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Out of hours endoscopy: how, and why, to do it
The increasingly loud clamour about 7 day hospital working should alert gastroenterologists to the still unresolved ‘hot potato’ of out of hours endoscopy. Whilst some, well provided for areas, provide outstanding access to emergency endoscopy, such provision is not uniformly possible. While the debate about the patient- and financial-benefit of such a service continues, Simon Greenfield and colleagues have gone about and set up such a service over a large geographical area covering two general hospitals. In this edition of Frontline Gastroenterology they present their ‘recipe’ as well as contributing data to that debate about the potential benefits to patients and endoscopy unit practice. As ever, we welcome readers’ thoughts on their experience of, and beliefs in, such services.
Anticoagulation: keeping the endoscopist up-to-date
Those endoscopists who are part of a general medical rota will be familiar with the emerging range of anti-coagulants that their patients are being prescribed. For those endoscopists with a more specialised practice, we are delighted to print a highly practical review of these agents by Andrew Muller in this edition of the journal. The 2008 British Society of Gastroenterology guidelines are the definitive source for such information about warfarin, clopidogrel and aspirin. Until those guidelines are updated, we feel Dr Muller's empiric guidance about safe endoscopy for the patient taking Dabigatran and Rivaroxaban, especially as these agents do not have an available reversal agent in the event of post-procedure haemorrhage.
Hard to treat ascites: TIPSS for the real world
This edition of Frontline Gastroenterology sees another valuable hepatology manuscript, researching an area where an RCT is not practicable. A controlled study of TIPSS placement in patients with refractory ascites would be almost impossible to recruit to, so Mark Wright and colleagues have written up their 10 year experience of outcomes for this indication. The impact of TIPSS on encephalopathy and portal haemodynamics is well described in the literature, so the authors have focussed on treatment related costs and hospitalisations. They present a persuasive cost-efficacy analysis of the procedure in patients with medically refractory ascites. They also hint at the patient profiles which may be especially suited to such intervention.
Gastro-oesophageal dynamics: clinical presentations of abnormal physiology
Over the last decade, transient lower oesophageal sphincter relaxations have emerged as a key physiological substrate of GORD in many patients. Given the complexity of overlap with other, longer described pathophysiological changes such as reduced lower oesophageal pressure and hiatus hernia, the evolution of targeted therapies has been slow to emerge. But as these, and potential toxicity issues come to be addressed, it is timely to include a review of the clinical relevance of these transient relaxations. In a separate article, Nigel Trudgill presents a highly practical approach to the diagnosis and management of rumination syndrome. This under-recognised condition has a distinctive symptom profile and associated physiological changes which can aid diagnosis.
Pouchitis: established and emerging therapies
Patients with chronic pouch dysfunction are increasingly being seen in gastroenterology clinics, referred on by surgical colleagues. Establishing the presence of dysfunction requires both a knowledge of normal pouch function as well as a logical approach to investigation. We are delighted to publish a review by Hillary Steinhart and Ofer Ben-Basatt of Mount Sinai Toronto which helps with this knowledge base. In addition, there is a highly downloadable algorithm, to help the clinician to organise a rational approach to treatment of this highly troublesome condition.