A single centre retrospective review of acute kidney injury in neonates with congenital diaphragmatic hernia
Aoife Ryan, Megan Gilhooley, Neil Patel and Ben Reynolds
Department of Neonatology, Royal Hospital for Children, UK
Abstract
Background: Congenital diaphragmatic hernia (CDH) is a complex syndrome characterised by severe cardio-respiratory impairment within the neonatal period. Affected infants are exposed to multiple potentially nephrotoxic factors, predisposing them to acute kidney injury (AKI) which is associated with poorer outcomes in critically ill neonates. Children who survive neonatal AKI are at risk of long-term renal complications (including chronic kidney disease and hypertension). Improved understanding and recognition of contributory factors for AKI in CDH may ameliorate prognostic outlook.
Aims: We hypothesised that infants born with CDH have a high incidence of AKI. The purpose of this study was to investigate AKI prevalence within the neonatal period of infants with CDH and to identify variables which may potentiate subsequent renal failure.
Methods: We retrospectively reviewed patient health records within a CDH cohort (n = 55) treated at our tertiary level centre between 2011 and 2017. AKI risk factors (nephrotoxic medication exposure, significant infection, requirement for ECMO support, etc.), demographic data and outcome measures (duration of hospital stay, survival status) were recorded.
AKI severity was defined according to established international pRIFLE criteria (Risk of renal dysfunction, kidney Injury, Failure or Loss of kidney function and End-stage renal disease). Patients were stratified based on percentage increase from baseline serum creatinine and urine output. Division into two further sub-groups occurred as follows: neonates who did not meet pRIFLE criteria / those categorised as being at Risk were identified as having ‘No AKI’; while those assigned to the remaining pRIFLE classifications met criteria for the ‘AKI’ grouping. Statistical analysis was performed using SPSS.
Results: Fifty-five eligible CDH cases were identified; of whom 38% developed AKI (pRIFLE categories: Injury, Failure or Loss). AKI was significantly associated with prolonged hospital stay (p = 0.017) and mortality (p = 0.004); in addition to vancomycin and steroid administration (p = 0.004 and p = 0.009 respectively), CDH defect size (p = 0.002), patch repair (p = 0.032) and requirement for ECMO support (p = 0.004). Hypertension was a highly significant variable (p = 0.008): only n = 2 (5.9%) of those in the ‘No AKI’ group demonstrated evidence of hypertension; in contrast to n = 7 (33.3%) of those classified as having ‘AKI’. This is consistent with the correlation between kidney injury and anti-hypertensive prescription during both hospital admission and at discharge (p = 0.001 and p = < 0.001 respectively). There were no statistical correlations found between AKI status and gentamicin prescription, UAC insertion or significant infection. Incomplete recording of urine output prevented stratification of AKI based on this parameter.
Conclusions: AKI is common in CDH and associated with adverse sequelae. Modifiable risk factors for AKI development in CDH include exposure to nephrotoxic medications (particularly aminoglycosides such as vancomycin and steroid agents). Urine output is not routinely well documented in CDH patients within our institution. Earlier recognition and prevention of AKI progression could improve overall CDH outcome. (a 14% mortality rate was identified in neonates categorised as kidney injury versus 75% in those with renal failure).
Risk stratification of atraumatic limp, before and after: a retrospective cohort study
R Russell, J Smith, A Kidd, J Mills, Y Del Monte and E Timony-Nolan
Emergency Department, Royal Hospital for Sick Children, UK
Abstract
Aims: To review the investigation and outcomes of children presenting with atraumatic limp to a tertiary Paediatric Emergency Department (PED) over a 12-month period following introduction of a revised guideline advocating targeted investigation where red flags exist. To compare the data to that from the 12 months preceding introduction of the revised guideline to ensure safety and efficacy. To assess adherence to the guideline by local doctors and emergency nurse practitioners (ENP).
Results of univariate analysis of variables according to AKI grouping (odds ratios are provided where appropriate).
Methods: All patients who attended the PED clinic from May 2016 to April 2017 with limp/lower limb pain in the absence of clear trauma were manually identified and the following information gathered: age, sex, presenting complaint, duration of symptoms, examination findings, pyrexia, blood results, X-ray and ultrasound (USS) results, clinical diagnoses and final outcomes. This was compared with results from the 12 months preceding the new guideline when all patients regardless of clinical findings had blood tests and USS.
