Introduction

As part of the NHS Long Term Plan, ambitions were set that from 2028, an extra 55,000 people will survive for five years or more following cancer diagnosis. The aim was in part to minimize time taken from initial presentation to definitive diagnosis of cancer. “Serious non-specific symptom” (SNSS) cancer pathways were developed in 2019, to aid GPs in referral of patients with vague alarm symptoms, that were still concerning for malignancy, although maybe not fitting a pre-existing system specific, cancer referral pathway (1). Non-specific symptoms commonly include weight loss, unexplained pain and fatigue which could suggest an underlying cancer diagnosis. Within our trust, GPs can refer for an urgent CT Chest, Abdomen and Pelvis, and results are reviewed in a weekly multi-disciplinary meeting. Following this, patients are either discharged back to their GP with advice, or referred on to appropriate cancer pathways. Due to common presentations such as weight loss, this is currently run by the Gastroenterology department. Benign disease is also highlighted to GPs to consider appropriate onward referral.

Aims & Methods

This audit aimed to look at patients referred to our local SNSS pathway, evaluate cancer pick-up rate, cancer type, and benign disease prevalence. To date, there are little relevant published data within the UK, despite information being available within Europe, such as one Danish study which detected a pick-up rate of between 11-20% (2).  We designed a retrospective audit looking at all patients referred via the SNSS pathway from February 2023 to September 2023 in South Tyneside and Sunderland NHS Foundation Trust. Electronic notes were reviewed. We looked at referral indication, inappropriate referrals (those that met pre-existing suspected cancer pathways), cancer pick-up rate, type, and whether this was metastatic at diagnosis.

Results

502 patients were reviewed, over 30 MDT meetings. This was evenly split between male (45%) and female (55%) patients, with an average age of 71 years. The most common symptom prompting referral was weight loss, in 74.1% of referrals. Of these patients, 7.5% were diagnosed with cancer. Other common symptoms included fatigue (22.5%), abdominal pain (20.7%), anorexia (13.9%) and generalised pain (13.1%).  The overall cancer pick-up rate was 8.6%, with 43 patients found to have a cancer diagnosis. Almost 6% of patients were inappropriately referred to this pathway, having met criteria for pre-existing system specific cancer pathways. However, excluding these patients, overall cancer pick-up rate remained at 8.4%. The most common primary cancers were upper gastrointestinal (25.6%), lung (23.3%) and haematology (11.6%). 37.2% of cancer diagnoses had metastatic disease. Benign pathology was detected in 65% of patients.

Conclusion

Overall cancer-pick up rates in our audit, suggest that the SNSS pathway has a similar pick-up rate to existing urgent suspected cancer pathways (around 7%). This shows that the pathway is valuable in assessing vague symptoms that may not meet pre-existing diagnostic pathways but still have a high incidence of cancer. This is a valuable tool for GPs to use when they have clinical concern about cancer, but non-specific presentations. There are areas for improvement, with 5.6% of inappropriate referrals, potentially highlighting a lack of awareness of pre-existing criteria for cancer diagnostic pathways. We suggest that further national analysis could be done, on impact and effectiveness of SNSS pathways, including long-term outcomes of patients, as improvements in 5-year cancer survival remain unclear.

References

1. NHS Cancer Programme: Faster Diagnosis Framework (2019) , www.england.nhs.uk/cancer/faster-diagnosis [accessed 21 March 2025]
2. Grønnemose, R.B., Hansen, P.S., Worsøe Laursen, S. et al. Risk of cancer and serious disease in Danish patients with urgent referral for serious non-specific symptoms and signs of cancer in Funen 2014–2021. Br J Cancer 130, 1304–1315 (2024). https://doi.org/10.1038/s41416-024-02620-y

Clinical Case Summary

A 58-year-old male attended with epigastric pain, acid reflux and dyspepsia. An upper endoscopy was performed showing a longitudinal ulcer in gastric incisura of which biopsies were taken (Figure 1). Histopathology revealed lymphoid proliferation of large cells with discrete cytoplasm and irregular, vesicular nuclei, with nucleoli and frequent mitotic figures. Helicobacter pylori (HP) was positive in the samples and immunohistochemistry analysis revealed positive CD20 and CD79a and negative CD3 and CD5. CD10 was also negative and Ki67 proliferation index was of 80-90%. Immunofluorescence analysis with FISH technique revealed EBER, c-MYC, BCL2 and BCL6 all negative (Figure 2). A diagnosis of diffuse large B-cell lymphoma (DLBCL) was made, and the patient was referred to hematology department. Positron emission tomography and Computed tomography (PET-CT) showed gastric involvement (SUVmax 10,35) and hilar, paratracheal, interlobar, subcarinal and mediastinal areas of increased metabolism demonstrating active lymphoproliferative supra and infra-diaphragmatic disease (Figure 3). He started treatment with R-CHOP according to guidelines. After 3 months a reduction in size and hypermetabolism was observed in control PET-CT revealing adequate response to treatment.
Lymphoproliferative diseases can present with gastrointestinal involvement and first symptoms in a low percentage of cases, being gastric location the most prevalent. Symptoms are most times nonspecific as reflux and dyspepsia so endoscopic studies are crucial to establish a differential diagnosis with other entities, with a remarkable importance of adequate biopsy samples in order to stablish a correct diagnosis. HP infection has a role in pathogenesis of gastric lymphomas, and it must be eradicated. Molecular and extension studies nowadays guide best treatment and prognosis in DLBCL.

