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Nutrition/Coeliac/Small bowel free papers 063–076

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063 CLINICAL RESULTS OF WIRELESS CAPSULE ENDOSCOPY

M. Mylonaki, A. Fritscher-Ravens, P. Swain.Department of Gastroenterology, Royal London Hospital, Whitechapel, London E1 1BB, UK

Background: The development of wireless capsule endoscopy allows painless imaging of the gastrointestinal tract. The clinical utility and performance characteristics of this examination are unknown.

Aim: To assess the clinical efficacy and technical performance of wireless capsule endoscopy in a series of 55 patients.

Methods: A wireless capsule endoscope measuring 11 x 27 mm was used. It contained a light source, CMOS imager, colour television transmitter and silver oxide batteries encapsulated in a strong plastic container with a transparent optical dome window. The 50,000 transmitted images are received via an array of 8 aerials and stored on a portable solid-state recorder, which is carried on a belt.

Results: In a subset of 38 patients push-enteroscopy was compared with capsule endoscopy. A bleeding source was discovered in the small intestine in 21 of 38 patients (55%). These included angiodysplasia (11), fresh blood (5), ileal ulcer (1) tumour (2), Meckel's diverticulum (1) vasculitis (1). Active intestinal bleeding was seen in 3. No additional intestinal diagnoses were made by enteroscopy. The yield of push-enteroscopy in evaluating obscure bleeding was 30% (12/38). The capsule found significantly more intestinal bleeding abnormalities than push enteroscopy (p<0.05). A source of bleeding was identified beyond the reach of the push enteroscope in 9/21 (42%). Therapy was altered in 50% and in 3 patients, who had required more than 100 units of blood, directed surgery cured (2) or markedly reduced (1) the bleeding. Patients always preferred capsule endoscopy to push-enteroscopy (p<0.001). There were no complications. Preparation with picolax improved images in patients on iron or with blood in the intestine. 7 patients had no push-enteroscopy. Studies in volunteers (7) and patients with chronic abdominal pain (3) were mostly normal – erosions in 1, lymphangectatic cysts in 3.

Conclusions: This study shows that capsule endoscopy provides small intestinal imaging comparable to push-enteroscopy and can diagnose intestinal bleeding at sites beyond the reach of push-enteroscopes. It was safe and well tolerated.

064 THE RELATIONSHIP OF ADULT COELIAC DISEASE WITH IRRITABLE BOWEL SYNDROME, IRON DEFICIENCY ANAEMIA AND FATIGUE: A PRIMARY CARE CROSS-SECTIONAL STUDY

D.S. Sanders, D. Patel, T.J. Stephenson, A. Milford Ward, E.V. McCloskey, M. Hadjivassiliou, A.J. Lobo.Supra-Regional Protein Reference Unit, Northern General Hospital & Gastroenterology and Liver Unit, Royal Hallamshire Hospital, Sheffield, UK

Background and Aims: Our aim was to determine the prevalence of undiagnosed adult coeliac disease in the general population of mainland United Kingdom. We also sought to establish the relationship in primary care between coeliac disease, irritable bowel syndrome, iron deficiency anaemia, fatigue and other coeliac related conditions.

Methods: A cross-sectional study using immunoglobulins, IgA/IgG antigliadin antibodies and endomysial antibodies to initially recognise coeliac disease. 1200 volunteers were recruited (January 1999 to June 2001) from Five General Practices in South Yorkshire. Any participant with a positive IgA antigliadin antibody, positive endomysial antibody or only IgG antigliadin antibody in the presence of IgA deficiency was offered a small bowel biopsy to confirm the diagnosis of coeliac disease.

Results: 12 new cases of coeliac disease were diagnosed from 1200 samples. The prevalence of coeliac disease in this general population sample is 1% (95% CI 0.4–1.3%). The prevalence of coeliac disease in participants with irritable bowel syndrome was 3.3% (4/123), for iron deficiency anaemia 4.7% (3/64) and for fatigue 3.3% (3/92).

Conclusions: This is the first study to establish the prevalence of undiagnosed adult coeliac disease in a general population from England. Underdiagnosis of coeliac disease is common in primary care. A case finding approach would avoid delays in diagnosis and the associated morbidity or potential complications of coeliac disease. A low threshold for serological screening of patients with coeliac associated symptoms or conditions would be an optimal strategy in primary care.