Results: Three hundred and eighty-six patients attended the PED review clinic with atraumatic limp after introduction of the revised protocol. Of these 226 patients (59%) had investigations on their first PED attendance, and of those investigated, 93.6% had a documented appropriate ‘red flag’ justification for doing so. All febrile patients had investigations. Five patients (1.2%) with duration of history that merited investigations did not have them performed at first PED attendance. 30 patients (8%) had a significant pathology including seven patients with juvenile idiopathic arthritis (JIA), four with osteitis/osteomyelitis, two with Perthes’ disease, two with acute lymphoblastic leukaemia, one with Langerhans Cell Histiocytosis and one with metachromatic leukodystrophy. 23/30 had investigations appropriately at first presentation. Of the seven that did not, one ought to have had for duration of symptoms and subsequently had a diagnosis of JIA. The remaining 92% had insignificant pathology, predominantly transient synovitis (73%) with a small number of soft tissue injuries and unexpected minor fractures. Compared to the 498 patients attending in 2014–15 who all had investigations (with significant pathology diagnosed in 10%) we are doing 62% fewer blood tests and 72% fewer USS.
Conclusions: Children presenting with atraumatic limp in the absence of red flags can be safely managed at first presentation without blood and radiological investigations. Prevalence of significant pathology in those who do have investigations remains low but it is pertinent to follow these patients up given the serious nature of the conditions we may find.
The clinical utility of ambulatory EEG in Childhood
Rebeka Nagyova1, Gillian Horsburgh2, Angela Robertson2 and Sameer Zuberi1,2
1School of Medicine, College of Medical and Veterinary Life Sciences, University of Glasgow, UK
2Paediatric University Neurosciences Research Group & EEG Department, Royal Hospital for Children, UK
Abstract
Objectives: To evaluate the clinical utility of the ambulatory electroencephalogram (AEEG) in children.
Method: Data from 200 consecutive referrals for a paediatric AEEG were reviewed retrospectively. Information was gathered on various aspects of the referral process, the characteristics of the children referred and the reasons for referral. Clinical utility was calculated as the percentage of cases in which the investigation provided useful information with respect to the question asked of the test.
Results: The AEEG was useful in 63.5% cases overall. In 51.4% of cases the reason for referral was to capture events, however the test was only useful in 46.4% of these. The most common reason for an unsuccessful investigation was failure to capture events (57.4%). Suspected electrical status epilepticus in slow-wave sleep (ESES) was the indication in a substantial number of cases (30.2%), and the investigation was useful in most of these (87.7%).
Conclusion: The paediatric AEEG was useful in roughly two thirds of patients. Failure to capture events appears to be the most significant limiting factor, yet frequency of events is often not taken into consideration in the referral process. The AEEG is very useful in investigating suspected ESES.
Trainee empowerment delivering service and trainee improvement
M Lister, F Osborne, A Murray, M Ellen, L Thompson, D Murphy and S Joseph
NHS Lothian, UK
Abstract
Trainees are often well placed to identify areas in need of improvement in healthcare and develop system changes to drive positive change. Enabling senior doctors and hospital managers to work closely with enthusiastic trainees helps to facilitate this process. In our quaternary paediatric centre we focused on the theme of medical handover to initiate multiple quality improvement initiatives, led by empowered trainees, which successfully resulted in measurable service improvements.
Project 1: One such project tackled ineffective and inefficient communication at handovers. Twelve PDSA cycles with collaborative team review of data and small interventions to address specific points led to a reduction in average handover length from 94 to 34 min. Additionally, 93% of trainees felt task allocation was more robust and efficient, 86% felt there was improved patient ‘ownership’ and 93% agreed an active ‘pause’ at the end of the handover to ask questions or discuss staff/service issues was beneficial.
Project 2: Trainees identified that overnight escalation processes for deteriorating children, particularly in surgical subspecialties for regional services, were not robust with workload imbalances prevalent throughout the team. The resulting strain within the night team raised patient safety concerns in addition to welfare concerns for resident staff. A multidisciplinary working group was set up and several audits and ‘time in motion’ studies performed. Solutions derived from data included obtaining funding for a specially adapted ‘Hospital At Night Room’ containing appropriate facilities, a new and improved escalation policy, ward-level training on identifying and managing deteriorating patients with significant improvement in workload management and team communication; enabling a distributive leadership model. Trainee experience has improved as a result: In the 2016 GMC survey and deanery visit, handovers were rated poorly by trainees but in 2018 survey handovers are now rated in the top 25% of UK training placements.
