records of the Oxford University Hospitals National Health Service Foundation Trust. We compared the cohorts with regard to several outcomes (including death, hospitalisation, intensive care unit [ICU] admission, requirement for intensive care, and need for invasive ventilation). A propensity score-matched analysis was done to test for an association between liver transplant and death.Between March 25 and June 26, 2020, data were collected for 151 adult liver transplant recipients from 18 countries (median age 60 years [IQR 47-66], 102 [68%] men, 49 [32%] women) and 627 patients who had not undergone liver transplantation (median age 73 years [44-84], 329 [52%] men, 298 [48%] women). The groups did not differ with regard to the proportion of patients hospitalised (124 [82%] patients in the liver transplant cohort vs 474 [76%] in the comparison cohort, p=0·106), or who required intensive care (47 [31%] vs 185 [30%], p=0·837). However, ICU admission (43 [28%] vs 52 [8%], p0·0001) and invasive ventilation (30 [20%] vs 32 [5%], p0·0001) were more frequent in the liver transplant cohort. 28 (19%) patients in the liver transplant cohort died, compared with 167 (27%) in the comparison cohort (p=0·046). In the propensity score-matched analysis (adjusting for age, sex, creatinine concentration, obesity, hypertension, diabetes, and ethnicity), liver transplantation did not significantly increase the risk of death in patients with SARS-CoV-2 infection (absolute risk difference 1·4% [95% CI -7·7 to 10·4]). Multivariable logistic regression analysis showed that age (odds ratio 1·06 [95% CI 1·01 to 1·11] per 1 year increase), serum creatinine concentration (1·57 [1·05 to 2·36] per 1 mg/dL increase), and non-liver cancer (18·30 [1·96 to 170·75]) were associated with death among liver transplant recipients.Liver transplantation was not independently associated with death, whereas increased age and presence of comorbidities were. Factors other than transplantation should be preferentially considered in relation to physical distancing and provision of medical care for patients with liver transplants during the COVID-19 pandemic.European Association for the Study of the Liver, US National Institutes of Health, UK National Institute for Health Research.

Background & Aims Acetaminophen (APAP)-induced acute liver failure (ALF) remains the most common cause of ALF in the Western world. Conventional prognostic models, utilising markers of liver injury and organ failure, lack sensitivity for mortality prediction. We previously identified a microRNA signature that is associated with successful regeneration post-auxiliary liver transplant and with recovery from APAP-ALF. Herein, we aimed to use this microRNA signature to develop outcome prediction models for APAP-ALF. Methods We undertook a nested, case-control study using serum samples from 194 patients with APAP-ALF enrolled in the US ALF Study Group registry (1998-2014) at early (day 1-2) and late (day 3-5) time-points. A microRNA qPCR panel of 22 microRNAs was utilised to assess microRNA expression at both time-points. Multiple logistic regression was used to develop models which were compared to conventional prognostic models using the DeLong method. Results Individual microRNAs confer limited prognostic value when utilised in isolation. However, incorporating them within microRNA-based outcome prediction models increases their clinical utility. Our early time-point model (AUC = 0.78, 95% CI 0.71–0.84) contained a microRNA signature associated with liver regeneration and our late time-point model (AUC = 0.83, 95% CI 0.76–0.89) contained a microRNA signature associated with cell-death. Both models were enhanced when combined with model for end-stage liver disease (MELD) score and vasopressor use and both outperformed the King’s College criteria. The early time-point model combined with clinical parameters outperformed the ALF Study Group prognostic index and the MELD score. Conclusions Our findings demonstrate that a regeneration-linked microRNA signature combined with readily available clinical parameters can outperform existing prognostic models for ALF in identifying patients with poor prognosis who may benefit from transplantation. Lay summary While acute liver failure can be reversible, some patients will die without a liver transplant. We show that blood test markers that measure the potential for liver recovery may help improve identification of patients unlikely to survive acute liver failure who may benefit from a liver transplant.

Background The COVID-19 pandemic has placed increased strain on healthcare systems worldwide with enormous reorganisation undertaken to support ‘COVID-centric’ services. Non-COVID-19 admissions have been shown to have reduced due to public health measures to halt viral transmission. We aimed to understand the impact of the response to the COVID-19 pandemic on the outcomes of upper gastrointestinal bleeds (UGI). Methods A pan-London retrospective observational multi-centre study comparing outcomes following endoscopy for UGI bleeds from 24th March 2020 to 20th April 2020 to the corresponding dates in 2019. Primary outcome was in-hospital survival at 30 days with secondary outcomes of major re-bleeding within 30 days post-procedure and intervention at time of endoscopy. Results 224 endoscopies for 203 patients with UGI bleeds were included within this study. 19 patients were diagnosed with COVID-19. There was a 44.4% reduction in the number of procedures performed between 2019 and 2020. Endoscopies performed for UGI bleeds in the COVID-19 era were associated with an adjusted reduced 30-day survival (OR 0.25, 95% CI 0.08–0.67) (figure 1). There was no increased risk of major re-bleeding or interventions during this era. Patients with COVID-19 did not have adjusted reduced survival or adjusted increased complication rates. Conclusions Endoscopy for UGI bleeds in the COVID-19 era is associated with reduced survival. No clear cause has been identified but we suspect this is a secondary effect of the response to the COVID-19 pandemic. Urgent work is required to encourage the public to seek medical help if required and to optimise patient pathways to ensure that the best possible patient care is provided.

