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Endoscopy free papers 033–048

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033 WORKLOAD AND TRAINING: AN AUDIT COMPARING THE WORK PATTERNS OF GASTROENTEROLOGY TRAINEES WITH OTHER MEDICAL SPECIALTIES

I.G. Beveridge, I.R. Gooding, M.J. Lockett, J.E.D. Mawdsley. Department of Gastroenterology, St Mary's Hospital, London W2, UK

Background: Most consultant gastroenterologists provide a service in both acute medicine and gastroenterology and most trainees seek dual accreditation. Reports confirm a growing workload for consultants and the need for workforce expansion. One of the aims of the “Calman” specialist registrar programme was to provide higher quality training in a shorter time period. A recent survey in our region suggested that changes arising from the “New Deal” would lead to reductions in clinic and endoscopy experience amounting to a loss of about 30 weeks of training. The aim of this study was to compare the workload and training patterns of gastroenterology trainees with those of other medical specialties.

Methods: All trainees in our region were asked to complete a survey documenting their typical weekly timetable and an identical survey was completed by a sample of trainees from other medical specialties.

Results: 25 gastroenterology trainees from 14 hospitals (5 teaching, 9 DGH) completed questionnaires. 23 trainees from other specialties in 4 hospitals (1 teaching, 3 DGH) participated. Specialties represented included; cardiology, endocrinology, respiratory medicine, rheumatology and elderly care. Gastroenterology trainees attend a median of 2 clinics (range 2–3) and 3 endoscopy sessions (range 2–5) per week. By contrast other trainees attend a median of 2 clinics (range 1–5) but have only 1 session (range 0–2) for other specialty activities (e.g. bronchoscopy, angiography etc.). Gastroenterology trainees had less available time for general ward-work and the majority (55%) had no allocated session for adminstration, teaching or research. 85% of other trainees had at least 1 session allocated for these activities.

Conclusions: Gastroenterology trainees, like their consultant trainers, have work patterns which reflect the increasing pressures on both general medical and gastroenterology services. The “New Deal” and future “working time directives” are likely to affect the provision of services and training in gastroenterology and specialty bodies must consider these pressures in order to continue to provide high quality training in gastroenterology.

034 WHAT DOES OPEN ACCESS ENDOSCOPY ACHIEVE?

N. Sharma, K. Kane, R. Boulton. Department of Gastroenterology, University Hospital Birmingham NHS Trust, Birmingham

Background: Open access endoscopy is widely practiced in the UK and recent government emphasis on rapid access and assessment of suspected cancer has increased demand.

Aims: (1) To determine whether open access endoscopy identifies significant numbers of patients with malignant upper GI disease. (2) To determine whether we could identify low risk groups that could be managed without endoscopy.

Methods: Data on all open access endoscopies was collected over a 2 year period. A retrospective analysis was undertaken to identify patients with a diagnosis of gastric and oesophageal cancer. All patients with cancer had their notes reviewed for referral symptoms.

Results: See table. All patients with cancer under the age of 55 years had at least one alarm symptom of weight loss or dysphagia.

Abstract 034

Conclusion: 36% of endoscopies were performed in under 55s. Upper GI malignancy was rare in this group. All patients in the younger group with cancer had symptoms that would have been appropriate referrals under urgent investigation of cancer guidelines. Recent meta-analyses suggest a “test and treat” policy in young patients is cost effective. Our study suggests that adoption of this policy should reduce the number of endoscopies in young patients.

035 DOES A NORMAL OPEN ACCESS UPPER GI ENDOSCOPY (OAE) RESULT IN BENEFIT TO THE PATIENT AND THE GP?

G. Mulholland, J.A.H. Forrest. Stobhill Hospital, Glasgow, UK

Introduction and aim: Stobhill Hospital offers GPs an unrestricted OAE Service. GPs receive a standard endoscopy report and no management advice is given. The aims of the study were to ascertain if a normal endoscopy changed the number of GP consultations, investigations, hospital outpatient referrals, admissions and drug prescribing costs in the year following the procedure compared with the previous year.

