Mohd Syafiq Ismail

Background: There has been a reduction in successful H. pylori eradication rates recently, which is largely attributed to increasing antibiotic resistance. In areas of high dual clarithromycin and metronidazole resistance such as ours, Maastricht VI/Florence guidelines recommend bismuth quadruple therapy (BQT) as first line of therapy; however, the availability of bismuth was poor in Ireland until recently. Similarly, tetracycline, a component of BQT, is restricted locally, with doxycycline (D) being approved and reimbursed for most indications. Aims: To assess the efficacy of BQT-D therapy for H. pylori eradication in an Irish cohort. Methods: All patients testing positive for H. pylori in three Irish referral centres by urea breath test, stool antigen, or histology were treated prospectively with BQT-D (bismuth subcitrate 120 mg QDS, metronidazole 400 mg TDS, doxycycline 100 mg BD and esomeprazole 40 mg BD) for 14 days. Eradication was evaluated with a urea breath test (UBT) >4 weeks after therapy cessation or by stool antigen testing, as available. Outcomes were recorded and analysed according to demographics and H. pylori treatment history of the patients. Results: 217 patients completed post-eradication testing. Of which, 124 (57%) were female, with a mean age 52 years. 180 patients (83%) were treatment-naïve. A total of 165/180 (92%) of the treatment-naïve patients had successful eradication. There was no association between eradication and gender or age in this cohort (p = 0.3091, p = 0.962 respectively). A total of 29 patients received this therapy as second-line therapy, of which 22 (76%) had successful eradication. Eight patients received the regimen as rescue therapy, with seven (88%) having successful eradication. No serious adverse events were reported. Eleven individuals (6.5%) commented on the complicated nature of the regimen, with 11 tablets being taken at five intervals daily. Conclusions: BQT-D as first-line therapy for H. pylori infection is highly effective in a high dual-resistance population, achieving >90% eradication. BQT-D as a second-line treatment performed less well. Our data support BQT-D as a first-line treatment.

Background: CCE is a diagnostic tool lacking clinical data on false negative rates. We aimed to assess this rate and the reader/technical error breakdown. Methods: False negative CCEs were identified after comparing to a colonoscopy database. Missed pathology characteristics and study indications/quality were collated. Cases were re-read by experts and newly identified lesions/pathologies were verified by an expert panel and categorised as reader/technical errors. Results: Of 532 CCEs, 203 had an adequately reported comparative colonoscopy, 45 (22.2%) had missed polyps, and 26/45 (57.8%) reached the colonic section with missed pathology. Of the cases, 22 (84.6%) had adequate bowel preparation. Indications included 13 (50%) polyp surveillance, 12 (46%) GI symptoms, 1 (4%) polyp screening. CCE missed 18 (69.2%) diminutive polyps and 8 (30.8%) polyps ≥ 6 mm, 18/26 (69.2%) of these were adenomas. Excluding incomplete CCE correlates, colonoscopy total and significant polyp yield were 97/184 (52.7%) and 50/97 (51.5%), respectively. CCE total polyp and significant polyp false negative rate was 26.8% (26/97) and 16% (8/50), respectively. Following re-reading, reader and technical error was 20/26 (76.9%) and 6/26 (23.1%). Total and significant missed polyp rates were 20.6% (20/97) and 14% (7/50) for reader error, 6.2% (6/97) and 2% (1/50) for technical error. Conclusions: False negative CCE rate is not insubstantial and should be factored into clinical decision making.

Background: Colon Capsule Endoscopy (CCE) has proven efficacy in a variety of gastrointestinal diseases. Few studies have assessed patient-reported outcomes and preference between colonoscopy and CCE. Methods: Patients from our centre who had both a CCE and colonoscopy within a 12-month period were identified. We performed over-the-phone interviews focused on satisfaction, comfort, and overall preference with a 10-point Likert scale. Electronic records were reviewed; reported Modified-Gloucester-Comfort-Scale (GCS) score, sedation, bowel preparation and endoscopist grade were documented. Data was compared between procedures. A Fishers exact test was used to compare proportions and a Student t-test was used to compare means, a p < 0.05 was considered significant. Results: In all, 40 patients were identified, 57.5% (23/40) were female and the mean age was 48 years (24–78). All patients were referred for investigation of lower gastrointestinal symptoms as part of an ongoing study [Endosc Int Open. 2021;09(06):E965–70]. There was a significance difference in mean comfort (9.2 vs 6.7, p < 0.0001, 95% CI − 3.51 to − 1.44) but not satisfaction (8.3 vs 7.7, p = 0.2, 95% CI − 1.48 to 0.33) between CCE and colonoscopy. Main cause of dissatisfaction with CCE was bowel preparation and for colonoscopy was discomfort. Age and gender were not found to be variables. The correlation between GCS and patient reported values was weak (R = − 0.28). Overall, 77.5% (31/40) of patients would prefer a CCE if they required further bowel investigation. Of these, 77.4% (24/31) preferred a CCE despite the potential need for follow-up colonoscopy. Conclusions: CCE has a high satisfaction rating (8.3 vs 7.7) and has a higher patient reported comfort rating (9.2 vs 6.7) than colonoscopy. Studies have confirmed CCE and colonoscopy have equivalent diagnostic yields. The majority of patients in our cohort prefer CCE to colonoscopy. CCE should be considered as an alternative to colonoscopy in selected individuals.

