ABSTRACT
Introduction ACPGBI and ESCP guidelines suggest colonic examination after acute complicated diverticulitis due to a higher prevalence of colorectal cancer (CRC), but colonoscopy in this cohort can be challenging. We examined completion rates, pain scores and analgesic use in endoscopic follow-up of complicated diverticulitis in a district general hospital. Methods Patients were identified from hospital records with a coded diagnosis of acute diverticulitis from 01/01/2021 - 01/ 07/2021. Electronic records were examined to identify those with complicated diverticulitis on CT who had not had surgery. The endoscopy system was interrogated from 01/01/2021 - 01/01/2022 for these patients. Information was collected on: whether colonoscopy was requested and performed, site reached, quality of mucosal views, pain scores (average of physician and nurse), analgesia and sedation use, and reason for incomplete colonoscopy. We gathered the same data for the preceding and/or succeeding patients on the endoscopy list for comparison. Results From 01/01/2021 - 01/07/2021 there were 49 cases of acute complicated diverticulitis;4 had emergency surgery. of the remaining 45 cases, 28 had a colonoscopy requested. By 01/01/2022, 17 had an colonoscopy (group 1), and the mean time from discharge to endoscopy was 108 days. These were compared to the 26 colonoscopies immediately preceding or succeeding the group 1 colonoscopies (group 2). Colonoscopy completion rates were lower in group 1, and reasons for incomplete examination were: patient discomfort x2, tight angulation x1, muscular hypertrophy x1. Reasons for incomplete examination in group 2 were: poor bowel prep x2. In group 1 the mean pain scores were higher, as was use of fentanyl and midazolam. Entonox use was about equivalent. Conclusions Endoscopic follow-up of complicated diverticulitis was not universal. There was a delay beyond the recommended follow-up at 6 weeks which corresponds with delays in endoscopy for other indications since the COVID-19 pandemic. Completion rates were lower for the complicated diverticulitis group and the procedure was more poorly tolerated. Colonoscopy completion rates have not been looked at specifically for complicated diverticulitis follow-up elsewhere. The completion rates in this sample are lower than those for the endoscopic follow-up of all diverticulitis in other studies. If these rates are found in a larger sample then alternative methods for examining the colon, such as CT colonoscopy, may be a more attractive option.
ABSTRACT
Introduction: Klippel-Trenaunay syndrome (KTS) is a rare congenital vascular disease which is characterised by capillary, venous and lymphatic malformations. We describe the anaesthetic management of a 36 year old parturient with COVID-19 and KTS, who underwent an elective caesarean section. Very few such cases have been described and the multi-system nature of condition poses various challenges to both the obstetrician and the anaesthetist. Case Report: We had a 36-year-old woman who had experienced three previous normal vaginal deliveries and an elective caesarean section (CS) four years previously under general anaesthetic(GA) at 36 weeks gestation. She was told by a vascular surgeon that she was not suitable for regional anaesthesia. There was no recent imaging of her back to rule out arteriovenous(AV) malformations. Her past history included gastric bypass surgery under GA two years ago. She also had depression, varicose veins and three previous deep venous thrombosis andwas on prophylactic lowmolecularweight heparin. She had tested positive for COVID-19 4 days previously, and had mild symptoms of cough and sore throat. After a multi-disciplinary discussion involving an obstetrician, vascular surgeon, haematologist and anaesthetist, a decision was made to proceed with GA despite recent COVID-19, because of the possibility of AV malformations, in agreement with the patient. After securing two wide bore cannulae and adequate preoxygenation, a modified Rapid Sequence Induction was performed, and a tracheal tube was secured. Anaesthesia was maintained with oxygen, nitrous oxide and sevoflurane. After delivery of the baby, oxytocin 5U, followed by an infusion, midazolam, morphine, ondansetron and dexamethasone were administered. Extubation was performed when the patient was fully awake. In recovery, further opioids were given for pain. There were no concerns for the newborn. Estimated blood loss was 200 mL. Discussion: Gestation and its physiology may further exacerbate the manifestations of KTS, with increased obstetric risk. The success in the management of these patients requires the participation of a multidisciplinary team, consisting of obstetrician, anaesthetist, urologist, haematologist and vascular surgeon, with appropriate collaboration among the professionals involved. Periodic imaging and clotting tests are recommended to evaluate the evolution of vascular malformations in the pelvis, uterus and vagina, and identify neuraxial changes, to guide the safest way of delivery and anaesthesia.
ABSTRACT
Background/Aims To understand the impact of COVID-19 on UK paediatric rheumatology services, to determine the learning points that could change future practice and provide information for trainees to plan further quality improvement projects. Methods Survey details with a Microsoft forms link were emailed to consultants in each UK paediatric rheumatology centre. Consultants were asked to forward the survey onto any regional units linked. The survey was also sent to the paediatric rheumatology trainee's network. The questionnaires covered blood monitoring, joint injections, oral corticosteroid use, modes of consultations, positive and negative impacts and what changes should be carried forward. Results 20 staff responded to the survey;17 consultants and three trainees (registrar level). 85% (17) reported changes had occurred to the frequency of blood monitoring to rheumatology patients on Disease Modifying Anti-Rheumatic Drugs (DMARDs) and/or biologics during the pandemic. 60% (12) reported this was due to patient/family reluctance to attend or due to unavailability of appointments. 75% (15) recorded no complications following changes of blood frequency on disease activity or flare. Of those that did have a flare, a number of factors were described including: parents not contacting their service, patient/family discontinuation of treatment, lack of clinic attendance, running out of treatment and safety concerns re prescribing from primary care or local department. One patient on methotrexate experienced significantly deranged liver function tests.75% (15) reported changes with provision of joint injections due to theatre unavailability. As a consequence, 60% (12) reported an increase in the use of oral corticosteroids with 20% (4) performing more ward-based injections with local anaesthetic or Entonox on younger children. 100% (20) changed their mode of consultation. Between 5 and 40% of all appointments are now virtual (telephone or video) and 60-95% are face-face. 60% (12) report that frequency of review appointments has now returned to normal. Major disruption has occurred in seeing new patients due to a backlog of patients created by the pandemic. Some patients have been referred to units with possible arthritis that haven't been examined or seen face-face in primary care prior to referral. Conclusion COVID-19 caused significant changes to UK paediatric rheumatology services. The results highlighted the use of virtual consultations where appropriate, consideration of joint injections without general anaesthetic as much as possible, enabling virtual teaching/conferences and also raising the need to review blood monitoring frequency for patients on DMARDs/biologics. Longer waiting lists, increased anxiety amongst children and young people, increase in disease activity and the impact on learning opportunities for trainees were concerning negative aspects of the pandemic. It is likely the impact of these negative consequences will continue to be experienced for some time. Future planning and consideration is required to minimise the negative impact of these aspects on our patients and colleagues.