References

1. Fox CP, Chaganti S, McIlroy G, Barrington SF, Burton C, Cwynarski K, Eyre TA, Illidge T, Kalakonda N, Kuhnl A, McKay P, Davies AJ. The management of newly diagnosed large B-cell lymphoma: A British Society for Haematology Guideline. Br J Haematol. 2024 Apr;204(4):1178-1192.
2. Graham DY. History of Helicobacter pylori, duodenal ulcer, gastric ulcer and gastric cancer. World J Gastroenterol. 2014 May 14;20(18):5191-204.
3. Doglioni C, Ponzoni M, Ferreri AJ, Savio A; Gruppo Italiano Patologi Apparato Digerente (GIPAD); Società Italiana di Anatomia Patologica e Citopatologia Diagnostica/International Academy of Pathology, Italian division (SIAPEC/IAP). Gastric lymphoma: the histology report. Dig Liver Dis. 2011 Mar;43 Suppl 4:S310-8.

Introduction

Duodenal covered self-expandable metal stent (SEMS) placement is used to treat gastric and duodenal stenosis. The main adverse event after duodenal SEMS placement is stent migration. We evaluated the stent fixation with a novel over-the-scope clip device (stentfix OTSC^® System; Ovesco Endoscopy AG, Tübingen, Germany) to prevent migration.

Aims & Methods

This is a single-center retrospective observational cohort study performed to analyze stent migration rates before and after availability of the stentfix OTSC^® System. A cohort of patients who underwent SEMS fixation with the stentfix OTSC^® system (SC cohort) was compared with an historical cohort of patients (NC) who did not receive any other stent fixation method before the stentfix OTSC system became available. Outcome variables including technical success, adverse events and clinical success were analyzed.

Results

45 patients (SC cohort, 15; NC cohort, 30) underwent covered duodenal SEMS implantation for benign conditions. The technical success rate of stent fixation was 100%. No procedure-related adverse events occured. The stent migration rate was significantly lower in the SC cohort compared with the NC cohort (6.66% vs 36.66%). 20% of adverse events were observed during the withdrawal of the OTSC (3 AGREE grade IIIa :one delayed bleeding, one buried-in stentfix treated with APC and one mucosal tear fixed with classic clips).

Conclusion

In patients with benign pyloro-duodenal stenosis, there was a significantly lower stent migration rate with the stentfix OTSC system compared with those without stent fixation. The application was technically successful in all cases, no adverse events related to OTSC fixation and 20% moderate adverse events following the removal were observed.

References

Duodenal stent migration. Tringali A, Mutignani M, Spera G, Costamagna G.Gastrointest Endosc. 2003 Nov;58(5):759. doi: 10.1016/s0016-5107(03)01878-9.
Patient-related adverse events and device failures associated with commercially available enteral or duodenal self-expanding metal stents: an analysis of the MAUDE database.Kennington D, Ramai D, Adler DG.Gastrointest Endosc. 2023 Feb;97(2):309-313. doi: 10.1016/j.gie.2022.10.008. Epub 2022 Oct 8.PMID: 36220381

Introduction

Psychological stress as a result of the war in Ukraine negatively affects children's health, leading to the onset/exacerbation of metabolic dysfunction [1, 2]. Metabolic dysfunction-associated steatotic liver disease (MASLD) is a multifactorial condition that affects both adults and children and includes several mechanisms associated with excessive fat accumulation in hepatocytes, inflammation, and insulin resistance [3].

Aims & Methods

The aim of the study was to determine the impact of war-related anxiety on proinflammatory cytokines (IL-6, TNF-α) and insulin resistance in Ukrainian children with MASLD.
The study included 42 obese children with MASLD aged 6 to 17 years; the mean age was 12.00±0.56 years. Determination of the presence of liver steatosis was performed by transient elastography (FibroScan®502touch, Echosence, France). The presence of obesity was confirmed by bioimpedance analysis (TANITA MC-780MA, Japan). Screening for anxiety was performed using the Screen for Child Anxiety-Related Disorders (SCARED) questionnaire. Depending on the presence of anxiety, obese children with MASLD were divided into 2 groups: Group I - 12 children without anxiety disorders, Group II - 30 children with anxiety disorders. The control group consisted of 10 children of normal weight without anxiety disorders. Quantitative determination of insulin concentration in the serum was performed by ELISA using Monobind Inc. test systems, USA, and the HOMA-IR was calculated. Quantitative determination of the concentration of IL-6 and TNF-α in the blood serum was performed by ELISA using test systems from LDN LaborDiagnostika (Germany).

