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Endoscopic biopsies: when to do it and, as importantly, when not to do it
Gastrointestinal (GI) pathology practice and research in the UK has a distinguished academic and clinical history. Neil Shepherd and colleagues from the Endoscopy and Pathology Sections of the British Society of Gastroenterology have authored a trio of articles published in this edition of Frontline Gastroenterology to offer practical guidance on upper and lower GI endoscopic biopsy practice. The articles are written jointly by a pathologist and an endoscopist and provide practical guidelines to rationalize the use of biopsies in the gastrointestinal tract. The authors have clearly defined the value, or lack of value, of taking biopsies in common clinical and endoscopic scenarios. The articles set the grounds for specific guidelines in upper and lower GI tract biopsies which will help defining gold-standards and rational use of precious histopathology resources. The twin factors of (1) inception of the cancer screening programmes has seen an increased workload in histopathology departments and (2) improved endoscopic techniques allowing for targeted biopsies makes these articles especially timely. A move toward rationalising biopsy protocols to maximise histopathological diagnosis and minimise unnecessary biopsies would have profound effects for patients, clinicians and service provision. The papers feature tabular guidance of what to biopsy and what not to, as well as instructions on how to take samples: these are tailor made of mounting on walls of Endoscopy Units as well as forming a reference standard for audit projects.
Up to date guidance on management of alcoholic hepatitis and pregnancy in hepatitis B infection
The Curriculum Based Review series in Frontline Gastroenterology offers the opportunity for trainees to learn and self-assess with regard to discrete areas of the core curriculum, but the series also provide for state-of-the-art reviews on important clinical areas. And there are few topics that are currently hotter than alcoholic liver disease, given the burden of the problem in general hospitals and specialist hepatology units. This edition's review of the up to date management of alcoholic hepatitis, from the unit in Birmingham UK, is an important publication summarising information that has recently been reviewed by NICE and the European and American societies for the study of liver disease. In a disease as prevalent and fatal as alcoholic hepatitis it is a surprise that the evidence base features so many underpowered series, reinforcing the need to provide consensus and point to future research directions. This review by Parker and McCune informs the reader of the utility of severity scoring systems and also provides a contemporary review of appropriate pharmacological and nutritional approaches.
Also in this edition is a retrospective study from the group in Newcastle, looking at the management of pregnant women with active Hepatitis B virus (HBV), specifically those with high levels of HBV DNA. The key findings that as many as 17% of the women had active infection, of whom two-thirds had no knowledge of being HBV positive, makes a strong argument for the undiagnosed prevalence of the condition.
Do you follow guidance or not? Use of NSAIDs in prevention of post-ERCP pancreatitis
A survey of practice can provide for interesting, and occasionally uncomfortable reading. Hanna et al in this edition report on such a survey regarding post-ERCP pancreatitis (PEP) prevention – one of the great strengths of their findings is a high response rate (60%) in comparison to other similar reports. As such the approximately 50% use of prophylactic pancreatic stent is a helpful benchmark; more surprising was the observation that only about a third used NSAIDs to prevent PEP. In light of the European Society of Gastrointestinal Endoscopy guidelines summarising the data for stenting and NSAIDs, this paper highlights the potential for updating practice in all units.
The constant belcher
The patient who is referred to practice with incessant belching is usually easily identified as not having any underlying organic pathology. The trickier issue is the approach to management. Disney and Trudgill in this edition of Frontline Gastroenterology provide an update of the new evidence on formal and office-based behavioural therapies to manage some of these highly symptomatic individuals.