Pancreatic exocrine insufficiency (PEI) occurs when the amounts of enzymes secreted into the duodenum in response to a meal are insufficient to maintain normal digestive processes. The main clinical consequence of PEI is fat maldigestion and malabsorption, resulting in steatorrhoea. Pancreatic exocrine function is commonly assessed by conducting a 3‐day faecal fat test and by measuring levels of faecal elastase‐1 and serum trypsinogen. Pancreatic enzyme replacement therapy is the mainstay of treatment for PEI. In adults, the initial recommended dose of pancreatic enzymes is 25 000 units of lipase per meal, titrating up to a maximum of 80 000 units of lipase per meal. In infants and children, the initial recommended dose of pancreatic enzymes is 500 units of lipase per gram of dietary fat; the maximum daily dose should not exceed 10 000 units of lipase per kilogram of bodyweight. Oral pancreatic enzymes should be taken with meals to ensure adequate mixing with the chyme. Adjunct therapy with acid‐suppressing agents may be useful in patients who continue to experience symptoms of PEI despite high‐dose enzyme therapy. A dietitian experienced in treating PEI should be involved in patient management. Dietary fat restriction is not recommended for patients with PEI. Patients with PEI should be encouraged to consume small, frequent meals and to abstain from alcohol. Medium‐chain triglycerides do not provide any clear nutritional advantage over long‐chain triglycerides, but can be trialled in patients who fail to gain or to maintain adequate bodyweight in order to increase energy intake.

Summary Sorbus bristoliensis, BRISTOL WHITEBEAM, is described and illustrated. The history of the discovery and the origin of this narrow endemic are discussed. Notes on propagation and cultivation are also included.

IntroductionThere is increasing demand for gastroscopy in the United Kingdom. In around 10% of patients, gastroscopy is presumed to have missed oesophagogastric (OG) cancer prior to diagnosis. We examine patient, endoscopist and service level factors that may affect rates of missed OG cancers.MethodsGastroscopies presumed to have missed OG cancers performed up to 3 years prior to diagnosis were identified over 6 years in Sheffield, UK. Factors related to the patient, endoscopist and endoscopy lists were examined in a case–control study. Procedures which missed cancer were compared with two procedure controls: the procedures which subsequently diagnosed cancer in the same patient, and second, endoscopist matched procedures diagnostic of small benign focal lesions.ResultsWe identified 48 (7.7%) cases of missed OG cancer. Endoscopy lists on which OG cancer diagnoses were missed contained a greater number of total procedures compared with lists on which diagnoses were subsequently made (OR 1.42 95% CI 1.13 to 1.78) and when compared with lists during which matched endoscopists diagnosed benign small focal lesions (OR 1.25, 95% CI 1.02 to 1.52). The use of sedation, endoscopist profession and experience, or time of procedure were not associated with a missed cancer.Conclusion7.7% of patients diagnosed with OG cancer could have been diagnosed and treated earlier. Our study suggests that endoscopy lists with greater numbers of procedures may be associated with missed OG cancers. The use of sedation, endoscopist background or time of procedure did not increase the risk of missed cancer procedures.

BackgroundThe main risk of capsule endoscopy is retention of the capsule behind a stricture. Passage of an intact Agile patency device (Medtronic, Dublin, Ireland) through the small bowel is widely used to ensure luminal patency, although capsule retention has occurred in patients who have had a reassuring patency study. The device is designed to remain intact for at least 30 hours postingestion, such that loss of signal from the radiofrequency identification tag contained within, or absence of the device on radiological imaging, implies unimpeded intestinal transit.AimTo identify the rate of premature dissolution (<30 hours postingestion) of the Agile patency device.MethodsOutcomes of all consecutive patients having an Agile patency device were analysed.ResultsPremature dissolution of the patency device occurred in 5 of 307 patients, an incidence of 1.3%. This was recognised by the detection of a persistent radiofrequency signal after radiological imaging had failed to identify the patency device, prompting a careful search for the radiofrequency tag on the CT scout film. The tag was difficult to detect because of an oblique lie making it appear smaller than its 13×3 mm size and confusion with intra-abdominal or other metallic fragments.ConclusionsIn the absence of radiological evidence of an intact Agile patency device, premature dissolution should be suspected in patients registering a persistent radiofrequency signal and confirmed by identifying the radiofrequency identification tag. Failure to do so might result in false reassurance that capsule endoscopy could be performed without risk of retention.