Serum ammonia use: unnecessary, frequent and costly

This is an important topic and an interesting paper to work through. Serum ammonia is important for the diagnosis and management of urea cycle disorders and acute liver failure. Based on the premise that serum ammonia levels are unreliable for the diagnosis of hepatic encephalopathy (HE) and not associated with the severity of HE in individuals with cirrhosis Aby and colleagues looked at serum ammonia ordering in adult patients presenting to a large mid-western healthcare system – 20 338 tests (8536 patients) over 5 years. 53% of the cohort had chronic liver disease, 8 patients had a Urea Cycle Disorder, 69 patients had Acute Liver Failure and 148 were on Sodium Valproate. Of the 20 338 tests, 1138 (6.5%) were ordered for a definitive, appropriate indication, while the remainder were felt to have been ordered inappropriately. There was no change in the proportions over time. This data has significant financial implications with hence the title – serum ammonia use: unnecessary, frequent and costly with the need to educate clinicians regarding appropriate ammonia testing - in essence when to do and when not to do – we don’t, for example, want to miss a urea cycle disorder. There is an excellent accompanying commentary Testing for ammonia: do as I say, not as we do which includes a nice table on when to test in the hospital setting (See page 275) .

Anorexia nervosa and the gastrointestinal tract

Anorexia nervosa is a complex eating disorder associated with a high morbidity and mortality. The incidence (and therefore prevalence) is increasing. In this issue Jafar and colleagues review the presenting features relating to and impacting on the gastrointestinal tract. There is significant overlap with the symptoms and signs of organic and non- organic gastrointestinal disease which can make the diagnosis and management challenging. Early involvement of the multidisciplinary team in management is essential including, when nutritional impairment is severe, careful nutritional therapy under the guidance of nutritional support teams. The authors discuss specifics including the diagnostic criteria, multiple gastrointestinal manifestations (there is an excellent figure) and impact of treatment. Essential reading for gastroenterologists – listen to the accompanying podcast – Editor’s Choice this month (See page 316) .

Is duodenal biopsy always necessary for the diagnosis of coeliac disease

This is controversial in adults although well established in paediatric practice where a ten fold increase in anti-tissue transglutaminase antibody (anti-TTG IgA) plus anti-endomysial antibody positivity is sufficient to make the diagnosis of Coeliac Disease (CD) without the need for biopsy. In this issue Beig et al report on 144 patients (anti-TTG IgA antibody positive) biopsied between 2013 and 2018. Of the 144, 88 had CD confirmed. In this cohort all of the patients with greater than 10 times the upper limit of normal anti-TTG IgA had Coeliac Disease confirmed on biopsy. This is consistent with other data. Life threatening co-existent conditions were rare. The detail is in the paper. These findings support the approach of serology-based diagnosis of CD in risk stratified patients where ‘red flags’ for other conditions are not present. This has the potential to reduce unnecessary procedures and reduce the wait time for more urgent cases in the stressed healthcare system post COVID-19 (See page 287) .

Photodocumentation in colonoscopy: the need to do better?

There is wide variation in the recommendations for photodocumentation at colonoscopy. In this issue Ahmad et al review current guidance - photographic proof of ileo-caecal valve, terminal ileum or anastomosis, documentation of any other part of the colon is not mandated – and present the potential for, strategies for and the challenges of improving. In essence discussing the pertinent question as to whether more comprehensive photodocumentation will lead to improvements in the quality and reliability of the examination. The authors discuss current standards – audits 2011,2018 showed photodocumentation to confirm caecal intubation in just over 50%, barriers to improvement and future strategies including how to take better photographs. The paper should be read by all endoscopists and challenge us to look at our own practice – many factors are relevant including time taken to take the images and the quality of the image capture and recording system. I am sure standardisation of guidance (like for gastroscopy) would at least help move things forward (See page 337) .

Artificial intelligence and inflammatory bowel disease: practicalities and future prospects

Artificial Intelligence (AI) is an emerging field which has the potential to impact significantly on the quality of care and outcome in clinical medicine. In this issue Brooks-Warburton and colleagues review the recent development and opportunities for application in Inflammatory Bowel Disease. The authors discuss the common approaches including deep and machine learning (see figure one). The different methodologies can be applied to all aspects of the patient journey including genomics, endoscopy, disease classification, risk stratification, self-monitoring and personalised management – nicely summarised in figure two. The potential is massive and adds to clinical trial data when deciding how best to diagnose then manage the new patient to achieve the best long term outcome (See page 325) .

Twitter debate: controversies in pregnancy in IBD and liver disease

Please read and enjoy the write up the twitter debate on controversies in pregnancy in IBD and liver disease – important discussions on management of IBD during pregnancy, colonoscopy during pregnancy, liver disease in pregnancy, acute fatty liver disease in pregnancy and the importance of the multidisciplinary team. Please consider participating in our future debates – great way to engage and discuss important topics (See page 355) .

Gastroenterology 2022: Groundhog Day

Finally – our trainee associate editors challenge us to ‘learn by reflection’ with an engaging summary of where we are with COVID-19 written during the January 2022 surge in infections – so much has happened over the last 2 years – unprecedented times – we have had to learn how to adapt and be resilient while constantly striving to improve all aspects of the ways we work, learn and provide healthcare (See page 349) .

Please enjoy this issue. Please continue to read, enjoy, and feedback on the journal. Follow us on twitter @FrontGastro_BMJ and listen to our regular podcasts accessed via the journal website https://fg.bmj.com/