Study design: GP case records of every patient with a normal OAE over a 12 month period were scrutinised. Data collected included patient characteristics and past medical history. In the year preceding and following OAE, consultation rates, prescribing costs, the number of investigations, hospital referrals and admissions were obtained. Total drug costs were calculated for each patient.

Results: 247 patients were identified (150 females and 97 males). Age range 18–84 (mean 48.3 yrs). 13% had a past history of previous GI disease and 20% had a history of psychiatric illness. Following OAE there were significant falls in both the average number of consultations (6.5 vs 5.7, p<0.05) and those for upper GI symptoms (2.2 vs 0.7, p<0.01). There were no changes for other GI symptoms (0.31 vs 0.30, p>0.05) and non GI symptoms (4.1 vs 4.7, p>0.05).The average drug cost per patient (£83.3 vs £82.9), the cost of drugs for dyspepsia (£64.5 vs £62.50) and for psychotropic drugs (£16.6 vs £16.0) did not alter significantly (p>0.05). The number of investigations (38 vs 69, p<0.05), hospital referrals (132 vs 206, p<0.01) and admissions (21 vs 58, p<0.01) rose in the post endoscopy year.

Conclusion: The overall number of consultations and those for upper GI symptoms fell significantly in the year following endoscopy compared with the previous year, whilst those for other GI symptoms and non GI symptoms did not change. Overall prescribing costs did not alter whilst the number of investigations, hospital referrals and admissions rose significantly. A normal OAE confers little benefit to the patient and the GP.

036 WHY DO PATIENTS FAIL TO ATTEND FOR OPEN ACCESS UPPER GI ENDOSCOPY?

G. Mulholland, M. McConnachie, J.A.H. Forrest. Stobhill Hospital, Glasgow, UK

Introduction and aims: The DNA rate to our GP Open Access Endoscopy Service (OAE) is approximately 15%. We carried out a study to ascertain if those failing to attend had specific characteristics which would allow us to advise GPs which patients might be unsuitable for OAE.

Methods: Characteristics of 50 consecutive patients who failed to attend were compared with 50 who attended over the same time period. Both groups completed three questionnaires, namely: (1) Demographic and lifestyle details, including alcohol and cigarette consumption, employment and home circumstances. (2) The modified Glasgow Dyspepsia Scoring Questionnaire, as an index of their dyspepsia. (3) Fear of the endoscopy (where 0 = no fear and 10 = terrified). The DNA group was asked to select an appropriate reason for failure to attend from a list of prepared options.

Results: There was no significant difference between the mean ages of the DNA group (48.0 yrs) and those attending (54.8 yrs) (p>0.05). The DNA group were more likely to be male (p<0.05), smokers (p<0.05), to live alone (p<0.05) and had a significantly higher fear score (6.9 vs 3.9; p< 0.05) but a lower dyspepsia score (7.4 vs 8.9; p<0.05) than those attending. The most frequently stated reason for non-attendance was fear of the test (44%), and 46% of those stated they would have attended had the test been better explained to them.

Conclusion: Those who fail to attend for OAE tend to be male, are smokers, live alone and have a high fear score for the test. The DNA rate could be reduced if GPs were advised of the characteristics of those likely to fail to attend and a better explanation of the procedure was given to patients, especially those with a high fear score.

037 THE IMPACT OF PATIENT CHOICE ON GASTROENTEROLOGY (GI) CLINIC AND ENDOSCOPY SERVICE EFFICIENCY

A. Douglass, P.A. Cann. Endoscopy Centre, James Cook University Hospital, Middlesbrough, UK

Introduction: Direct Booking, a part of the Government's NHS plan, empowers patients to choose the timing of their forthcoming hospital appointment. This is intended to promote patient ownership of care. It is anticipated, as a consequence of this, that there will follow a reduction in hospital cancellations/rearrangements and an increase in attendance rates.

Aims: To re-design GI clinic and endoscopy booking systems to allow patients a choice of hospital appointments. To assess the effect on cancellation, rearrangement and attendance rates.

Methods: Initially, all patients being referred from GPs to our open access colonoscopy service and to one of our GI clinics were involved. Upon receipt of the referral, patients were contacted immediately by return of post, inviting them to telephone the unit to negotiate a convenient date. Two call centres were established—for clinic and open access colonoscopy referrals.