Conclusion: By empowering and supporting trainees to identify issues through systems curiosity, to utilise quality improvement methodology and actively evolve solutions, we have demonstrated both service and training improvement. This has given trainees insight into how, as future senior leaders in the workforce, they can make a meaningful impact to patient care.
Diagnosis delay, clinical features and complications of patients with cryopyrin associated periodic syndrome
Thomas Broome and Janet Gardner-Medwin
University of Glasgow, UK
Abstract
Introduction: Cryopyrin Associated Periodic Syndromes (CAPS) are a rare group of autoinflammatory disorders associated with mutations in the NLRP3 gene. This leads to IL-1β overproduction, causing symptoms that commonly present from birth including urticarial-like rash, joint pain, periodic fevers and conjunctivitis. If untreated, this leads to significant morbidity and mortality, such as significant growth retardation, sensorineural deafness, developmental delay, skeletal deformity and amyloidosis, which are preventable with early IL-1β blockade.
Objective: To examine the clinical journey of CAPS patients in Scotland.
Methods: In this retrospective case review, clinical notes were studied of known CAPS patients diagnosed since 2002. Anonymised data were recorded and analysed, including symptom onset and age at diagnosis.
Results: Of 10 known patients, 8 had notes available for review. Patients were referred to rheumatology/genetics by median age of 6y2m (2y5m–13y5m) and had a suspected diagnosis of CAPS by a median age of 5y11m (2y11m–13y5m). Prior to diagnosis, all patients had persistent, erythematous, macular and/or urticarial but non-itchy rashes, five patients from birth and transiently in one. Notes documented rash from 7 m in one and 7y6m in another; however, notes prior to these dates were unavailable. The rashes were predominantly located on the face and limbs, and were described as migratory in four patients. Other symptoms included musculoskeletal pain (7/8), conjunctivitis (5/8), headaches (4/8) and recurrent fevers (3/8). Hearing was significantly impaired in three, growth in two and vision in one patient. One patient had rash only but genetic testing due to their symptomatic twin led to diagnosis. Features overlooked despite multiple presentations were persistent arthritis/arthralgia, rash (often labelled as reactive arthritis and chronic urticaria), and acute phase responses that never settled. Two had microcytic anaemia not corrected by iron. Three fathers of the six families had a confirmed genetic CAPS diagnosis following their children’s diagnosis; one father died of complications. Two children had a de novo mutation, another was negative for currently known CAPS mutations and treated on clinical grounds.
Conclusion: Four of the eight patients (and two fathers) had irreversible sequelae as a result of several years of delay in diagnosis despite symptoms from birth. Rare autoinflammatory diseases such as CAPS are treatable but understandably easily missed. They should be considered in paediatric patients with persistent symptoms despite investigation and attempted treatments. Early rheumatology/ genetics referral in these cases is important to allow investigation and treatment initiation if a diagnosis is reached.
Dignity in death – shared decision making and promoting realistic medicine
A Arthur, K Marshall, E Fairley, J Richardson and U Khan
Paediatric Intensive Care Unit, Royal Hospital for sick Children, UK
Abstract
Introduction: Shared decision making and respecting patients’/parents’ wishes regarding direction of care and more importantly ‘place of care’ is a key concept of realistic medicine. Admission to a paediatric intensive care unit is often both aggressive and invasive, with an aim for restorative therapy. Despite this, there is inevitably a small cohort of patients where re-orientation of care becomes most appropriate and withdrawing invasive treatment is in their best interest. The practice of reorientation of care has evolved through the years and involves close collaboration with a multidisciplinary team and with parents.
Objectives: To review current literature regarding re-orientation of care at home for children at the end of life, with an aim to develop a local guideline for implementation and practice for our local PICU.
Methods: An initial literature search was performed to identify UK current practice of re-orientation of care and acknowledgement of any existing guidance. A retrospective analysis of deaths that occurred in our critical care unit from 2010 to 2017 and identification of those who may have been applicable for re-orientation of care out-with the critical care environment was done. Thereafter, in collaboration with the paediatric palliative care team, a guideline and discharge checklist to implement in clinical practice was introduced.