Acknowledgements: We wish to acknowledge the support of Action Research. This study was entirely funded by Action research. Dr Sanders is an Action Research Training Fellow.

065 SEROPREVALENCE, CORRELATES AND CHARACTERISTICS OF UNDETECTED COELIAC DISEASE IN ENGLAND

J. West1, R.F.A. Logan1, P.G. Hill2, C.A. Lloyd2, S. Lewis3, R. Reader4, G.K.T. Holmes5, K.T. Khaw4.1Divn of Public Health and Epidemiology, University Hospital, Nottingham; Depts of 2Chemical Pathology and 5Medicine, Derbyshire Royal Infirmary, Derby; 3Medical & Surgical Sciences, Nottingham City Hospital; 4Clinical Gerontology Unit, Addenbrooke's Hospital, Cambridge, UK

Background: Recent studies using various antibody tests to screen for undetected coeliac disease have shown that the prevalence of coeliac disease (CD) in several countries is between 0.5–1.0% of the population. So far the numbers detected have been small and information as to the characteristics and consequences of undetected CD is limited. We have examined the seroprevalence of undetected CD in a large population sample from the Cambridge area.

Methods: The Cambridge General Practice Health Study identified individuals aged 45–74 from the age-sex registers of 11 general practices and invited them for a health survey and a bone density scan between 1990–1995. We tested 7550 of the serum samples collected for antiendomysial antibody (EMA) and used multivariate analyses to compare EMA positive and negative subjects.

Results: The seroprevalence of undetected CD in this general population sample was 1.2% (95% CI 0.9–1.4) and did not vary significantly with age or sex. EMA +ve subjects (n=87) were 2.2kgs lighter (p = 0.07) and 0.1cms shorter (p = 0.09), were more likely to have reported their general health as being “good to excellent” (Odds Ratio (OR) 1.8, 95% CI 0.9–3.5), and were less likely to report being a current or ex-smoker (OR for current versus never 0.36, 95% CI 0.14-0.90). Undetected CD was associated with a 8% reduction in mean serum cholesterol (0.5mmol/1, p<0.01) and small reductions in mean haemoglobin (0.3g/dl, p<0.01), total protein (1.0g/l, p<0.05) and corrected serum calcium (0.02mmol/1,p<.05). There was an increased prevalence of osteoporosis in the EMA +ves (OR 3.1, 95% CI 1.3–7.3) and of mild anaemia (OR 4.6, 95% CI 2.5–8.2). Five EMA +ves (6%) had died, a proportion similar to that in EMA –ves(8%).

Conclusions: Undetected coeliac disease is likely to affect about 1% of the population of England, a figure similar to several other countries. Although affected subjects report no increase in “poor or moderate” health they have an increased prevalence of osteoporosis and mild anaemia. In contrast they have a favourable cardiovascular profile which is likely to afford substantial protection from ischaemic heart disease and stroke.

066 WHAT FACTORS INFLUENCE COMPLIANCE WITH A GLUTEN-FREE DIET? A COMPARISON OF WHITE CAUCASIAN AND SOUTH ASIAN COELIAC PATIENTS

J.R. Butterworth1, L. Banfield2, T.H. Iqbal1, B.T. Cooper1.1Department of Gastroenterology and 2Department of Dietetics, City Hospital NHS Trust, Dudley Road, Birmingham B18 7QH, UK

Introduction: Lifelong and strict adherence to a gluten-free diet is mandatory in patients with coeliac disease (CD) to improve nutrition and prevent long-term complications. Little is known about what factors influence compliance with a gluten-free diet.

Aims: To identify factors that may influence compliance to a gluten-free diet amongst Caucasians and South Asian patients with coeliac disease.

Methods: A questionnaire survey was sent to 130 coeliac patients followed-up at our unit, (90 Caucasians and 43 South Asian).

Results: Eighty seven (66.9%) of the 130 questionnaires were returned-66 from the Caucasians, and 21 from the South Asian patients (p=0.003). Patients own assessment of their strictness to a gluten-free (GF) diet was significantly correlated with both small bowel histological recovery and negative endomysial antibody status among the Caucasian patients (p=0.005 and <0.0001 respectively), but not amongst the South Asians. In the Caucasian patients, eight factors appeared to correlate with compliance with a GF diet: 1.Membership of the Coeliac Society (p<0.0001). 2.Understanding food labelling (p=0.014). 3.Obtaining GF products on prescription (p=0.047). 4.Affordability of GF products (p=0.01). 5.Getting sufficient prescription GF products (p=0.017) 6.A detailed explanation of CD by a physician (p=0.006). 7.Having a follow-up small bowel biopsy (p=0.03). 8.Regular dietetic follow up (p=0.01). No factors were identified amongst the South Asians, who were less likely to attend dietetic clinics (p=0.005), or be members of the Coeliac Society (p=0.02) and were more dissatisfied with information provided by doctors (p=0.026) and dieticians (p=0.011) compared with the Caucasian coeliac patients.