Results: Clinic: In the preceding 6 months, 259 were seen, the “Did Not Attend” (DNA) rate was 9 % and the cancellation & rearrangement rate was 15 %. In the first 2 months of the new system, 119 patients were seen. The DNA rate and patient cancellation & rearrangement rate had fallen to 2.5 % (p < 0.05) and 2 % (p < 0.05) respectively.

Open Access Colonoscopy: In the preceding 6 months, 619 were seen. The DNA rate was 5 % and the cancellation & rearrangement rate was 32%. In the first 2 months of the new system, 189 patients were seen. The DNA rate and patient cancellation & rearrangement rate had fallen to 2% (p < 0.05) and 11% (p < 0.05) respectively.

Conclusions: This new approach to the organisation of hospital appointments demonstrates that allowing patients to choose a convenient date, does result in a significant reduction in DNA and cancellation & rearrangement rates. This not only reduces time wasted in clinics and endoscopy sessions but also by administrative staff, secretaries, GPs and patients. The system is now being implemented across all of our GI subservices and will most likely act as a template for other departments.

038 AUDIT OF FAST TRACK 2-WEEK GI CANCER WAIT

E. Stoker, A. Elsender, D. Bradbury, M. Cullen, V. Chirnside, N. Thompson. The Newcastle upon Tyne Hospitals NHS Trust, UK

Aims: To audit the first 6 months of the 2-week cancer wait for Upper and Lower GI malignancy over 3-hospital site and 17 Consultant teams.

Methods: Prospective audit of a centralised fast tracked GI 2-week cancer referral system, GPs are offered either outpatient appointment or outpatient endoscopy. Main outcomes were to measure the number of patient's referred and subsequent number of cancers diagnosed. The data was also analysed to assess (1) time from referral to assessment, (2) age and symptoms of those with cancers, (3) differential uptake by GP practices.

Results: 87 GP surgeries were offered the service. A total of 263 patients were referred in the 6-month period. 112 upper from 38 GP practices (mean 2.8 patients per practice), 151 lower from 42 GP practices (mean 3.2 patients per practice). 25 cancers were detected, 7 upper (6.3%), 18 lower (11.3%). 50% of upper + 59% of lower GI referral were male. Age range was 25–89 years with 55% being 60–79yrs. Time from referral to initial assessment: upper < 1 week 56 patients (50%), < 2 weeks 54 patients (48.2%), >2 weeks 2 (1.8%) pt preference: lower < 1 week 57 patients (37.7%), < 2 weeks 91 patients (60.3%), > 2 weeks 3 patients (2%) pt preference. Age at diagnosis of carcinoma upper 1- 50–59, 3- 70–79, 3- 80>, lower 4- 60–69, 6- 70–79, 6–80>. Symptomatic presentation of carcinoma, upper GI: dyspepsia 2, dyspepsia + weight loss 2, dyspepsia + vomiting 4, dyspepsia + anorexia 2, dysphagia 4. Lower GI: abdominal mass 7, rectal mass 1, rectal bleeding + change in bowel habit +6 weeks 6, rectal bleeding – anal symptoms >60yrs 5, change in bowel habit >60yrs 8, Iron deficiency anaemia 3. Outpatient appointment requests accounted for 34.8% of upper and 71.6% of lower GI referrals. Conclusion The proportion of diagnosed carcinomas is in excess of with the expected targets. The 2-week referral system has been successfully implemented despite logistical difficulties, but use of the system by GPs is patchy.

039 DOES PRECEEDING TREATMENT WITH A PROTON PUMP INHIBITOR (PPI) DELAY OESOPHAGO-GASTRIC CANCER DIAGNOSIS?

V. Kaushik, J. Limdi1, A.D. Higham. Departments of Medicine, Royal Lancaster Infirmary, Ashton Road, Lancaster; 1North Manchester General Hospital, Delaumay's Road, Crumpsall, Manchester

Background: Previous presentations to the society have highlighted concerns over the use of PPI's and their potential to delay the diagnosis of oesophago-gastric cancer.