Results

An increased level of proinflammatory cytokines was observed in 50.0% of the children of group I and 56.7% of the children of group II. The median level of TNF-α was 3.2 times higher (p<0.05) in patients of group I and 2.5 times higher (p<0.05) in patients of group II compared to the control group. The content of anti-inflammatory IL-10 in the I and II groups did not differ from the control.
Moreover, the indicators of carbohydrate metabolism in obese children showed statistically significant differences: in patients of group I a significant increase in the median insulin level (2.1 times, p<0.05) and the HOMA-IR (2.7 times, p<0.05) was found compared to control group as well as in patients of group II - in 2.1 times (p<0.05) and the HOMA-IR - in 2.8 times (p<0.05), respectively.

Conclusion

Thus, the presence of anxiety in children with MASLD is accompanied by the elevation of proinflammatory cytokines and insulin resistance.

References

1. Wang, Z., Jiang, B., Wang, X., Li, Z., Wang, D., Xue, H., & Wang, D. (2023). Relationship between physical activity and individual mental health after traumatic events: a systematic review. European journal of psychotraumatology, 14(2), 2205667. https://doi.org/10.1080/20008066.2023.2205667.
2. López-Medina JA, López-Rodriguez C, Estornell-Gualde MA, Rey-Fernández L, Gómez-Senent S, Joaquín-Ortiz C, et all. Relationship between nutritional treatment compliance and nutritional status improvements in patients with gastrointestinal impairment taking an oral peptide-based supplement. Nutrition. 2022 Oct;102:111734. doi: 10.1016/j.nut.2022.111734.
3. Jebeile, H., Kelly, A. S., O'Malley, G., & Baur, L. A. (2022). Obesity in children and adolescents: epidemiology, causes, assessment, and management. The Lancet. Diabetes & endocrinology, 10(5), 351–365. https://doi.org/10.1016/S2213-8587(22)00047-X.

Introduction

Exclusive enteral nutrition (EEN) is a well-established first-line treatment for inducing remission in paediatric Crohn's disease, however, its use in adult Crohn’s disease treatment remains limited. In adults, 22% of patients require surgery within the first five years after diagnosis¹, with postoperative complication rates reaching around 25%². This study investigates whether preoperative EEN can reduce postoperative complications in adults with Crohn’s disease undergoing elective surgery.

Aims & Methods

A systematic search was conducted on October 26, 2024, across three databases: PubMed, EMBASE, and the Cochrane Library. Studies were included if they involved at least two weeks of preoperative EEN and reported postoperative outcomes. The primary outcomes were anastomotic leakage, stoma formation, and abscess formation, while the secondary outcome was the length of hospital stay. The odds ratio (OR) and mean differences (MD) with their 95% confidence interval (CI) were calculated using a random-effect model.

Results

A total of 11 studies, including 2112 patients, were included in the analysis. EEN significantly reduced the odds of anastomotic leakage (OR=0.29, CI: 0.19-0.47), stoma formation (OR=0.39, CI: 0.09-1.73), and abscess formation (OR=0.41, CI: 0.23-0.72). However, there was no significant reduction in the length of hospital stay (MD: 0.88 days, CI: -1.85-0.09).

Conclusion

Preoperative EEN significantly reduces the risk of anastomotic leakage, stoma formation, and abscess formation, leading to improved postoperative outcomes. These findings support adding EEN into preoperative management for adult Crohn’s disease patients undergoing elective surgery to enhance recovery and minimize complications.

References

1. Burisch, J., et al.,(2019). Natural disease course of Crohn's disease during the first 5 years after diagnosis in a European population-based inception cohort: an Epi-IBD study. Gut, 68(3), 423–433. https://doi.org/10.1136/gutjnl-2017-315568
2. Luglio, G., et al.,(2022). Post-operative morbidity in Crohn's disease: what is the impact of patient-, disease- and surgery-related factors?. International journal of colorectal disease, 37(2), 411–419. https://doi.org/10.1007/s00384-021-04076-5

Introduction

The endoscopy suite is the primary workplace where most gastroenterologists spend the majority of their clinical practice time. With the advancement of increasingly complex diagnostic and therapeutic procedures, an ergonomically designed gastrointestinal endoscopy unit is not only desirable but essential.
The objective of our study is to assess compliance with ergonomic measures in endoscopic practice, as well as the various impacts on health.