Background and study aims Colon capsule endoscopy (CCE) is a recommended viable alternative to colonoscopy for colonic visualisation in a variety of clinical settings with proven efficacy in polyp detection, surveillance, screening and Inflammatory Bowel Disease (IBD) assessment. CCE efficacy in an unselected average risk symptomatic cohort has yet to be established. The aim of this study was to determine the feasibility of CCE imaging assessment in average risk symptomatic patients as an alternative to colonoscopy with and without additional biomarker assessment. Patients and methods This was a prospective, single-center comparison study of colonoscopy, CCE and biomarker assessment. Results Of 77 invited subjects, 66 underwent both a CCE and colonoscopy. A fecal immunochemical test (FIT) and fecal calprotectin (FC) were available in 56 and 59 subjects. In all 64 % (n = 42) had any positive finding with 16 (24 %) found to have significant disease (high-risk adenomas, IBD) on colonoscopy. The CCE completion rate was 76 %, five (8 %) had an inadequate preparation, the CCE polyp detection rate was high at 35 %. The sensitivity, specificity, positive and negative predictive values of CCE for significant disease were 81 %, 98 %, 93 % and 94 % respectively. In addition, three (5 %) significant small bowel diagnoses were made on CCE. FC and FIT were frequently elevated in patients with both colitis (5/7, 71 %) and high-risk adenomas (4/7 57 %). While both had a low positive predictive value for clinically significant disease, FIT 32 % and FC 26 %. Conclusions CCE is a safe and effective alternative to colonoscopy in symptomatic average risk patients with or without the addition of biomarker screening.

Introduction:Colon Capsule Endoscopy (CCE) has proven efficacy in a variety of gastrointestinal diseases. Few studies have assessed patient-reported outcomes and preference between colonoscopy and CCE.Aims:To identify comfort scores and patient preferences between CCE and colonoscopy.Methods:Patients from our centre who had both a CCE and colonoscopy within a 12-month period were identified. We performed over-the-phone interviews focused on satisfaction, comfort, and overall preference with a 10-point Likert scale. Electronic records were reviewed; reported Modified-Gloucester-Comfort-Scale (GCS) score, sedation, bowel preparation and endoscopist grade were documented. Data was compared between procedures. A Fishers exact test was used to compare proportions and a Student t-test was used to compare means, a p < 0.05 was considered significant.Results:In all, 40 patients were identified, 57.5% (23/40) were female and the mean age was 48 years (24 – 78). All patients were referred for investigation of lower gastrointestinal symptoms as part of an ongoing study (1).There was a significance difference in mean comfort (9.2 vs 6.7, p<0.0001, 95% CI -3.51 to -1.44) but not satisfaction (8.3 vs 7.7, p=0.2, 95% CI -1.48 to 0.33) between CCE and colonoscopy. Main cause of dissatisfaction with CCE was bowel preparation and for colonoscopy was discomfort. Age and gender were not found to be variables. The correlation between GCS and patient reported values was weak (R = -0.28).Overall, 77.5% (31/40) of patients would prefer a CCE if they required further bowel investigation. Of these, 77.4% (24/31) preferred a CCE despite the potential need for follow-up colonoscopy.Conclusions:CCE has a high satisfaction rating (8.3 vs 7.7) and has a higher patient reported comfort rating (9.2 vs 6.7) than colonoscopy. Studies have confirmed CCE and colonoscopy have equivalent diagnostic yields. The majority of patients in our cohort prefer CCE to colonoscopy. CCE should be considered as an alternative to colonoscopy in selected individuals.

Purpose of review: Small bowel diseases pose a unique diagnostic and management challenge and often requires tertiary specialist referral. The use of biomarkers may provide a cheap, noninvasive tool to assess the small bowel in terms of diagnosis, offering a better way to triage referrals and select patients for early management. This review looks at the most recent evidence behind the use of several faecal and urine biomarkers for small bowel diseases. Recent findings: Faecal calprotectin shows the most promise, with evidence to support its role in predicting relapse postsurgery and monitoring treatment response in patients with Crohn's disease. A faecal calprotectin less than 50 μg/g may also be used as a cut-off to triage further investigation. Faecal lactoferrin also appears promising as a marker of small bowel inflammation. A positive faecal immunohistochemistry test precapsule may help to prioritize referrals for obscure bleeding. Summary: The use of biomarkers in the diagnosis and management of small bowel disease is still controversial and remains unclear. More studies are required to further develop their potential and before societal guidelines can be developed to direct their appropriate use in clinical practice.