Aim: To determine whether PPI treatment prior to endoscopy results in delay in diagnosis of oesophago-gastric cancer in a district general hospital setting.

Method: A retrospective case notes audit of patients with oesophago-gastric cancer diagnosed within Morecambe Bay NHS Trust within the last year. All patient records identified with appropriate documentation were studied.

Results: A total of 62 case note records were identified. 21 patients (33.9%) were taking a PPI and 41 patients (66.1%) had not received a PPI prior to their first endoscopy. No significant difference was seen in the rate of missed cancers in either group. In those patients receiving PPI treatment one case of cancer was missed at first endoscopy (4.8%) compared to two patients in the untreated group (4.9%). Interestingly, whilst the majority of endoscopies were performed by either consultant physicians or surgeons, all cases of missed cancer had their first endsocopy performed by a junior hospital doctor.

Conclusions: Preceeding treatment with a PPI does not seem to delay the diagnosis of oesophago-gastric cancer. In contrast, cancers are more likely to be missed by relatively inexperienced endoscopists.

040 A 10 YEAR RETROSPECTIVE STUDY OF UPPER GI ADENOCARCINOMA. HOW CAN WE IMPROVE EARLY DIAGNOSIS?

S.J. Panter1,3, H. O'Flanagan2, M.G. Bramble1,3, A.P.S. Hungin2,3. 1James Cook University Hospital, Middlesbrough; 2NoReN, Eaglescliffe Health Centre, Stockton; 3CIHR, University of Durham

Background: The detection of Early Gastric Cancer (EGC) in the UK remains low despite the widespread availability of gastroscopy. It has been suggested that acid-suppressing therapy (AST) given prior to gastroscopy can delay diagnosis.

Aims: This large retrospective study aimed to examine the history prior to the diagnosis of oesophago-gastric adenocarcinoma and identify the potential for making the diagnosis earlier.

Methods: All upper GI adenocarcinomas diagnosed in South Tees Health District (population ∼ 350,000) were identified from the pathology and NYCRIS databases. The GP records were reviewed and the data correlated with the pathology and hospital records.

Results: 747 patients were identified (April 1991 to April 2001). 92% had primary adenocarcinomas (29% oesophageal; 71% gastric). 6% were excluded (mis-coded on database) and in 2% information was missing. The M: F was 65.8:34.2; mean age at diagnosis was 70 years (range 28–94). The symptoms at time of diagnosis included of anaemia/weight loss/dysphagia in 78.4%, epigastric pain (without alarm symptoms) in 10.1%, dyspepsia/ reflux/ heartburn in 6% and haematemesis/malaena in 5.5%. Of the 685 patients with adenocarcinoma 48% had AST between 1st GP consultation and diagnosis and in 67% this was initiated immediately. Overall a cancer diagnosis was suspected by the GP in 38.3% of cases. For those treated prior to gastroscopy the mean time from 1st GP visit to diagnosis was 26.7 weeks compared with 8.8 in those not treated (p<0.001). Of the 357 patients not treated with AST prior to diagnosis only 12.6% had had a previous gastroscopy within 3 years of diagnosis, whereas of the 328 prescribed AST prior to diagnosis this figure was 42.4% (p<0.001). Overall, 35.5% of patients had a previous upper GI investigation within 3 years of diagnosis (75.7% OGD, 14.8% barium studies, 9.5% US.) 28% had investigations more than 3 years previously.

Conclusion: 1 in 2 patients receive AST prior to diagnosis increasing the mean time from 1st GP visit to diagnosis by 17.9 weeks. 35% of cancers were not diagnosed at the time of their first investigation. As 22% had only benign symptoms at diagnosis decisions regarding treatment or investigation should not be based solely upon symptoms but on an overall assessment of risk.

041 EMPIRICAL ACID-SUPPRESSING DRUG THERAPY (AST) IS ASSOCIATED WITH DELAYED DIAGNOSIS OF OESOPHAGO-GASTRIC CANCER

S.J. Panter1,2, H. O'Flanagan3, M.G. Bramble1,2, A.P.S. Hungin 2,3. 1James Cook University Hospital, Middlesbrough; 2CIHR, University of Durham; 3NoReN, Eaglescliffe Health Centre, Stockton on Tees

Aims: This retrospective study aimed to identify whether there are differences in the patterns of presentation of oesophago-gastric adenocarcinoma and so identify any potential to improve detection.