Aims & Methods

We conducted a cross-sectional study over a six-month period, from August 2024 to January 2025, based on an anonymous individual electronic questionnaire in French. The survey was distributed via social media platforms and targeted gastroenterology residents and specialists.
The questionnaire consisted of two sections: endoscopic procedures, and ergonomics and personal protection.
Data were entered and analyzed using Excel 2021.

Results

A total of 38 participants completed the questionnaire. The mean age was 30.65 years [26–39], with a female predominance (63.2%), corresponding to F/H ratio of 1.7.
Overweight status was reported in 50% of respondents (n=19). Physical activity was practiced by 65.7% (n=25) of participants, of whom 76% (n=19) exercised occasionally and 24% (n=6) regularly.
The majority of respondents were gastroenterology residents (68%, n=26), while 12 were specialists with an average of 2.9 years [5–10] of endoscopy experience. Right-handedness was reported in 92% of cases (n=35).
The average number of procedures per week included six upper endoscopies and 3.6 colonoscopies, with an average of 8.5 hours of endoscopic activity per week per respondent.
Only 50% (n=19) of participants performed interventional endoscopy, with polypectomy being the most common procedure (94%, n=18/19).
None of the respondents had received prior ergonomic training before practicing endoscopy.
Regarding the assessment of knowledge on ergonomic practices, several key elements were analyzed.
A neutral posture of the neck and head was correctly identified by 57% of respondents.
Concerning optimal monitor positioning, 65% of participants correctly recognized that it should be placed directly in front of the operator, and 70% cited the appropriate viewing distance of 50 to 180 cm.
The ideal viewing angle between 15° and 25° below eye level was accurately identified by 81% of respondents.
Continuing with the evaluation of working conditions in endoscopy, the analysis of workplace setups aimed to determine whether practitioners benefit from an ergonomic environment.
The configuration of workstations revealed some variability:
Monitor height was adjustable for 81% of practitioners,
An adjustable procedure table was available to 86% of respondents,
And 73% of physicians had access to modifiable lighting.
All endoscopists inserted the scope using their right hand. Manipulation of the control dials was performed with a single hand in 55.3% (n=21) of cases.
However, the use of ergonomic support devices remains very limited: only 11% of endoscopists reported using anti-slip flooring, and just 2.7% used cushioned insoles.
Musculoskeletal pain was reported by 57.9% (n=22) of respondents, primarily in the lower back (68.2%, n=15) and the neck (54.5%, n=12).

Conclusion

Ergonomic training should be an integral part of every endoscopist’s professional development, aiming to minimize musculoskeletal injuries associated with overuse of endoscopes. Among the most important ergonomic principles is the maintenance of neutral postures, which allow for maximum force production with minimal energy expenditure.

Introduction

Hypertriglyceridemia (HTG) is an underdiagnosed etiology of acute pancreatitis (AP), traditionally reported in 1–7% of cases. However, emerging evidence suggests that its true prevalence may be significantly higher. Prompt identification and effective management of HTG-induced AP are essential, yet standardized treatment approaches remain limited. This study aimed to assess the prevalence of HTG-induced AP and evaluate insulin infusion as a first-line therapeutic strategy.

Aims & Methods

We retrospectively analyzed 200 adult patients admitted with AP at [Hospital Name] between January 2023 and December 2024. Patients with serum triglyceride levels ≥11.3 mmol/L (≥1000 mg/dL) and no other identifiable causes of AP (e.g., gallstones, alcohol use) were included. Demographic data, comorbidities, treatment modalities, and outcomes were reviewed. A favorable response to insulin therapy was defined as a ≥50% reduction in serum triglyceride levels within 72 hours. Statistical analysis was performed using SPSS; p<0.05 was considered statistically significant.

Results

HTG was identified as the primary cause of AP in 40 out of 200 patients (20%). Among these, 60% had type 2 diabetes mellitus, 50% were obese (BMI ≥30 kg/m²), and 35% reported regular alcohol use. All patients were initiated on insulin infusion. Thirty-four patients (85%) responded favorably, while six (15%) required plasmapheresis. The mean hospital stay was significantly shorter in the insulin-only group compared to those requiring plasmapheresis (5 vs. 8 days, p<0.01), with a lower complication rate as well (10% vs. 25%, p<0.05). No in-hospital mortality occurred.

Conclusion

HTG-induced AP may be substantially more prevalent than previously recognized. Routine triglyceride screening should be considered in AP cases with no obvious cause. Insulin infusion is a safe, effective, and widely accessible first-line therapy that may reduce complications and length of hospital stay. These findings support early metabolic assessment and proactive risk factor management to improve clinical outcomes.