This is the first series to report the clinical experience of four modalities of small-bowel endoscopy from a single centre. The use of CE as first-line investigation, followed by PE/DBE or IOE, is potentially both less invasive and tolerable.

IntroductionThe use of double balloon enteroscopy (DBE) in the UK has been relatively slow and limited to tertiary centres. The authors evaluated the demand for DBE in the UK and impact on patient management. Methods Data was collected prospectively for all DBE procedures performed since 2006. All patients underwent CE (either at our centre or elsewhere) prior to DBE. The majority of CE was positive which directed the route for DBE. Patient demographics, indications, procedural details and change in management were collected. Results A total of 166 procedures were carried out in 121 patients over 50 months (85 oral route, 81 retrograde route). 74% of the referrals were from outside the region. There were 65 females with a median age of 52 years (range 20-83 years). The most common indication for DBE was iron defi ciency anaemia (IDA) in 43% followed by Crohn's disease in 32% and overt bleeding in 12%. The median procedure time was 66 min (2-160 min). Pan enteroscopy was achieved in one patient. The overall diagnostic yield for DBE was 46% for all indications. The complication rate was 0.8% with one case of pancreatitis postpolypectomy which was managed conservatively. Four patients with small bowel tumours on CE were referred for surgery as the tumour was not reached at DBE. The yield for DBE for vascular lesions was 52% (15/29). In two patients from this cohort, alternative diagnosis were found while a repeat CE locally was normal in 3 other patients. Polyps were seen in 6 patients on CE, 4 of these underwent polypectomy at DBE. In the 2 remaining patients, the isolated polyp at CE was thought to be incidental and not pursued. Therapeutic intervention was performed during DBE in 20% (n=24: argon plasma coagulation (n=17), endoscopic mucosal resection (n=5) and endo clips (n=2). Patient management was altered in 38% of the cohort after DBE which included intervention at DBE (n=24), referral for surgery (n=2), infl ammatory bowel disease directed therapy (n=6), helicobacter pylori eradication (n=1), chemotherapy (n=1) and stopping NSAIDs (n=1). The technique of DBE is associated with a learning curve. In this series, the diagnostic yield in the latter 50 patients was 56% compared to 40% in the initial 50 patients (p=0.1). The procedural time also decreased but was not statistically signifi cant (70 vs 63 min, p=0.1). In 2009, for every 17 CE's performed one patient underwent DBE locally. Conclusion DBE has a high diagnostic yield, low complication rate and positive impact on patient management with the ability to perform biopsies or therapeutics for pathology seen

complications (bleeding/pain) were analysed. Pearson chisquare tests were used to compare experiences by gender, high vs. low levels of socioeconomic deprivation (using Index of Multiple Deprivation scores), and whether patients reported receiving sedation or not. Results After excluding patients outside the target date range and those who did not have colonoscopy, 76,717 patients were eligible for analysis, of whom 60,581 (79.0%) responded to the questionnaire. Nearly all patients felt they understood the risks (95.7%) and benefits (98.2%) of the test, and 97.8% felt the preparation instructions were clear. Comparison by gender and deprivation did not yield clinically meaningful (≥3%) differences. In terms of the hospital experience, virtually all patients felt they were treated with respect (98.5%) and had privacy (98.0%), but 20.8% experienced more discomfort than expected (although only 5.2% asked for the test to be stopped/paused). Procedural discomfort was moderated by gender, with more women than men reporting higher-thanexpected discomfort (25.4% vs. 17.9%; p < 0.0005), and requesting that the test be stopped/paused (7.1% vs. 3.9%; p < 0.0005). Use of sedation showed only a weak association with patient experience: 22.2% of sedated vs. 20.2% of nonsedated patients reported unexpected discomfort; 6.4% vs. 4.8% asked for the test to be stopped/paused; both p-values <0.0005). Post-test, 14.3% of patients reported pain and 6.9% reported rectal bleeding. Pain was more common in women (18.0% vs. 11.9%; p < 0.0005) but there were no other clinically meaningful differences post-test related to gender or deprivation level. Conclusion Most patients referred for colonoscopy as part of the Bowel Cancer Screening Programme have a positive colonoscopy experience. The most negative aspect of the experience was the test being unexpectedly uncomfortable. Patients are extensively counselled pre-procedure but more emphasis on managing expectations, along with continued measures to reduce discomfort and pain are required, particularly for women.

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