Results: Between 2010 and 2017, throughout our hospital, 18 children utilised a service to allow death out-with the hospital setting; 15 had a haematological or oncological diagnosis, and 3 had a non-malignant diagnosis. Within the critical care unit, there were 76 deaths, 28 of these (37%) were identified as appropriate for re-orientation of care out-with the critical care environment; around 3 per year. Guidelines in place (Evelina London’s Children Hospital and Glasgow PICU) were reviewed.
Recommendations: The proposed guideline involves six steps. At introduction, it aims to identify a possible patient and involve the palliative care team, have an initial meeting with parents to clarify their wishes and choice of place of care, and discuss with the appropriate service for taking over the patient’s care. Pre-transfer then involves rationalisation of invasive treatment, completion of CYPADM/ACP and logistical planning of transfer, with the aid of a discharge checklist. Transfer would be performed by two critical care team members, met at the destination by the chosen service, prior to compassionate re-orientation of care. Following re-orientation, a symptom review is performed, and handover of care completed. Death would be certified by a designated medical professional.
Abstracts for Cases
Lessons learned from central line extravasation from the left ascending lumbar vein into the cerebrospinal fluid causing neurological impairment in two infants
Claire Granger, Joyce O’Shea, Louise Leven and Laura McGlone
Neonatal Intensive Care Unit, Royal Hospital for Children, UK
Abstract
Introduction: Peripherally inserted central catheters (PICCs) are often required for long-term venous access. Insertion into the great saphenous vein (GSV), with line tip in the inferior vena cava (IVC) is common. Malposition, within the left ascending lumbar vein is possible when the left GSV is used. If not recognised and removed promptly, vein perforation can occur, resulting in fluid entering the cerebrospinal fluid space with possible neurological sequelae.
Aims: We report two recent cases and summarise action taken to reduce recurrence.
Methods/Results: Both children, born at 28 weeks gestation, required parenteral nutrition while recovering from laparotomy and bowel resection. The first infant had a PICC inserted into his left GSV. The tip was reported on X-ray as in satisfactory position. Five to eight days later he developed irritability, pyrexia and seizures. He was investigated for meningitis and lumbar puncture revealed white, lipaemic CSF. PICC malposition was suspected and the line removed. The second infant also had a left GSV PICC inserted. Line tip was initially at T5 so was pulled back to below the diaphragm. Twelve days later she developed seizures. A lateral X-ray showed the PICC tracking posteriorly and advancing parallel to the vertebral column, likely within the left Ascending Lumbar Vein. It was promptly removed. Both children suffered severe neurological impairment. The cases underwent significant clinical incident review. Retrospective review of the X-rays found that the PICCs never crossed the midline to the right-sided IVC. Actions following the SCI review included distribution of a rapid alert and a detailed learning bulletin nationally, local education sessions, alteration of the guideline and our central line documentation stickers.
Conclusion: We wish to raise awareness of this rare complication and to propose a set of ‘red flags’ that may warn the user that a PICC line is in a potentially unsafe location.
Managing risk in complex disease presenting with simple symptoms
A Babiker, A Slater, S Joseph, S Baird and D Elleri
Royal Hospital for Sick Children, UK
Abstract
Introduction: Paediatric care offers a cohesive multidisciplinary team working towards the common purpose of the child’s well being. But, what happens when young adolescents present with high-risk adult pathology in a paediatric setting?
Case presentation: We present the case of a previously well 13-year-old girl of Indian origin who presented with two days of worsening right leg pain, swelling, and general malaise. She denied systemic symptoms and examination revealed a tender, erythematous right calf with restricted range of motion. An ultrasound scan confirmed an extensive deep vein thrombosis (DVT) and lower limb infection. She had no respiratory symptoms at rest but a CXR, performed empirically, showed significant consolidation. A CT scan of her chest confirmed small bilateral pulmonary emboli, right heart strain, and multifocal, mixed morphology pulmonary consolidation. She was treated with antibiotics and therapeutic heparin; with multi-specialty discussion to ascertain the primary diagnosis and define the potential risk of a catastrophic respiratory event from pulmonary embolism. As her limb swelling and mobility improved, her inflammatory markers changed from unified elevation of ESR and CRP to discordantly high ESR with low CRP within three weeks. During this time frame, she also developed a widespread pruritic rash and continued to report ongoing lethargy with intermittent fevers. She was investigated extensively for potential TB, malignant or autoimmune primary diagnosis. Further results revealed positive Lupus anti-coagulant, anti-dsDNA. This finding, in addition to the inflammatory markers and clinical changes, enabled a diagnosis of Juvenile Onset Systemic Lupus Erythematosis (JoSLE). She responded well to treatment, completed her antibiotics and was bridged onto oral anticoagulants.