Conclusions: In contrast to the South Asians, a number of factors seem to influence compliance with a GF diet amongst Caucasian patients with CD. Compliance seems poor amongst South Asian patients, and a different approach is required in terms of education and dietetic supervision compared to the Caucasian patients with CD.

067 DETECTION OF GLUTEN IN ALCOHOLIC BEVERAGES IS FEASIBLE USING DRY STRIP IMMUNOCHEMISTRY IN THE “GLUTEN HOME TEST” KIT

M.M. Skelly, C.J. Hawkey.Division of Gastroenterology, University Hospital, Nottingham, UK

Introduction: It is unclear which cereal-based alcoholic drinks are suitable for coeliac patients. A gluten “home test” (GHT) detection kit has been developed utilising dry-strip immunochemistry format with a range of detection of wheat gluten from 50 to 1200 ppm. Recommended acceptable levels are <20ppm for food naturally gluten free and <200ppm for food rendered gluten free.

Aim: To demonstrate that the gluten content of a number of alcoholic beverages can be determined by Gluten Home Test kit.

Methods: Alcoholic beverages were tested with the GHT and ELISA. Control samples contained known quantities of gluten (starch) or were not cereal based (Coca-Cola). Test samples are as reported. The GHT strip contains antibodies specific for omega gliadin, a stable gluten protein, which bind to gliadin in the test beverage. When the beverage is loaded on the strip, a gliadin-antibody-blue latex particle combination migrates along the strip until it is trapped by immobilised gliadin antibody in one of three positions. The positions indicate gluten level less than 50ppm (“Negative test”), 50–200ppm or greater (“Positive”) and more than 10% gluten (“Strong positive”). Gliadin content of the test and control samples was determined using a direct sandwich ELISA that utilised a monoclonal antibody to omega gliadin. See table.

Abstract 067

Summary: Gluten can be readily detected in alcoholic beverages using dry strip immunochemistry. Results from GHT and ELISA broadly correlate. Kits may be useful for coeliacs to guide choice of alcoholic beverage.

068 ASSOCIATION OF COMMON HFE GENE MUTATIONS WITH COELIAC DISEASE RESULTS IN PROTECTION AGAINST IRON DEFICIENCY ANAEMIA

J.R. Butterworth1, W.M.C. Rosenberg2, S. Jobson3, M. Hathaway3, D. Briggs3, W.M. Howell4, D.H. Adams5, B.T. Cooper1, T.H. Iqbal1.1Gastroenterology Unit, City Hospital, Birmingham, UK; 2Liver Group, Division of Infection, Inflammation and Repair, University of Southampton, UK; 4Division of Human Genetics, University of Southampton, UK; 3National Blood Service, Birmingham, UK; 5Liver Research Laboratories, MRC Centre for Immune Regulation, University of Birmingham, UK

Introduction: Coeliac disease (CD) and haemochromatosis are common conditions in populations with Celtic origins, but are associated with different defined human leukocyte antigen (HLA) haplotypes.

Aims: To determine if a genetic relationship exists between the two diseases, and if HFE mutations protect against iron deficiency anaemia.

Methods: Polymerase chain reaction amplification using sequence specific primers capable of identifying the 2 HFE gene mutations (H63D and C282Y), and the HLA class I and II alleles was used to type 77 Caucasoid patients with CD, and 187 matched controls. Haemoglobin and serum iron were measured at diagnosis.

Results: The two HFE gene mutations were identified in 36 patients with CD (46.7%), and 61 (32.6%) of the controls (P=0.035). Amongst the control population, the C282Y mutation was strongly associated with the HLA-A*03 and B*07 alleles and H63D with the HLA-A*25 allele but these associations were not observed in the CD group. By contrast, the C282Y mutation in the CD patients was associated with the HLA-A*01 and B*08 alleles. CD patients with a C282Y mutation had significantly higher mean haemoglobin and serum iron compared to the HFE wildtype (P=0.04 and 0.0015 respectively). No such relationship was found for the H63D mutation.

