What is the clinical significance of low serum amylase? A systematic review of the conditions associated with low serum amylase

We (mostly) think of abnormal serum amylase as being elevated. In this issue, Jalal and colleagues report a systematic review of the conditions associated with low serum amylase. The authors found 19 studies reporting 15 097 patients. The main conditions associated with low serum amylase were diabetes mellitus, metabolic syndrome, chronic pancreatitis (CP), non-alcoholic fatty liver disease and obesity. Low serum amylase showed a high specificity (94%) with low sensitivity (38.7%–59%) in diagnosing CP. The clinical implications are of interest. The authors suggest low amylase can be part of a metabolic process making it a useful metabolic marker in cases like obesity, metabolic syndrome and diabetes mellitus. It can be used as an exocrine marker and trigger investigation for pancreatic exocrine insufficiency. (See page 153)

Chronic abdominal pain in inflammatory bowel disease: a practical guide

Chronic abdominal pain is common in inflammatory bowel disease (IBD) and not always straightforward to manage. In this issue, Baille and colleagues present a practical guide. The authors start by reviewing pain pathways (see figure 1). It is important to listen to the patient’s symptoms and acknoweldge their impact. It is important to assess, investigate and treat modifiable causes (see figure 2). Pain management requires an integrated, holistic and multimodal approach. Multiple different medications and dietary approaches can be tried—discussed in detail in the paper including sections on non-steroidal anti-inflammatory drugs, antispasmodics, antidepressants (including tricyclic antidepressants), cannabinoids and gabapentin. Opioid medications are not generally helpful. Addressing diet and lifestyle is essential. The FODMAP diet may offer short-term benefit to those with coexistent irritable bowel syndrome. Psychological therapies, if available, including cognitive-behavioural therapy can improve pain as well as quality of life. The detail in the review reflects the challenge of pain management in IBD and many other chronic medical conditions. Essential Reading. Editor’s Choice this month. (See page 143)

Novel, nurse-led early postdischarge clinic is associated with fewer readmissions and lower mortality following hospitalisation with decompensated cirrhosis

Patients with decompensated cirrhosis have a high rate of (unplanned) readmission following discharge from a hospital mostly due to complications such as ascites or hepatic encephalopathy, which are potentially avoidable if medical treatment is optimised. In this issue, Giles and colleagues report on the impact of a nurse-led early postdischarge clinic delivering goal-directed care for cirrhosis complications and evaluating the impact. Seventy eight patients seen in the clinic were matched with 91 controls (standard care). Median time to readmission was increased from 51 days (controls) to 98 days (intervention group) with fewer admissions at 30 and 90 days and a significant reduction in bed day usage and mortality. This strategy—early postdischarge support and review—is an essential part of the ambition to reduce the time in hospital and improve quality of care in patients with chronic liver disease. (See page 123)

Significance and structure of clinical research in the UK: an introduction for gastroenterology and hepatology nurses

Research is an essentail part of a modern, effective health service and integral to the delivery of safe and effective high-quality clinical care. In the first of two articles in this issue, the British Society of Gastroenterology (BSG) Nurses Association and Research Committee review the current landscape. This includes the discussion of the structure of the National Institute for Health Research and the importance of encouraging nurse engagement in research and the well-established clinical trial infrastructure in the UK. One of the first steps to getting involved in research is to understand the research environment. Good clinical practice training is generally straightforward to access and helpful. BSG plans to work with teams to move things forward. In the second article, ‘Stepping into nursing research: an introduction for gastroenterology and hepatology nurses’, some of the practicalities (and barriers) are discussed in detail. The aspiration is to move things forward—see the key points.

In summary, research embedded in practice, led by and supported by the full multidisciplinary team, is exciting, enables change and will deliver better care for our patients with chronic gastrointestinal disorders. (See page 169)

Cost-benefits and environmental impact of the no-biopsy approach for the diagnosis of coeliac disease in adults

Recent data suggest that patients with IgA tissue transglutaminase levels of ≥10× the upper limit of normal can be diagnosed with coeliac disease without undergoing endoscopy and biopsy. In this issue, Shiha and colleagues explore the potential environmental cost and benefit. The authors suggest that around 3000 fewer endoscopies could be done a year, that is, 30% of the current 10 000 based on previous data showing 30%–50% would fulfil the diagnostic cut-offs above. This could result in a very significant reduction of indirect and direct costs and a significant reduction in the endoscopy carbon footprint. The details are in the paper. This is an important consideration in an environment where healthcare resources are limited and climate change is advancing rapidly. (See page 94)

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