Background Acute liver failure (ALF) remains a rare but life-threatening condition which requires early prognostication for transplantation (LTx). Existing models such as the King’s College Criteria (KCC) lack sensitivity. We have previously demonstrated the potential for regeneration linked miRNA to perform as biomarkers in acute and chronic liver disease. The aim of this study was to develop a miRNA-based prognostic model for acetaminophen (APAP) ALF. Methods Samples were provided by the US ALF Study Group. We assessed serum miRNA expression from 193 patients (94 survivors, 89 non-survivors) with APAP-ALF at two time points (early; day 1, late; day 3–5). Transplanted patients were excluded. A panel of 24 miRNA identified from our previous studies were analysed. Multiple logistic regression was used to create early and late miRNA outcome prediction models. Clinical data were incorporated to improve prognostication. Results Early up-regulation of miR-150 and down-regulation of -16–2 were associated with mortality. The early detection of miR-20a and absence of miR-149 were associated with mortality. Late up-regulation of miR-30a and down-regulation of -122, 16–2 and -21 were significantly associated with mortality. Late detection of miR-149, -17 and -191 were associated with mortality. Prognostic models were made for early and late miRNA expression. The early model contained miRNA associated with regeneration (miR-20a, -27a, -140, -150, -191) and achieved an area under the receiver operator curve (AUC) of 0.78 (95% CI 0.71–0.84, p Conclusion We demonstrate that specific serum miRNA have prognostic value as biomarkers in ALF. Our early model utilised regeneration linked miRNA whereas our late model utilised cell-death linked miRNA; this may signify mechanistic differences at early and late time points which determine patient survival.

Background Obtaining a CCT (Certificate of Completion of Training) in Hepatology requires 24 months of dedicated Hepatology training. The non-academic pathway includes an advanced training program (ATP) year which is nationally competitive (17 posts) and often geographically challenging. Shape of Training will enforce a reduction in Gastroenterology training to 4 years requiring trainees to make earlier and more restrictive career decisions (e.g. dropping colonoscopy), and demands training program designers to provide sufficient timely training opportunities while meeting workforce requirements. Of note, the number of Hepatologists nationally is insufficient. With respect to Hepatology training, we sought to gauge the opinions of ST3/4 Gastroenterology trainees to help inform program design. Methodology Quantitative and qualitative data was collected using anonymised questionnaires which were completed by trainees attending the BSG-led ‘Introduction to Gastroenterology Day 2019’ with subsequent framework analysis of qualitative data. Results 44 trainees completed the questionnaire and 32 (73%) are considering a career in Hepatology (5 ‘definitely’, 17 ‘probably’, 10 ‘maybe’). Reasons include: positive clinical experiences, Hepatology patients and disease pathogenesis, and personal circumstances (mainly geographical). 5/32 (16%) aim to work in a Level 3 centre, 15/32 (47%) in a level 2 centre, 3/32 (9%) in a district general hospital (DGH) with the remainder undecided. Of note (considering the whole dataset), 5/44 (11%) are unsure if there is a transplant centre in their deanery. 10/32 (31%) would be able to move and 7/32 (22%) would want to move for an ATP. 16/32 (50%) trainees considering Hepatology favour current national allocation, regarding it as a fair process. The remaining 16/32 (50%) favour local allocation largely due to availability of level 2/3 centres in their deanery. Of the 22 trainees who are ‘probably’ or ‘definitely’ considering Hepatology, 12/22 (55%) are willing to drop colonoscopy training (including 4/5 (80%) who are ‘definitely’ considering Hepatology). Discussion Our results suggest that a significant proportion of early trainees are interested in a career in Hepatology providing reassurance regarding any potential increase in ATPs. Furthermore, outcomes regarding dropping colonoscopy (as necessitated by a shorter training program) are reassuring. Trainees are less interested in DGH Hepatology which is concerning as this is where the need is (Lancet Commission 2019). National ATP allocation is generally supported but would benefit from greater post coverage geographically. Providing trainees with salient information early- ideally prior to commencing specialty training- will facilitate decision making (including choosing or moving deaneries) to permit successful career planning.