Conclusion: HFE gene mutations are common in patients with CD. Different linkage disequilibrium between HFE mutations and HLA alleles in the CD and control groups allows for selection of HFE abnormalities in the disease, and a disease-specific haplotype which carries C282Y and DQB1*02 is suggested. In the context of CD we propose that HFE mutations provide a survival advantage by ameliorating the iron deficiency seen in this condition.

069 IN-VIVO TOXICITY OF AMINO ACIDS 57–75 OF ALPHA-GLIADIN IN COELIAC DISEASE

J.S. Fraser1, W. Engel2, E.L. Pollock1, S.J. Moodie1, H.J. Ellis1, H. Wieser2, P.J. Ciclitira1.1Gastroenterology (GKT), St Thomas' Hospital, London SE1 7EH, UK; 2Deutsche Forschungs Anstalt für Lebensmittelchemie, Garching, Germany

Background: Peptides from α-gliadin have been used to characterise the immunodominant coeliac toxic cereal epitope in vitro. Following incubation with a peptide corresponding to amino acids 57–73 of α-gliadin, peripheral blood mononuclear cells from coeliac patients secrete IFN-?; gluten-specific small intestinal T cell clones proliferate in response to peptides corresponding to residues 57–68 and 62–75 of α-gliadin.

Aim: We wished to investigate whether a peptide corresponding to residues 57–75 of A-gliadin exacerbates coeliac disease (CD) in vivo.

Methods: We studied four unrelated Caucasian patients with known CD, all of whom were on a gluten-free diet. The patients underwent three separate challenges. One g peptic-tryptic gliadin (PTG) served as a positive control. Twenty to 100mg of the test peptide was studied on a separate occasion, and on the third a negative control peptide from casein, which comprised 20 amino acids incorporating the same residues as the test peptide, but which were in a different order, was assessed. Following sedation, a Quinton hydraulic multiple biopsy capsule was positioned in the duodenum. The peptides were instilled into the duodenum over 2 hours. Biopsies were taken before the infusion, 2, 4 and 6 hours after commencing the infusions. The biopsy specimens were assessed blindly for villus height to crypt depth ratio and enterocyte surface cell height. We used the Mann-Whitney U test, with 95% confidence intervals, for statistical analysis.

Results: The negative control peptide caused no significant changes to villus morphology nor small intestinal villus enterocytes in any of the patients. The villus height to crypt depth ratio and the enterocyte surface cell height fell significantly 4 to 6 hours after commencing the infusions with both PTG and the test peptide, compared to the initial biopsy, in all subjects (n=4).

Conclusion: A peptide corresponding to residues 57–75 of A-gliadin, exacerbates coeliac disease in vivo.

070 BONE MINERAL DENSITY IN ANOREXIA NERVOSA: NO CHANGE OVER TIME

C. Preston1, C. Flynn1, B. Oldroyd2, J.G. Truscott2, E. Mann3, P.D. Howdle1.1Dept of Medicine, St James's University Hospital; 2Centre for Bone and Body Composition, Leeds General Infirmary; 3Yorkshire Centre for Eating Disorders, Leeds, UK

Introduction: Patients with anorexia nervosa (AN) are at high risk of osteoporosis. Body composition is also abnormal. The mechanisms behind these changes are unclear although oestrogen status and nutritional factors are believed to play a part. There is little information about the natural history of osteoporosis in patients with ongoing disease.

Methods: To investigate the natural course of bone mineral density (BMD) and body composition in AN, measurements were made using dual energy x-ray absorptiometry. We studied 16 adolescents (15–19.9yrs) and 31 adults (>20yrs) all females, none had primary amenorrhoea. Local age and sex-matched controls were used for comparison with the adult group. We monitored the change in BMD and body composition of 13 patients over a mean follow up period of 21 months.

Results: In keeping with earlier studies, our adult anorexic patients had significantly lower BMI (16.2vs22.2 kg/m2), BMD (PA Spine T score –1.92vs 0.2, total body T score -1.2 vs. 0.4), lean body mass (34.8 vs. 38.3kg) and fat mass (6.5 Vs 19.2kg) than the controls (all p<0.0001). The adolescent group did not differ significantly in either BMI, BMD or body composition from the adult group. Disease profiles were compared between adolescent and adult patients. Despite a shorter duration of illness (3.1 vs. 8.4yrs p=0.01) and of amenorrhoea (2.6 vs. 5.8yrs p=0.06) the adolescents' BMD did not differ significantly from the adults. This may be due to the earlier onset of disease in adolescents (14.2 vs. 17.6 yrs) i.e. before peak bone mass is achieved. Using WHO definitions 37% of our patients had osteoporosis and 44% had osteopenia. In the 13 follow up patients there was no significant change in weight over time, despite on-going psychiatric support. The BMD of these patients did not alter significantly over the follow up period.

