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Upfront October 2012
  1. Anton V Emmanuel

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The clinical diagnosis of abdominal pain – improving practice for gastroenterologists (and surgeons)

Patients with abdominal pain are often quickly labelled as having irritable bowel syndrome (IBS) once organic disease has been excluded. The possibility of chronic abdominal wall pain (CAWP) syndrome is not often considered in the differential at that stage, partly through lack of awareness and partly due to difficulty of specific diagnosis. van Assen and colleagues from the Netherlands have developed and validated an instrument for the identification of CAWP syndromes, which we are delighted to publish in Frontline Gastroenterology. Patients with CAWP have a three-fold increased risk for being operated on compared to matched population. Use of this novel instrument could have repercussions for both clinical practice and appropriate identification of patients for research.

Paediatric endoscopy: what is the standard of care?

Little is known of the state of practice of endoscopy amongst paediatric patients in the UK or indeed worldwide. The paper in this edition of Frontline Gastroenterology by Muhammed and colleagues provides important new information in this area. It is based on a survey questionnaire undertaken by the British Society of Paediatric Gastroenterology Hepatology and Nutrition (BSPGHAN). The results have important implications for provision and training of such paediatric endoscopy services, but also for the transition of paediatric patients in to adult care. The authors have also highlighted the potential options to address the clinical challenges highlighted by this survey, and the manuscript makes compulsory reading for all Units which undertake endoscopic procedures in children or offer anadolescent transition service. One hot topic raised by the manuscript is whether the final endoscopy prior to transition to an adult gastroenterology service should be under sedation. Could your Unit undertake this service if you agree it should be done as such?

This edition also features a second paediatric endoscopy paper, looking at the topic of wireless capsule endoscopy children under the age of four years. A review of the practice from a single expert centre at King's College Hospital London suggesting that it is a relatively complication-free procedure with reasonable diagnostic yield in that setting.

Setting up a local endoscopic mucosal resection EMR service

Is it preferable to develop a separate, new EMR service rather than simply sending cases to a regional expert who carries out the procedure and associated education? A high quality audit of such a newly established local service is described by Lamb and Barbour, allowing the reader to learn of the potential benefits, pitfalls and advantages of such a service initiative.

Use of hyoscine (buscopan) in colonoscopy: what do you do, and based on what evidence?

Current BSG guidelines suggest that a history of angle closure glaucoma is a contraindication for administering hyoscine at colonoscopy. But the ophthalmology knowledge base does not really support this recommendation. Bedford and colleagues suggest that such underuse of this smooth muscle relaxant drug may result in under-detection of colonic adenomas. An accompanying Opinion piece by Sunil Dolwani presents the evidence in favour and against this supposition. The key points arising from this pair of articles is that patients need to be appropriately counselled and that medication is not a substitute for optimal colonoscopic technique.

Steroid use in acute ulcerative colitis

Another common clinical situation with a surprisingly uncertain evidence base is the use of corticosteroids in acute severe ulcerative colitis. Maybe unsurprisingly, therefore, in this UK based survey study, there is wide variation in practice. This is especially the case with regard to steroid tapering regimes, and as such should act as a reminder to the reader of the toxicity issues associated with steroids. The manuscript ends with a challenge / opportunity for a young researcher to undertake a proposed possible study to provide the data to help iron out these inconsistencies.

Use of the FRAX tool in cirrhosis patients at risk of fracture

The WHO Fracture Risk Assessment tool (FRAX) has been studied in patients with inflammatory bowel disease who are vulnerable to osteoporosis. Ayres et al from Bristol present a first application of the FRAX tool in a cohort of patients with cirrhosis. Their study also compares this instrument with the BSG and NICE guidelines on managing patients at risk of osteoporotic fracture. Their data has direct patient and resource implications, showing that use of FRAX reduces both the number of DEXA scans required, and the proportion of low risk patients who receive osteoporosis treatment inappropriately.

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