Discussion: Juvenile onset Systemic Lupus Erythematosis (JoSLE) is a chronic, complex, multisystem autoimmune disease, which represents 15–20% of all SLE cases. Children most commonly present with pyrexia and haematological, mucocutaneous, renal or musculoskeletal manifestations. Unlike in adult SLE, there are no clear diagnostic criteria for JoSLE. Since end organ damage manifests within 5 years of disease onset in half of cases, early diagnosis is essential in achieving an optimal 50-year survival and normal lifespan. Atypical presentations could potentially result in late diagnosis, leading to treatment delays. The above case outlines the importance of remaining wary in uncommon presentations, always going back to review the clinical findings with the investigation profile, and effective multi-specialty communication and team work including specialties, adult and paediatric services.
Cannabis intoxication in an infant
Iona Morgan and Sarah Abernethy
Neurology Department, Royal Hospital for Children, UK
Abstract
Objective: To describe an unusual presentation of cannabis intoxication with encephalopathy and markedly abnormal respiration in a previously well child, and to highlight the importance of awareness of the potential toxicity of this drug.
Method/Case history: A previously fit and well 13 month old presented to a district general hospital with pallor and poor balance after waking from a nap. She went on to develop gasping respiration over the next few hours in association with worsening encephalopathy requiring transfer to a tertiary paediatric centre for specialist opinion. Clinical examination showed global hypotonia, conscious level varying between unresponsive and response to pain, and gasping respiration. The child was intubated, but improved over 24 h.
Results: Initial investigations in the local DGH including inflammatory markers and LP for microscopy were normal. CT brain and MRI brain with contrast were normal. EEG showed general changes in keeping with encephalopathy. Further blood and CSF tests were undertaken for neuroimmunological and metabolic causes which were all normal. Urine toxicology was positive for cannabinoids.
Conclusions: In older children and adults, acute cannabinoid intoxication is associated with psychosis, changes in observations and clinical signs. This case demonstrates that in infants a pattern of encephalopathy without other focal signs can be the only presenting feature. In this case, the child also had a markedly abnormal breathing pattern, which does not seem to previously have been reported in the literature. In addition, she had marked EEG change which recovered to baseline. Intoxication with cannabinoids should be suspected in cases of unexplained encephalopathy in infants and young children, and if results are available early may prevent invasive investigations. This is a time of intense interest in the use of cannabinoids, both in the medical fraternity and in the general public, but this case highlights that they are not without risk.
Neonatal transport using an iGEL for a difficult airway
Stacy Wightman, Graham Latta and Stewart Guthrie
Scotstar, UK
Abstract
Initial resuscitation: A baby boy was born by vaginal delivery at 40+1 weeks gestation. There was a history of polyhydramnios since 37 weeks gestation and group B streptococcus on high vaginal swab but no relevant family medical history. At delivery the baby was apnoeic requiring two person airway management. He was noted to have a cleft palate. There were two unsuccessful intubation attempts in labour ward and a further two unsuccessful intubation attempts in NICU. Blood gas was in keeping with an upper airway obstruction. The NICU team continued oral airway and jaw thrust and obtained IV access, blood cultures, commenced intravenous antibiotics and fluids.
Transport request: A conference call was made between the referring unit, neonatal transport team, tertiary neonatal unit and ENT at tertiary hospital. A plan was made for transfer for ENT to take baby to theatre for further airway assessment.
On arrival to referring unit: On arrival to the referring unit the baby’s airway was being managed with a jaw thrust and an oral airway and face mask CPAP. The blood gas was markedly improved. An iGEL was inserted which was well tolerated and CPAP was given the iGEL.
During transfer: The baby was clinically stable throughout transfer. The iGEL was secured by hand during transfer
On arrival to tertiary unit: The neonatal transport team were met by the ENT and anaesthetic team at the door and escorted the baby to theatre. The baby underwent an emergency tracheostomy in theatre. The procedure went well and he was extubated two days post op.