Background Common variable immunodeficiency (CVID) is a rare primary B-cell immunodeficiency disorder associated with multisystem complications of impaired humoral immunity. CVID is characterized by impaired adaptive responses to pathogen challenge and a paradoxical predisposition to a wide range of autoimmune and neoplastic complications. Methods We present a case series describing our experience of liver transplantation in two patients with CVID and perform a comprehensive literature review of post-transplant complications and survival outcomes detailing the global experience of 30 reported cases of adult liver transplantation for common variable immunodeficiency-related liver disease (CVIDrLD). Results Liver transplantation in CVIDrLD is frequently complicated by atypical infections, autoimmune complications and graft recurrence and is associated with suboptimal long term survival outcomes post-transplantation in comparison to established listing indications for liver transplantation; this is further compounded (median survival 3 vs. 5 years) when removing patients with concomitant chronic hepatitis C infection from the survival analysis. Conclusions Liver transplantation is associated with poor overall survival outcomes and careful consideration should be given to the phenotype and severity of immunodeficiency, the presence of chronic pathogen colonisation and the extrahepatic burden of disease at the time of assessment. At present, despite careful patient selection, survival post-transplant outcomes fall below acceptable listing thresholds, necessitating a conservative approach to consideration of single organ listing in this context with current available treatments. Patients with a secondary aetiological factor for liver disease may perform better post-transplant.

Aims and objectives This study aimed to explore the experiences of liver transplant recipients during their journey through the treatment and their need for psychotherapeutic support related to this process. Background Over time, measures of survival and quality of life in liver transplant recipients have continued to improve but their emotional needs remain under explored. In the longer-term recovery from transplantation, the focus shifts from physical health to psychological health. In the UK, there are no known embedded adult psychological services in liver transplant centres to react to this need. Design A qualitative descriptive design was used. Methods Grounded theory analysis was used to study the narratives of six adult liver transplant recipients. Through a process of coding, conceptual categories were established to describe the participant experiences. The study adhered to the EQUATOR checklist, SRQR. Results Four categories emerged that were related to the experience of liver transplantation for the recipients. These were a process of adjustment, the phenomenon of waiting, liver transplant as a transformative experience and on the value of support. The participants identified a lack of psychotherapeutic support provided by the liver transplant service and felt that an embedded psychotherapeutic service would promote accessing such support during challenging times. Conclusion Through the process of liver transplantation, recipients experience challenges with adjustment, waiting, feeling transformed and they value support with these feelings. In correlation with other studies, the findings of this study highlight the need for providing psychotherapeutic support within liver transplant services. Relevance to clinical practice The study provides evidence to support recommendations for a conjoined psychotherapy service within liver transplant services to support patients with their holistic needs.

One in 10 patients attends general practice with gastrointestinal symptoms.1 Irritable bowel syndrome (IBS) is typified by abdominal discomfort or pain, and bloating with disturbed defecation.2 It affects 10–20% of the general public,2 but it is difficult to define the prevalence of the disorder as it varies with different diagnostic criteria and many patients with IBS symptoms do not seek medical advice. The challenge for GPs is how to differentiate IBS from inflammatory bowel disease (IBD), which share a number of overlapping symptoms, enabling more appropriate referral to secondary care. The prevalence of IBS in general practice is far greater than IBD, which is 0.1–0.2% for ulcerative colitis and 0.05–0.1% for Crohn’s disease respectively.2 With significant demand for gastroenterology consultations and endoscopic investigations, a diagnostic pathway enabling GPs to confidently diagnose IBS will benefit both patients and secondary care gastroenterology services. The rate of colonoscopy procedures in England among primary care trusts varied from 71.6 to 194.1 per 10 000 of the population.1 The test is invasive and can be unpleasant for patients, and costs around £650 per procedure. It is estimated that the outcome of over 60% of colonoscopies performed in young patients are normal and therefore potentially avoidable. The development of alternative non-invasive tests accessible to primary care physicians is desirable and there is growing evidence …

Depression has major health and social consequences. There is concern that general practitioners (GPs), who manage most depression in primary care, are reluctant to use assessment tools such as questionnaires that might improve diagnosis and management. A Cochrane systematic review has recommended qualitative exploratory studies to explore the impact of questionnaires on GP management.To identify effects of using mental health questionnaires on views of GPs managing depression, and how this might influence patient care.Qualitative, formative evaluation using principles of grounded theory in analysis of semi-structured interviews and focus groups before and after introducing the mental health questionnaire.Four practices in South London.Twenty GPs, of whom four contributed to the pilot only, and 16 completed the main study.Identification of changes in GP views as a result of using the questionnaire with patients.Three themes emerged from analysis of GP views on managing depression: control and responsibility; the doctor-patient relationship, and support for the doctor. These were influenced by GPs' experience (years in practice), and perceived time spent dealing with depression (involvement). Use of the questionnaire enabled more experienced GPs to relinquish control, encourage patient involvement, and offer alternative sources of help. They felt less responsible for overall care. Less experienced, and less involved GPs found questionnaires supportive through increasing their confidence in asking difficult questions, and were encouraged to look for depression, which they might previously have avoided.Using mental health questionnaires helped GPs feel more confident in detecting and managing depression, and there was greater willingness to use questionnaires than found in previous studies. Most GPs sought reduced responsibility in ongoing care, using questionnaires to involve patients and pass responsibility to them or other agencies.