Methods: All upper GI adenocarcinomas diagnosed in South Tees Health District (population ∼ 350,000) were identified from the hospital pathology and NYCRIS databases (April 1991 to April 2001). The GP records were reviewed and the data collected correlated with the pathology and hospital records.

Results: 747 patients were identified. 92% had primary adenocarcinomas (29% oesophageal; 71% gastric). 6% were excluded (mis-coded on database) and 2% of information was missing. The M: F was 65.8:34.2; mean age at diagnosis 70 years (range 28–94). The naked eye appearance at diagnostic OGD was ulcer 43.2%, mass 29.2%, stricture 14.5%, a mucosal abnormality 9.9%, other 3.2%. Of the cancers presenting as a mucosal abnormality (n=68) 61.8% were treated with AST compared with 51.7% of the ulcer cancers (n=296), 43.4% of the strictures (n=99) and 39% of the tumour masses (n=200) (p=0.003). This treatment resulted in the diagnosis of mucosal abnormalities being delayed by 23.3 weeks (overall mean time from 1st GP visit to diagnosis 24.6 weeks, with AST 33.5 weeks, without AST 10.2 weeks), ulcer cancers being delayed by 23 weeks (overall 20.6, with AST 31.6, without AST 8.6 weeks), strictures being delayed by 11.1 weeks (overall 13.6, with AST 19.9, without AST 8.8 weeks) and the cancers presenting as tumour masses being delayed by 8.8 weeks (overall 12.1, with AST 17.5, without AST 8.7 weeks). Of the ulcer cancers 24.2% had had a previous gastroscopy within 3 years of the diagnosis compared with 27.9% of the mucosal abnormalities, 24.2% of the strictures and 19.5% of the cancers presenting as a tumour mass (p=0.008).

Conclusion: The results show that AST therapy is associated with a delay in the diagnosis of all morphological types of oesophago-gastric adenocarcinoma through all modes of referral including OP clinics and open access. Ulcer-cancers and mucosal abnormalities are more likely to have received AST and are more likely to have had a previous gastroscopy (within 3 years of diagnosis). This suggests more potential to diagnose these types of oesophago-gastric cancer earlier by avoiding AST treatment and performing a gastroscopy earlier.

042 PREDICTIVE VALUE OF ALARM SYMPTOMS IN DYSPEPSIA FOR SIGNIFICANT UPPER GASTROINTESTINAL PATHOLOGY

C.J. Larkin, C. Patterson, P. Murphy, N. McDougall, J.S.A. Collins, S.D. Johnston, T.C.K. Tham.Ulster Hospital, Belfast, Craigavon Hospital, Antrim Hospital, Royal Victoria Hospital, Belfast, N Ireland, UK

Background and Aim: Alarm symptoms in dyspepsia are thought to predict significant pathology at endoscopy (OGD). However few studies have assessed their predictive value. Our aim was to determine the predictive value of alarm symptoms for significant pathology.

Methods: Consecutive outpatients with dyspepsia undergoing OGD were studied prospectively. Inpatients with acute upper GI haemorrhage were excluded. Patient demographics, OGD indications, all symptoms including alarm symptoms, ie. vomiting, weight loss, dysphagia, haematemesis, melaena, anaemia were prospectively recorded. Logistic regression analysis with backward elimination was used to determine which symptoms were significantly associated with particular pathologies and the odds ratios were determined.

Results: 449 patients were recruited. Dysphagia was significantly associated with oesophagitis (odds ratio [OR] 2.5), oesophageal ulcer (OR 9.1), oesophageal cancer (OR 24.7). Haematemesis was significantly associated with oesophagitis (OR 5.6). Melaena was significantly associated with gastric ulcer (OR 12.5), duodenal ulcer (OR 5.8). Anaemia was significantly associated with Barretts (OR 5.2) and oesophageal ulcer (OR 9.1). Abdominal pain was significantly associated with duodenal ulcer (OR 4.8). Chest pain was significantly associated with oesophagitis (OR 4.5). Atypical dyspepsia was significantly associated with oesophagitis (OR 2.9). Vomiting, weight loss were not associated with significant pathology.

