We report a rare case of upper gastrointestinal bleeding in a 55-year-old man with monoclonal gammopathy of unknown significance presenting with abdominal pain, weight loss and melaena. Gastroscopy was unremarkable, but melaena persisted, with the development of symptomatic anaemia. While colonoscopy excluded a lower gastrointestinal aetiology, CT revealed jejunitis, confirmed at capsule endoscopy. Histopathological examination of specimens obtained at single balloon enteroscopy revealed an unusual aetiology: small bowel AL-amyloidosis. We review his clinical presentation, radiological, endoscopic and histological findings and review the literature of this unusual condition.

The development of portal hypertension has serious implications in the natural history of liver cirrhosis, leading to complications such as ascites, hepatic encephalopathy and variceal bleeding. The management of acute variceal bleeding has improved in the last two decades, but despite the advances in endoscopic methods the overall prognosis remains poor, particularly within a subgroup of patients with more advanced disease. The role of Transjugular Intrahepatic Portosystemic Shunt (TIPSS) is a well-established method of achieving haemostasis by immediate portal decompression; however, its use in an emergency setting as a rescue strategy is still associated with high mortality. It has been shown that ‘early’ use of TIPSS as a pre-emptive strategy in a patient with acute variceal bleed in addition to the standard of care confers superior survival outcomes in a subgroup of patients at high risk of treatment failure and death. The purpose of this review is to appraise the literature around the indications, patient selection, utility, complications and economic considerations of pre-emptive TIPSS.

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IntroductionAdenomas detected at Bowel Scope are classified based on the BSG guideline on adenoma follow up. Subjects with high or intermediate risk adenomas are referred for colonoscopy to clear the whole colon of polyps. Subjects with low risk adenomas (one or two sub 1 cm adenomas) undergo polypectomy and are discharged. However, in deviation to the guideline, if adenomas have villous component – tubulovillous adenoma (TVA) or villous adenoma (VA), they are upstaged to intermediate risk and subjects are referred for colonoscopy. We audit the outcome of the colonoscopies in subjects who have been upstaged.MethodInterrogating the Northamptonshire Bowel Scope database, subjects with upstaged adenomas were identified. Colonoscopy and histology reports were reviewed, data collated and analysed. This covered a time period from July 2014 to February 2017 (6000+ Bowel Scope procedures have been performed).Results• 64 subjects (~1% of Bowel Scope subjects) had upstaged adenomas.• 47 males (73.4%) and 17 females (26.6%), 60 TVAs and 4 VAs.• 58 subjects had 1 adenoma, six had 2 adenomas.• Two subjects had 2 adenomas with villous component (1 had two TVAs with high grade dysplasia).• 66 TVAs/VAs in total, mean and median size=6 mm.• 24 in rectum (36.4%), 35 in sigmoid colon (53.0%), 7 in descending colon (10.6%).• 6 subjects have not had colonoscopy (9.4%) - 4 (male) subjects declined, 2 subjects awaiting colonoscopy.• 36 (56.3%) had no further adenomas seen at colonoscopy (2 hyperplastic polyps).• 22/64 (34.4%) subjects had further adenomas – 17 males (81.0%), 4 females (19.0%).• 14 single adenomas, 3 multiple, 1 serrated adenoma (SSA) and 4 non-retrieved.• 27 adenomas resected, 23 diminutive (sub 5 mm, 20 TAs, 2 TVAs, 1 SSA).• 4 larger adenomas; 9 mm, 9 mm, 12 mm and 20 mm (all TVAs).• After colonoscopy, 54/58 (93.1%) patients classed as low risk, 1 (1.7%) as intermediate risk and 3 (5.2%) as high risk.Conclusion66 subjects with low risk adenomas at Bowel Scope upstaged due to villous component yielded 58 colonoscopies thus far (90.6% of eligible) with an overall polyp detection rate of 39.7% and adenoma detection rate of 31.0%. There is a male predominance, 56.3% yielded no adenomas. 85.2% of adenomas resected are diminutive. Only 4 (male) subjects remain upstaged after colonoscopy to intermediate or high risk groups (6.1%).This data opens up a debate to whether upstaging subjects found to have low risk adenomas with villous component is an effective strategy. 93.9% of subjects end up classed as low risk after colonoscopy and the vast majority of adenomas resected at colonoscopy are diminutive. The number needed to colonoscope to remain upstaged is 14.5.Reference. SR Cairns, JH Scholefield, RJ Steele, et al. Guidelines for colorectal cancer screening and surveillance in moderate and high risk groups (update from 2002). Gut2010;59:666–690.Disclosure of InterestNone Declared

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