On Going Care: A diagnosis of Pierre Robin was made. Post operatively he was cared for in the neonatal unit and underwent jaw distraction surgery at five weeks of age. Laryngeal Airway Masks (LMA) are devices which can be generally used effectively with minimal training. First developed in the 1980s, they have been increasingly used in paediatric and neonatal resuscitation. Current evidence shows that they are effective when used in term and near term neonates. There are published case reports of the use of LMAs in neonates with upper airway obstruction due to Pierre Robin, as in this case, and their use in neonatal transport. In this case report the use of an iGEL allowed the patient to be transferred with a fairly secure method of providing effective CPAP during transfer preventing clinician jaw thrust fatigue and therefore preventing upper airway obstruction during transfer.
Cervical spine subluxation in an infant secondary to retropharyngeal abscess
Claire Cockburn and Sarah Abernethy
Royal Hospital for Children, UK
Abstract
Objective: The pattern of spinal cord injury in children is related to age and mechanism of injury. Spinal cord injuries have been described in new born infants following traumatic deliveries or thromboembolism due to umbilical cord catheterisation. This case highlights an unusual cause of spinal cord injury in a 5-week-old baby.
Case report: Five-week-old baby presented in cardiac arrest with return of circulation after 12 min of resuscitation. The cause of his arrest was unclear although he was managed for sepsis. As his sedation was weaned he began to have unusual movements not suggestive of seizures. He also had an intermittent usual breathing pattern on the ventilator. He had evidence of ongoing inflammation but his cultures were negative. Prior to presentation in cardiac arrest there was a history of possible gastroesophageal reflux with reduced feeding, poor weight gain and back arching which was treated with omeprazole and gaviscon. His initial imaging was normal but he had additional imaging due to his unusual clinical picture not in keeping with hypoxic ischaemic encephalopathy. Follow-up imaging showed loss of alignment of C1/C2 with spinal cord compression. More detailed imaging revealed a retropharyngeal abscess. It was thought that subluxation was due to peg avulsion caused by osteomyelitis. He was treated with a custom made brace which prevented excessive flexion by the neurosurgical team. He had ongoing problems with ventilation and went on to have a tracheostomy. He was also found to have right elbow oesteomyelitis.
Discussion: Spinal injuries are rare in infants after the neonatal period. The aim of this case presentation is to discuss the presenting features and potential causes of spinal cord injury in this age group. Given its rarity retropharyngeal abscess in infancy will also be discussed.
Conclusion: Spinal cord injury in infancy is rarely described in literature after the newborn period. This is an unusual presentation of spinal cord injury in an infant with a usual aetiology.
We describe the cases of two patients referred to psychiatry for suspected psychogenic cause of ongoing weight loss and non-specific gastrointestinal symptoms who were subsequently diagnosed with inflammatory bowel disease (IBD). In one case the patient had a formal diagnosis of eating disorder prior to IBD diagnosis and exhibited disordered eating secondary to the worsening symptoms of undiagnosed ulcerative colitis (UC). She had altered her eating habits to reduce the undisclosed diarrhoea and rectal bleeding she was experiencing; contributing to significant weight loss and leading to the initial diagnostic suspicion of the paediatric gastroenterology team of small bowel Crohn’s disease (CD). The second patient was diagnosed with CD after being referred to gastroenterology via psychiatry, her GP and general paediatrics due to concern regarding continued weight loss and loose stools. In both cases IBD diagnosis was significantly delayed for over one year following initial presentation with implications for the physical and mental health of both patients and their families. It can be difficult to discern between organic and psychogenic causes of gastrointestinal symptoms. Patients may have a primary GI disorder with resulting disordered eating, or a primary eating disorder with consequent GI sequelae; both of which may present with non-specific symptoms such as abdominal pain, nausea, vomiting, altered bowel habit, anorexia, weight loss and growth failure on a spectrum of severity. The implications of a delayed diagnosis of IBD or incorrect diagnosis of eating disorder are severe both physically and psychologically. Elements of the patient’s history and examination may point to a diagnosis of organic disease; however, the onset of IBD may be insidious, leading to diagnostic uncertainty and ultimately delay. When performed in parallel blood tests (full blood count (FBC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and albumin) and faecal calprotectin are almost universally abnormal at diagnosis in patients with IBD; but it is important to highlight that normal laboratory values do not rule out organic disease and further investigation should be undertaken where a high index of suspicion is present regardless of negative results. We aim to highlight factors in the assessment of patients which may raise suspicion of organic GI disease such as IBD – an important differential diagnosis in those with non-specific GI symptoms and suspected eating disorder – and highlight baseline investigations which should be performed to ensure a diagnosis of IBD is not missed in these patients.