Conclusions: Alarm symptoms of dysphagia, haematemesis, melaena, anaemia were predictive of significant pathology at endoscopy. In particular dysphagia was strongly predictive of oesophageal cancer. Vomiting and weight loss were not predictive of significant pathology. Non alarm symptoms such as chest pain and atypical dyspepsia were predictive of oesophagitis.

043 CLO™ TESTING: OPTIMAL NUMBER OF BIOPSIES REQUIRED TO DIAGNOSE HELICOBACTER PYLORI INFECTION BASED ON ITS TOPOGRAPHICAL DISTRIBUTION

K.P. Basavaraju, P. Cleary, N.K. Ahluwalia.Department of Gastroenterology, Stepping Hill Hospital, Stockport, UK

Background: Due to increasing demand, there is immense pressure to perform more numbers of gastroscopies (OGD) per list in busy DGHs. Accurate diagnosis of H.pylori is critical to optimal management of patients undergoing OGD. It is customary to put 1 antral biopsy in a CLO™ well, though it is known that increasing the numbers & sites of biopsies increases the diagnostic accuracy. We have recently shown1 that taking 3 biopsies (2 antral + 1 body=CLO3) is superior to histology (77.5% sensitivity) as well as 2 antral biopsies (82.5% sensitivity).

Aims: To assess whether the increased accuracy of CLO3 is due to its topographical diversity rather than merely increased number of biopsies per CLO well, we compared CLO3 with 1 antral + 1 body biopsy (CLO2).

Methods: We recruited consecutive patients over the age of 18 years undergoing OGD in a busy DGH who had evidence of gastritis, duodenitis, gastric or duodenal ulcers.

Results: 100 patients underwent CLO testing. 30 patients were CLO positive. Of these 28 were positive in CLO2 & all 30 in CLO3. Assuming a gold standard of 100% sensitivity for CLO3 (based on our previous publication), the sensitivity of CLO2 is 93.3% (95% CI=78.7% to 98.2%) (see table).

Abstract 043

Conclusion: While it may be preferable to take 2 antral and 1 body biopsies for a CLO™, if due to time constraints or patient restlessness, less number of biopsies are taken, we propose at least 2 topographically different biopsies for CLO™ testing.

1Vassallo J, Hale R, Ahluwalia NK. Eur J Gastroenterol Hepatol 2001;13:387–90.

044 ECONOMIC ANALYSIS OF PROSPECTIVE RANDOMISED TRIAL OF ENDOSCOPY VERSUS NON-INVASIVE H. PYLORI TESTING IN DYSPEPSIA

K.E.L. McColl, L.S. Murray, D. Gillen, A. Walker, A. Wirz, J. Fletcher, C. Mowat, E. Henry, A. Kelman, A. Dickson.University Dept of Medicine & Therapeutics, Western Infirmary, Glasgow G11 6NT, UK

We have previously reported that non-invasive H. pylori testing is as effective and safe as endoscopy in uncomplicated dyspepsia and preferred by the patients.

Aim: To compare the two investigative strategies with respect to utilization and costs of medical care over the subsequent 12 months.

Methods: The study randomised 708 patients <55 years of age referred for endoscopic investigation of uncomplicated dyspepsia. 356 underwent endoscopy plus urea breath test and 352 had only the urea breath test. All H. pylori positive patients received eradication therapy. Details on utilization of health resources were obtained from patients, GP and hospital records. The costs of the health resources utilized were obtained from NICE, BNF and NHS Reference Costs.

Results: Endoscopy usage was 8.2% in the group randomised to the breath test compared to 101.7% in the endoscopy group. There was no increased utilization of other health resources in those randomised to non-invasive H. pylori testing (see table).

Abstract 044

Conclusion: Non-invasive H. pylori testing is considerably more cost effective than endoscopy for the management of uncomplicated dyspepsia.