Introduction Lower gastrointestinal symptoms (LGS) are a common cause of referral to the gastroenterology service. International guidelines are available to prioritise referrals. Some studies have reported that symptoms alone are a poor marker of clinically significant disease (CSD) but symptoms remain the main way to prioritise referrals in routine clinical practice. Aims/background To correlate LGS with colonoscopy findings in an unselected patient cohort and to investigate whether using National Institute for Health and Care Excellence (NICE) guidelines improve risk stratification. Method Colonoscopy data over a 2-year period were obtained from our endoscopy database. Only patients with assessment of symptoms as their primary indication for colonoscopy were included. Patient records were retrospectively reviewed. Exclusion criteria: known inflammatory bowel disease (IBD), familial cancer syndromes, polyp and colorectal cancer (CRC) surveillance, and prior colonoscopy within 5 years. Demographics, symptoms and colonoscopy findings were recorded and analysed. Results 1116 cases were reviewed; 493 (44%) males, age 54.3 years (16–91). CSD occurred in only 162 (14.5%); CRC 19 (1.7%), high-risk adenoma 40 (3.6%), inflammation 97 (8.7%) (IBD 65 (5.8%), microscopic colitis 9 (0.8%) and indeterminate-inflammation 23 (2%)), angiodysplasia 6 (0.5%). Diarrhoea gave the highest diagnostic yield for CSD of 5.3% (OR 3.15, 95% CI 2.2 to 4.7, pConclusions The overall prevalence of CSD in our unselected symptomatic patients is low (14.5%). A holistic approach including combining symptoms and demographics with novel tools including stool biomarkers and minimally invasive colonoscopy alternatives should be applied to avoid unnecessary colonoscopy.

Growing evidence shows that inflammatory bowel disease (IBD) results from dysregulation of immune responses to gut microbes. T-cell receptors (TCRs) expressed on the T-cell surface play critical roles in discriminating pathogens from commensal intestinal microorganisms at the front line of the adaptive immune system. The breakdown of this interaction may trigger persistent inflammatory responses to gut bacteria, resulting in IBD. Taking advantage of high-throughput sequencing, we developed an integrated approach to dissect the intestinal TCR repertoires underlying IBD by collecting peripheral blood and inflamed intestine from the same set of 11 IBD cases. The intestinal TCR repertoires show lower clonotype diversity (p < 0.05) and stronger clonal expansion (p < 0.02) than those in the blood. This pattern becomes more profound in TCRs unique to the inflamed tissue compared with shared TCRs. Our approach further identified the increased usage of TRAV12-3 (false discovery rate, FDR < 5%), which biases its choices of J genes towards the reduction of TRAJ37 and TRAJ43 usage (FDR < 20%) in the inflamed intestine. Our genomic profiling suggests that this selective bias of V and J gene usage may lead to a loss of diversity in the intestinal TCR repertoires and result in mucosal inflammation in IBD.

Background and study aims The completeness of a polyp resection is an important determinant of quality in colonoscopy, and may reduce incidence of interval cancers. Incomplete resection rates (IRR) vary widely and range from 6.5 % to 22.7 %. Residual disease is more likely with larger polyps, for sessile serrated adenomas, and with more proximal lesions. Chromoendoscopy is increasingly employed in lesion detection. The aims of this study were to assess local IRR, and to determine whether chromoendoscopy could correctly identify residual disease post polypectomy. Patients and methods This was a prospective study examining post polypectomy sites. Chromoendoscopy (0.13 % indigo carmine) was applied to resection bases to identify residual disease. Targeted base biopsies were taken from identified residual disease (positive group) or random base biopsies were taken when a clear base was visualised (negative group). Overall rates of incomplete resection were documented. Reported rates post chromoendoscopy and actual histological rates were documented and compared. Results A total of 102 polyps were identified for inclusion, of which 15 % (n = 16) were excluded. Resection quality was evaluated in 86 polyps of 61 patients (female n = 33 54 %; mean Age 62.3 years). Polyps were mainly removed by cold snare (n = 71, 82.5 %). Most polyps (n = 58, 67 %) measured between 5 to 10 mm. Polyps were largely located in the right colon (n = 57, 66 %). Overall histological residual disease occurred in 17 /86 (19.6 %). Chromoendoscopy correctly identified residual disease in 13 of 17 bases (76.5 %). Only four of /86 (4.6 %) of polyp bases were missclassified post-chromoendoscopy (odds ratio 0.284 (95 % CI 0.0857–0.9409), P = 0.03). Conclusion Indigo carmine chromoendoscopy improves early detection of residual disease post polypectomy, reducing incomplete resection rates.