K. R. Palmer

Acute upper gastrointestinal bleeding in the UK: patient characteristics, diagnoses and outcomes in the 2007 UK audit

Objective To describe the patient characteristics, diagnoses and clinical outcomes of patients presenting with acute upper gastrointestinal bleeding (AUGIB) in the 2007 UK Audit. Design Multi-centre survey. Setting All UK hospitals admitting patients with AUGIB. Participants All adults (>16 years) presenting in or to UK hospitals with AUGIB between 1 May and 30 June 2007. Results Data on 6750 patients (median age 68 years) was collected from 208 participating hospitals. New admissions (n=5550) were younger (median age 65 years) than inpatients (n=1107, median age 71 years), with less co-morbidity (any co-morbidity 46% vs 71%, respectively). At presentation 9% (599/6750) had known cirrhosis, 26% a history of alcohol excess, 11% were taking non-steroidal anti-inflammatory drugs and 28% aspirin. Peptic ulcer disease accounted for 36% of AUGIB and bleeding varices 11%. In 13% there was evidence of further bleeding after the first endoscopy. 1.9% underwent surgery and 1.2% interventional radiology for AUGIB. Median length of stay was 5 days. Overall mortality in hospital was 10% (675/6750, 95% CI 9.3 to 10.7), 7% in new admissions and 26% among inpatients. Mortality was highest in those with variceal bleeding (15%) and with malignancy (17%). Conclusions AUGIB continues to result in substantial mortality although it appears to be lower than in 1993. Mortality is particularly high among inpatients and those bleeding from varices or upper gastrointestinal malignancy. Surgical or radiological interventions are little used currently.

Use of endoscopy for management of acute upper gastrointestinal bleeding in the UK: results of a nationwide audit

Objectives To examine the use of endoscopy in the UK for acute upper gastrointestinal bleeding (AUGIB) and compare with published standards. To assess the organisation of endoscopy services for AUGIB in the UK. To examine the relationship between outcomes and out of hours (OOH) service provision. Design Multi-centre cross sectional clinical audit. Setting All UK hospitals accepting admissions with AUGIB. Patients All adults (≥16 yrs) presenting with AUGIB between 1st May and 30th June 2007. Data Collection A custom designed web-based reporting tool was used to collect data on patient characteristics, comorbidity and haemodynamic status at presentation to calculate the Rockall score, use and timing of endoscopy, treatment including endoscopic, rebleeding and in-hospital mortality. A mailed questionnaire was used to collect data on facilities and service organisation. Results Data on 6750 patients (median age 68 years) were analysed from 208 hospitals. 74% underwent inpatient endoscopy; of these 50% took place within 24 h of presentation, 82% during normal working hours and 3% between midnight and 8 am. Of patients deemed high-risk (pre-endoscopy Rockall score ≥5) only 55% were endoscoped within 24 h and 14% waited ≥72 h for endoscopy. Lesions with a high risk of rebleeding were present in 28% of patients of whom 74% received endoscopic therapy. Further bleeding was evident in 13% and mortality in those endoscoped was 7.4% (95% CI 6.7% to 8.1%). In 52% of hospitals a consultant led out of hours (OOH) endoscopy rota existed; in these hospitals 20% of first endoscopies were performed OOH compared with 13% in those with no OOH rota and endoscopic therapy was more likely to be administered (25% vs 21% in hospitals with no OOH rota). The risk adjusted mortality ratio was higher (1.21, p=0.10, (95%CI 0.96 to 1.51)) in hospitals without such rotas. Conclusions This audit has found continuing delays in performing endoscopy after AUGIB and underutilisation of standard endoscopic therapy particularly for variceal bleeding. In hospitals with a formal OOH endoscopy rota patients received earlier endoscopy, were more likely to receive endoscopic therapy and may have a lower mortality.

Acute gastrointestinal haemorrhage in anticoagulated patients: diagnoses and response to endoscopic treatment.

The underlying diagnosis and clinical course of 52 patients who presented with severe acute gastrointestinal haemorrhage while taking the anticoagulant warfarin is reviewed. A bleeding site was identified in 83% of cases, only slightly fewer than the 92% found in a control of group of 710 patients not taking warfarin who presented in the same four year period. The degree or duration of anticoagulation was unrelated to the frequency of establishing a diagnosis. The commonest diagnosis was peptic ulcer (25 cases) and endoscopic treatment by injection or heater probe was attempted in 23 of these. The outcome in this subgroup was compared with that in 50 closely matched control subjects who had similar risk factors for rebleeding from peptic ulcer. Permanent haemostasis was achieved in (91%) of the anticoagulated and in 92% of the control patients. There were no complications related to endoscopy. Patients who present with acute gastrointestinal haemorrhage while taking warfarin usually bleed from mucosal disease. They should be endoscoped after resuscitation and those with major bleeding from a peptic ulcer should be offered endoscopic treatment.