045 FIBRIN GLUE INJECTION FOR THE TREATMENT OF ACUTE UPPER GASTROINTESTINAL BLEEDING

K. Wallis, P. Vlavianos, H.J.N. Andreyev, D. Westaby.Dept of Gastroenterology & ICMS, Chelsea & Westminster Hospital, London, UK

Introduction: The rebleeding rate from bleeding peptic ulcers is still very high despite a range of available treatments. It has been suggested that Fibrin Glue (FG) injection improves the final outcome.

Aim: To review our experience with Fibrin Glue (FG) injection for the treatment of acute upper gastrointestinal bleeding, from high risk upper GI lesions.

Methods: Retrospective case note audit of clinical outcome, of the patients treated with FG injection for spurting or oozing bleeding or due to the presence of a visible vessel following an acute upper GI bleeding, were reviewed. The complication rate, the rebleeding rate, the need for radiological or surgical interventions and the mortality rate were recorded.

Results: From August 1999 to October 2001, 54 patients, 35 men and 19 women were treated with FG injections in 57 admission episodes. Mean age was 62 years (range 17–90). The source of bleeding was oesophageal in 20%, gastric in 27% , duodenal in 49% and multiple in 4% of the cases. A visible present was clearly seen in 81% of the cases, was highly suspected in 13% and in 6% spurting or oozing bleeding was present. In addition to FG, in 63% and 5% of the cases, adrenaline 1:10,000 and ethanolamine oleate respectively were injected. Twenty patients were re-injected in total, ten during a second look endoscopy and 10 due to rebleeding. There were no complication related to the treatment. There were 16 (28%) rebleeding episodes, 3 (5%) patients underwent embolisation after rebleeding, 4 (7%) patients had a surgical intervention (2 primary failures and 2 after further rebleeding) and 6 (11%) patients died, one of them having not rebled. From the patients who died, 2 had advanced malignancies and 2 died from post operative complications. Overall control of the bleeding episode with endoscopic treatment was 82%.

Conclusion: In our experience, FG injection is an effective way of treating upper gastrointestinal bleeding from high risk lesions. A prospective study is needed to investigate whether it offers better results than other endoscopic treatments.

046 ENDOSCOPIC CLOSURE WITH METALLIC CLIPS FOR MUCOSAL DEFECT AFTER ENDOSCOPIC MUCOSAL RESECTION IN PATIENTS WITH INTRAMURAL TUMOURS OF THE STOMACH

M. Inomata, M. Endo, H. Obara, Y. Hashimoto, Y. Miyamoto, S. Oana, T. Terui, T. Chiba, S. Orii, K. Suzuki.First Dept of Internal Medicine, Iwate Medical University School of Medicine, Morioka, Japan

Background and Aims: Endoscopic mucosal resection (EMR) is widely used in Japan for treating intramural gastric tumours. The success of this local treatment requires negative margins. To achieve this requirement, the area of the mucosa resected by EMR has been increasingly lager in recent years. The larger the mucosal defect, however, the greater is the risk of complications such as bleeding or perforation after the procedure. The purpose of this study was to clarify if endoscopic closure with metallic clips for mucosal defect by EMR was able to decrease the rate of bleeding

Methods: The population of the study consisted of 150 patients who underwent EMR for intramural tumours of the stomach. Patients were divided into two groups. The first group was the patients without endoscopic mucosal closure, and the second was the patients treated with endoscopic mucosal closure using metallic clips after EMR.

Results: The number of patients of the first group was 94. In 11 (12%) patients of this group, bleeding following EMR was observed. In patients with mucosal defect less than 20 mm in diameter in this group, bleeding was not detected. The number of patients of the second group was 56. The complete closure rate was 96% (54/56). In this group, bleeding following EMR was encountered in only two (3.6%) patients. Those two patients had been unsuccessful in complete closure of the mucosal defect, because the size of the defect was over 40 mm in diameter.

Conclusions: Endoscopic closure with metallic clips for mucosal defect after EMR was useful for decreasing the bleeding following EMR, especially in large defects over 20 mm in diameter.