Conclusions: Patients with AN have a significant reduction in BMD. Despite psychiatric support they remain underweight but fortunately the BMD does not deteriorate. Trials of specific treatments should be undertaken and will need to include patients of all ages.

071 OSTEOPOROSIS AND COELIAC DISEASE: IS THE 1500 MG/DAY GUIDELINE FOR CALCIUM ACHIEVABLE BY DIET?

A. Holdoway1, W.E. Fickling1, A.K. Bhalla2, D.A.F. Robertson1.1Royal United Hospital; 2Royal National Hospital for Rheumatic Diseases, Bath, UK

Background: Guidelines for treating and preventing osteoporosis in coeliac disease (CD) were published in 2000 in the international journal Gut. These guidelines recommend that patients with CD should achieve a calcium intake of 1500 mg/day and adhere to a strict gluten-free (GF) diet. UK dietary surveys have shown that >50% of female adults in the general population fail to achieve the Reference Nutrient Intake (RNI) of 700 mg/day (DoH, 1998). In addition, GF diets have been shown to reduce intake of foods that contribute dietary calcium. Consequently the 1500 mg target may be difficult to achieve by diet alone. Our aim was to establish the intake of dietary calcium in patients with CD.

Methods: 26 patients with CD; age range 33 – 71yrs, 8 males, 18 females, were recruited via gastroenterology out patient clinics and the local coeliac society. Median duration on a GF diet was 10 yrs, range 3–33yrs. Dietary calcium and compliance to a GF diet were determined using a 10-day weighed method, Dietetic interview and a dietary analysis programme using data from MAFF (Dietplan) and food manufacturers.

Results: 25/26 adhered to a strict GF diet (96% compliance). Median calcium intake was 1209 mg/day (range: 539 – 1898 mg/day). 31% (8/26) achieved the 1500 mg/day. 11% failed to achieve the RNI of 700mg/day, all were female and following a restricted energy intake for the purpose of intentional weight loss. Dairy products provided a median of 57% of dietary calcium, which is similar to the non-coeliac population. 2/26 adhered to a milk-free diet but achieved a calcium intake >1400 mg/day using calcium-enriched bread/soya products. 42% used the new generation calcium-enriched GF breads. Median contribution of calcium from GF bread was 27% in those using the calcium-enriched GF breads, compared to 8% in those using standard GF breads.

Conclusions: Whilst it is possible to achieve a calcium intake of 1500 mg/day on a strict GF diet, careful dietetic assessment is required in the majority of patients to identify those with sub-optimal intakes (up to 2/3 of patients) and improve calcium intake through diet and/or supplements. The new generation calcium-enriched GF breads may help achieve dietary intakes of 1500 mg of calcium/day.

072 MORTALITY RISK FACTORS AND TRANSPLANTATION INDICATIONS FOR PATIENTS ON HOME PARENTERAL NUTRITION (HPN)

R.S. Hodgson1, N. Latif1, E.A.B. Cameron2, J.A.H. Binnie2, C. Murray1, S.J. Middleton1, A. Forbes1, S.M. Gabe1.1St Mark's Hospital, Harrow HA1; 2Addenbrooke's Hospital, Cambridge CB2, UK

The overall mortality for HPN in the UK is 8% per year and reports suggest that 80–90% of these deaths are attributable to the underlying disease. We performed a retrospective analysis of all patients who died on HPN over the last 5 years at St Mark's and all patients who had undergone intestinal transplantation (ITx) at Cambridge.