The safety profile of anti-tumour necrosis factor therapy in inflammatory bowel disease in clinical practice: analysis of 620 patient-years follow-up.

Background  Anti‐TNF agents are now widely used in Crohn’s disease (CD), and in ulcerative colitis (UC).

Restrictive versus liberal blood transfusion for acute upper gastrointestinal bleeding (TRIGGER): a pragmatic, open-label, cluster randomised feasibility trial

BACKGROUND Transfusion thresholds for acute upper gastrointestinal bleeding are controversial. So far, only three small, underpowered studies and one single-centre trial have been done. Findings from the single-centre trial showed reduced mortality with restrictive red blood cell (RBC) transfusion. We aimed to assess whether a multicentre, cluster randomised trial is a feasible method to substantiate or refute this finding. METHODS In this pragmatic, open-label, cluster randomised feasibility trial, done in six university hospitals in the UK, we enrolled all patients aged 18 years or older with new presentations of acute upper gastrointestinal bleeding, irrespective of comorbidity, except for exsanguinating haemorrhage. We randomly assigned hospitals (1:1) with a computer-generated randomisation sequence (random permuted block size of 6, without stratification or matching) to either a restrictive (transfusion when haemoglobin concentration fell below 80 g/L) or liberal (transfusion when haemoglobin concentration fell below 100 g/L) RBC transfusion policy. Neither patients nor investigators were masked to treatment allocation. Feasibility outcomes were recruitment rate, protocol adherence, haemoglobin concentration, RBC exposure, selection bias, and information to guide design and economic evaluation of the phase 3 trial. Main exploratory clinical outcomes were further bleeding and mortality at day 28. We did analyses on all enrolled patients for whom an outcome was available. This trial is registered, ISRCTN85757829 and NCT02105532. FINDINGS Between Sept 3, 2012, and March 1, 2013, we enrolled 936 patients across six hospitals (403 patients in three hospitals with a restrictive policy and 533 patients in three hospitals with a liberal policy). Recruitment rate was significantly higher for the liberal than for the restrictive policy (62% vs 55%; p=0·04). Despite some baseline imbalances, Rockall and Blatchford risk scores were identical between policies. Protocol adherence was 96% (SD 10) in the restrictive policy vs 83% (25) in the liberal policy (difference 14%; 95% CI 7-21; p=0·005). Mean last recorded haemoglobin concentration was 116 (SD 24) g/L for patients on the restrictive policy and 118 (20) g/L for those on the liberal policy (difference -2·0 [95% CI -12·0 to 7·0]; p=0·50). Fewer patients received RBCs on the restrictive policy than on the liberal policy (restrictive policy 133 [33%] vs liberal policy 247 [46%]; difference -12% [95% CI -35 to 11]; p=0·23), with fewer RBC units transfused (mean 1·2 [SD 2·1] vs 1·9 [2·8]; difference -0·7 [-1·6 to 0·3]; p=0·12), although these differences were not significant. We noted no significant difference in clinical outcomes. INTERPRETATION A cluster randomised design led to rapid recruitment, high protocol adherence, separation in degree of anaemia between groups, and non-significant reduction in RBC transfusion in the restrictive policy. A large cluster randomised trial to assess the effectiveness of transfusion strategies for acute upper gastrointestinal bleeding is both feasible and essential before clinical practice guidelines change to recommend restrictive transfusion for all patients with acute upper gastrointestinal bleeding. FUNDING NHS Blood and Transplant Research and Development.