047 INTENSIVE CARE ENDOSONOGRAPHY AND GUIDED FINE-NEEDLE ASPIRATION FOR DIAGNOSIS AND MANAGEMENT OF POSTERIOR MEDIASTINITIS

A. Fritscher-Ravens, L. Schirrow, W. Pothmann, W.T. Knöfel, N. Soehendra, P. Swain.

Background: Acute mediastinitis is a serious complication, occurring after esophageal perforation, thoracic surgery and rarely spontaneously due to infections. Clinical and CT scan signs may be nonspecific, especially in postoperative patients.

Methods: We prospectively evaluated the value of endosonography (EUS) with guided fine-needle aspiration (FNA) in the diagnosis and identification of etiologic agents in critically ill patients with suspected posterior mediastinitis. EUS-FNA was performed at the bedside in the intensive care unit using a Pentax 34UX echoendoscope and a Hitachi console. 18 patients with clinically suspected medias-tinitis were examined with intensive care team support. CT was carried out prior to EUS in all 18 patients and was inconclusive in 9.

Results: EUS detected mediastinal lesions in 16 out of 18 patients (89%). Thirteen had recently undergone surgery (10 esophagectomy, 1 other esophageal surgery, 1 head/neck cancer surgery, 1 complication after dilatative tracheotomy, 3 with suspected “spontaneous” medias-tinitis). In all 16 patients infectious organisms were detected (bacterial: n=14, fungal: n=1, tuberculosis: n=1). Culture and sensitivity of EUS-FNA specimens lead to appropriate drug-therapy. In two patients MRSA were detected, leading to isolation care. Eleven patients improved, 6 patients died. In two patients, in whom EUS did not detect a mediastinitis, one was a false-negative on autopsy. There were no complications.

Conclusion: Bedside EUS-FNA of posterior mediastinal lesions in critically ill patients was an effective and relatively non-invasive way to detect mediastinitis and provide material to identify the etiologic agent.

048 ENDOOSONOGRAPHY GUIDED FINE-NEEDLE ASPIRATION (EUS-FNA) IN THE DIAGNOSIS OF SMALL SPLENIC LESIONS

A. Fritscher-Ravens1, N. Soehendra2, P. Swain1. 1Department of Gastroenterology, Royal London Hospital, London; 2Dept of Interdisciplinary Endoscopy, University Hospital, Hamburg, Germany

Background: Tissue diagnosis of splenic lesions is usually obtained using CT or US guidance, but is limited to a size of approximately minimum 1.5 cm. It may be dangerous if the lesion is adjacent to the splenic hilum or not surrounded with sufficient residual splenic tissue to protect the puncture site. However, tissue diagnosis is essential in a variety of diseases to direct therapy. We used EUS-FNA, performed in real time conditions in unknown splenic foci to reveal tissue diagnosis.

Methods: EUS-FNA was performed in 12 patients, when US- or CT-guided biopsy failed to achieve the diagnosis (n=5), was not attempted due to the small size of the lesions (n=5, size of foci: 0.9–1.4 cm), or was supposed to be too dangerous due to the fear of it being a hemangioma, or covered by insufficient residual splenic tissue. EUS and EUS-FNA was carried out using a linear echo-endoscope and 22 gauge needles for cytology. In each of the patients a separate pucture for bacteriology was carried out in addition to that for cytology.

Results: The age of the patients was 19–68 years (median: 32; 7 males). The size of the lesions was 0.8–4.2 cm; median: 1.4 cm. Cytology was inadequate in 1 patient, in whom only blood was aspirated. Bacteriology was positive for staphylococcus aureus in one patient and cultures were positive for mycobacterium tuberculosis in two. Final diagnosis was tuberculosis in 2, Hodgkin's disease in 2, sarcoidosis in 2 and metastasis of colon cancer, abscess, infarction and exclusion of a recurrent non Hodgkin's lymphoma in one each. All patients with or exclusion of a suspected malignancy were followed up for at least 6 months. Those with benign diseases were followed up to check that other techniques including bacteriological culture, confirmed diagnosis. There were no complications despite the fact that 2 patients had severe septicemia and one agranulocytosis.

Conclusion: EUS-FNA cytodiagnosis in patients with unknown splenic lesions seems feasible even in very small foci, when CT- or US guided biopsy fail. Additional material for bacteriology may show benign diseases such as abscesses or tuberculosis.

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