Results: At St Mark's, 37 patients died on HPN since 1996 and 33 complete sets of notes were traced (89%). These patients had a median age of 58 years (30–77) and a median time on HPN of 543 days (7–6777) [20F:13M]. 25 patients (76%) died from their original disease (HPN-disease), 4 (12%) died from complications of HPN (HPN-comp) and 4 (12%) died from other causes (HPN-other). HPN-comp deaths were sepsis (1) and liver failure (3). 2 of the 3 patients who developed liver failure had chronic cholestasis and received >1g lipid/kg/day. In Cambridge, 9 patients had ITx since 1991. 1 set of notes could not be traced and 1 patient did not have HPN prior to transplantation. The remaining 7 had a median age of 25.8 years (21–42 years) and a median of 730 days on HPN (14–2920 days) prior to transplantation [2F:5M]. Indications for ITx were recurrent thromboses (4), recurrent central venous catheter (CVC) sepsis (3) and PN related liver disease (2). See table.

Abstract 072

Conclusions: HPN patients die predominantly of their underlying disease. ITx patients had a higher frequency of infectious and thrombotic complications prior to transplantation and perhaps HPN patients with similar complications should be considered earlier for transplantation.

073 EFFECTS OF LOW FIBRE DIETS AND VITAMIN CONTENT ON NEOPLASIA AND CELL PROLIFERTION IN THE MIN MOUSE

O. Bashir, A.J. FitzGerald, N. Mandir1, R.A. Goodlad1.Histopathology Department, Imperial College School of Medicine, Hammersmith Hospital, London; 1Imperial Cancer Research Fund, 44 Lincoln's Inn Fields, London, UK

Background: Loss of APC and the production of a truncated APC protein leads to familial adenomatous polyposis (FAP) in man and multiple intestinal neoplasia (Min) in the mouse. Both phenotypes are characterised by multiple intestinal polyps. The Min mouse is thus a useful model for the study of exogenous factors on gut biology and tumour progression.

Methods: We have used the Min mouse (C57BK/6J-ApcMin) to investigate the actions of chow diets and fibre-free semisythetic diets on polyp progression, cell proliferation and crypt fission. The semisythetic diet was then used to investigate the actions of altered vitamin content (lowered to a third of the RDA and a SS diet where the vitamin content was increased fivefold (except for retinol and folate which were doubled). 60 Min mice and wild type littermates, 4 weeks old, were divided into 4 groups and fed the four diets for 8 weeks. The number and size of polyps in the small and large intestines were scored later (number*volume = burden), as was the number of native mitoses and the percentage of branching crypts.

Results: The guts of the chow fed mice were heavier, and all Min groups had heavier guts. The intestines of the low and high vitamin groups were heavier than the SS control. There were fewer polyps and the tumour burden was lower in the SS group. Both low and high vitamin levels lead to increased polyp number, especially in the proximal small intestine. There was more proliferation and crypt fission in the SS group, and this was reduced in the low and high vitamin groups. The effect of vitamins was most pronounced in the proximal intestine.

Conclusion: Low fibre semisythetic diets may reduce polyp formation, suggesting that the lack of `fibre' may be beneficial. Alteration of vitamin content can enhance polyp number and tumour burden. Both low or high vitamin content may be a risk factor.

074 IS THE CURRENT SERVICE FOR THE INSERTION OF ENDOSCOPIC FEEDING TUBES APPROPRIATE AND ACCEPTABLE? A UK SURVEY

A.J. Hughes, T.E. Bowling.City General Hospital, Newcastle Road, Stoke on Trent ST4 6QG, UK

We were concerned that gastroenterologists may be putting themselves in a vulnerable position, in terms of clinical risk, by inserting PEGs purely as a service for other clinicians. A questionnaire was therefore sent out to hospitals in the UK to clarify current practice. Responses were received from 196 of 242 units (>80%).

The number of PEGs placed ranged from 1 to 100/100,000 population covered/year with a median of 22 with most placed by medical gastro-enterologists. 59% of responding hospitals have a nutrition team but in 22% of these the patients are still assessed for suitability of PEG only by their own team. The endoscopist does not know what assessment has been made of patients attending for PEG placement in 25% of hospitals. In the hospitals where patients are assessed by a gastro/nutrition team the endoscopist is unaware of the details of the assessment in <3%.

Consent is clearly a difficult issue as many patients are mentally incapacitated but despite this <50% of hospitals have an appropriate, known consent policy for this group. Time from referral to insertion of PEG is >1 week in 33% of patients and this delay may well impact on physical wellbeing and also on bed occupancy.

Gastroenterology follow up is rare. >70% of hospitals do not provide any routine review or a review mechanism should complications arise post PEG insertion. <10% of patients are followed up beyond 1 week. 80% of patients are followed up in the community, often only by district nurses.