Adenocarcinoma arising in columnar lined oesophagus following treatment with argon plasma coagulation

Editor,—Following the recent report by Van Laethem et al ( (2000) Gut 46:574–7. [OpenUrl][1][CrossRef][2][PubMed][3][Web of Science][4] ) of adenocarcinoma developing in a patient whose columnar lined oesophagus had been treated by argon plasma coagulation, we wish to highlight a second case. A 67 year old man presented with epigastric discomfort but no “alarm” symptoms of dysphagia or weight loss. Endoscopy revealed a 5 cm length of columnar lined oesophagus with no evidence of ulceration or stricture. Histology showed intestinal metaplasia with low grade dysplasia. He consented to enter a study of argon plasma coagulation treatment in Barretts oesophagus. One half of the affected oesophagus was treated with argon plasma coagulation (Erbe APC 300, Erbe Elektromedizin GmbH, Germany). He was commenced on omeprazole 40 mg. Repeat endoscopy at two months showed macroscopic regrowth of the squamous epithelium in the area treated by argon plasma coagulation. This was confirmed histologically and the previously noted dysplasia had disappeared. He … [1]: {openurl}?query=rft.jtitle%253DGastrointestinal%2Bendoscopy%26rft.stitle%253DGastrointest%2BEndosc%26rft.aulast%253DLaine%26rft.auinit1%253DL.%26rft.volume%253D44%26rft.issue%253D5%26rft.spage%253D523%26rft.epage%253D526%26rft.atitle%253DProspective%2Bcomparison%2Bof%2Bcommercially%2Bavailable%2Brapid%2Burease%2Btests%2Bfor%2Bthe%2Bdiagnosis%2Bof%2BHelicobacter%2Bpylori.%26rft_id%253Dinfo%253Adoi%252F10.1016%252FS0016-5107%252896%252970002-0%26rft_id%253Dinfo%253Apmid%252F8934155%26rft.genre%253Darticle%26rft_val_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Ajournal%26ctx_ver%253DZ39.88-2004%26url_ver%253DZ39.88-2004%26url_ctx_fmt%253Dinfo%253Aofi%252Ffmt%253Akev%253Amtx%253Actx [2]: /lookup/external-ref?access_num=10.1016/S0016-5107(96)70002-0&link_type=DOI [3]: /lookup/external-ref?access_num=8934155&link_type=MED&atom=%2Fgutjnl%2F48%2F4%2F580.3.atom [4]: /lookup/external-ref?access_num=A1996VT20700002&link_type=ISI

Outcomes following early red blood cell transfusion in acute upper gastrointestinal bleeding

Aliment Pharmacol Ther 2010; 32: 215–224

The use of adalimumab in the management of refractory Crohn’s disease

Background Adalimumab is a humanized monoclonal antibody targeting tumour necrosis factor‐α. Recent clinical trials have demonstrated its efficacy in Crohn’s disease; however, experience in clinical practice remains limited.

Mortality from acute upper gastrointestinal bleeding in the United kingdom: does it display a "weekend effect"?

OBJECTIVES:An increased mortality in patients presenting to hospital at weekends has been observed for several medical conditions. The aim of this study is to examine the relationship between weekend presentation to hospital following acute upper gastrointestinal bleeding and mortality.METHODS:Data were collected on 6,749 patients presenting to 212 UK hospitals. A logistic regression model was used to examine the relationship between weekend presentation to hospital and mortality.RESULTS:Patients presenting at the weekend were more likely to present with shock (39% vs. 36%), hematemesis (41% vs. 38%), and receive red cell transfusion (42% vs. 39%). Only 38% of those presenting at weekends underwent endoscopy within 24 h compared with 55% admitted on weekdays (adjusted odds ratio (OR)=0.47, 95% confidence interval (CI)=0.41–0.54), although the proportion of all patients receiving endoscopic therapy was identical at weekends compared with weekdays (24%). After adjustment for confounders, there was no evidence of a difference between weekend and weekday mortality (OR=0.93; 95% CI=0.75–1.16). Similar results were seen when restricting the analysis to those patients who underwent endoscopy (n=5,004) (OR=0.87, 95% CI=0.65–1.16). There was no difference in the OR for mortality for weekend compared with weekday presentation between patients presenting to hospitals with an out-of-hours (OOH) endoscopy rota compared with those presenting to hospitals without such a facility.CONCLUSIONS:In this large prospective study of acute upper gastrointestinal bleeding in the United Kingdom, there was no increase in mortality for weekend vs. weekday presentation despite patients being more critically ill and having greater delays to endoscopy at weekends. Provision of an OOH endoscopy service at weekends in the remaining UK hospitals may not lead to further reductions in case fatality, although a reduction in OOH endoscopy provision from current levels could lead to an increase in mortality at weekends.

OUTCOMES FOLLOWING EARLY RED BLOOD CELL TRANSFUSION IN ACUTE UPPER GASTROINTESTINAL BLEEDING

Aliment Pharmacol Ther 2010; 32: 215–224