Current practice for PEG insertion is highly variable and in many hospitals doesn't seem to be either appropriate or acceptable. We believe many endoscopists are exposing themselves to potential risk by acting as technicians and feel that national minimum standards should be considered.

075 COLONIC MUCOSAL INJURY FROM NATURAL AND SYNTHETIC SULPHATED POLYSACCHARIDES

E.T. Donnelly, M. Hoper, W.G. McCluggage1, F.C. Campbell.Departments of Surgery and 1Pathology, Queen's University Belfast, Institute of Clinical Science, Grosvenor Road, Belfast BT12 6BJ, Northern Ireland

Undegraded lambda λ Carrageenan (λCgN) is widely used as a human food additive but is chemically related to the pro-inflammatory agent dextran sodium sulphate (DSS). This study tests the hypothesis that λCgN has pro-inflammatory effects in colon.

Methods: Acute and subchronic oral administration of λCgN vs DSS vs drinking water only control against colonic disease activity and mucosal inflammation in 2 species viz mice and rats. λCgN, DSS (1–4%) or drinking water control were administered for 2–72 days to Balb/c mice (n=225) and Sprague-Dawley rats (n=45) which were maintained on AIN76A antioxidant and mutagen-free diet. Disease activity was assessed by stool consistency, blood loss, weight loss and lethargy. Mucosal injury was assessed histologically by semiquantitative scores of crypt loss, shortening, distortion, hyperplasia, and inflammatory infiltration.

Results: Both λCgN and DSS induced colonic inflammation, crypt injury and crypt hyperplasia in mice and rats. Effects on colonic function and mucosal injury were dose dependent and increased with duration of exposure. DSS had greater adverse effects on disease activity than CgN in doses of 3–4% in mice and 1–3% in rats.

Conclusion: Although less toxic than DSS, λCgN produced cumulative dose dependent colonic mucosal injury and adverse effects on colonic function of 2 species.

076 OUTCOMES IN HOME PARENTERAL NUTRITION IN A NATIONAL UNIT

F.C. Leslie, M.A. Bradley, J.L. Shaffer.Intestinal Failure Unit, Hope Hospital, Stott Lane, Salford, Manchester M6 8HD, UK

Hope Hospital is one of the UKs two largest units covering patients on Home Parenteral Nutrition (HPN). In 1998 it was decided to review all new patients commencing on HPN, to study morbidity and mortality. A mean of 27 patients started HPN each year and no patients were lost to follow-up.

85 patients commenced HPN between 15th February 1998 and 15th May 2001, aged 19 years 11months – 76 years 11months, (mean 50.2 years ±16.8 months) (50 females). 19 patients were <40 years, 43 were 40–60 years and 23 were >60 years. 76 patients were entirely self-caring for their line, 9 requiring input from family or outside care e.g. district nurse. The main diagnoses in these patients were Crohns (29), mesenteric vascular disease (20) and surgical complications e.g. short bowel syndrome after surgery for e.g. ulcerative colitis or malignancy (18). Conditions e.g. radiation enteritis, scleroderma and volvulus made up smaller numbers. 2 patients were treated for a diagnosis of active malignancy.

Of these 76 are alive, 57 on HPN, 19 have discontinued HPN and 9 have died. Mortality rates were 0% at 1 year and 10.6% at 3 years, compared to 1-year and 3-year mortality rates of 7–15% and 30–32% in published series. 4 patients died of malignancy (3 previously recognised and 1 new case), and 5 of unrelated conditions i.e. 3 patients died of their underlying diagnosis and 6 of unrelated causes. No deaths were related to HPN. 19 patients (22.3%) developed a confirmed line complication - 10 (11.8%) with catheter-related sepsis, (7 patients developed >1 complication). No patients developed significant liver disease.

19 (22.3%) patients came off HPN during this period with an average duration of 9.15±1.05months (range 4–21 months). No clear diagnosis was associated with an increased chance of discontinuing HPN, but 10 patients had surgery (9 reanastomosis) prior to discontinuing. Patients who discontinued HPN were younger (47years±37.5 months) than those who died (55.3 years±64.4 months) and those that continued on HPN (50.8years±19.4), but this was not significant.

Over this time we treated increasing numbers of patients and included patients previously thought not appropriate for HPN e.g. those not self-caring and older age groups. Despite more patients being considered suitable for HPN and new methods e.g training carers, mortality and complication rates are low and there were no HPN-related deaths. We appear to be widening the net without worsening outcome.

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