M Groome

Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation

BACKGROUND Upper-gastrointestinal haemorrhage is a frequent reason for hospital admission. Although most risk scoring systems for this disorder incorporate endoscopic findings, the Glasgow-Blatchford bleeding score (GBS) is based on simple clinical and laboratory variables; a score of 0 identifies low-risk patients who might be suitable for outpatient management. We aimed to evaluate the GBS then assess the effect of a protocol based on this score for non-admission of low-risk individuals. METHODS Our study was undertaken at four hospitals in the UK. We calculated GBS and admission (pre-endoscopy) and full (post-endoscopy) Rockall scores for consecutive patients presenting with upper-gastrointestinal haemorrhage. With receiver-operating characteristic (ROC) curves, we compared the ability of these scores to predict either need for clinical intervention or death. We then prospectively assessed at two hospitals the introduction of GBS scoring to avoid admission of low-risk patients. FINDINGS Of 676 people presenting with upper-gastrointestinal haemorrhage, we identified 105 (16%) who scored 0 on the GBS. For prediction of need for intervention or death, GBS (area under ROC curve 0.90 [95% CI 0.88-0.93]) was superior to full Rockall score (0.81 [0.77-0.84]), which in turn was better than the admission Rockall score (0.70 [0.65-0.75]). When introduced into clinical practice, 123 patients (22%) with upper-gastrointestinal haemorrhage were classified as low risk, of whom 84 (68%) were managed as outpatients without adverse events. The proportion of individuals with this condition admitted to hospital also fell (96% to 71%, p<0.00001). INTERPRETATION The GBS identifies many patients presenting to general hospitals with upper-gastrointestinal haemorrhage who can be managed safely as outpatients. This score reduces admissions for this condition, allowing more appropriate use of in-patient resources.

Prevalence of Laryngopharyngeal Reflux in a Population With Gastroesophageal Reflux

Objective: Laryngopharyngeal reflux (LPR) is a syndrome associated with a constellation of symptoms usually treated by ENT surgeons. It is believed to be caused by the retrograde flow of stomach contents into the laryngopharynx, this being a supra‐esophageal manifestation of gastroesophageal reflux disease (GERD). It has been cited that LPR and GERD can be considered separate entities. Our hypothesis was that LPR is a supra‐esophageal manifestation of GERD and therefore that patients with GERD should have a degree of symptoms suggestive of LPR because of the reflux of the gastric contents. We examined a population of patients with both upper gastrointestinal endoscopy and symptom‐proven GERD and, using a questionnaire, looked at their existing symptoms to help assess the prevalence of LPR. We also looked at whether, with more severe GERD (suggestive of increased gastric content reflux), the degree of symptoms suggestive of LPR would be increased, as would be expected.

OC-022 Multicentre comparison of the Glasgow Blatchford and Rockall scores in the prediction of clinical endpoints in upper gastrointestinal haemorrhage

Introduction The pre-endoscopic Glasgow Blatchford Score (GBS) can identify low-risk patients with upper gastrointestinal haemorrhage (UGIH) who may be suitable for out-patient management. Although it does not include the patients age, the GBS appears to have high accuracy in predicting clinically relevant endpoints. Our aim was to compare the GBS with both the pre-endoscopy (admission) and post-endoscopy (full) Rockall scores in predicting need for clinical intervention and mortality. Methods Data on consecutive patients presenting to four UK hospitals (Glasgow Royal Infirmary, Royal Cornwall Hospital Truro, University Hospital of North Tees and Ninewells Hospital Dundee) were collected. Admission history, clinical and laboratory data, endoscopic findings and treatment, and clinical follow-up were recorded. We used ROC curves to compare the three scores in the separate prediction of death, endoscopic or surgical intervention and transfusion. Results 1556 patients (mean age 56.7 years; 62% male) presented with UGIH to the four hospitals during the study period. 74 (4.8%) died, 223 (14.3%) had endoscopic or surgical intervention and 363 (23.3%) required transfusion. The GBS was equally effective at predicting death compared with both the admission Rockall score (area under ROC curve 0.804 vs 0.801) and the full Rockall score (AUROC 0.741 vs 0.790). In predicting endo/surgical intervention, the GBS was superior to the admission Rockall score (AUROC 0.858 vs 0.705, p<0.00005) but similar to the full Rockall score (AUROC 0.822 vs 0.797). The GBS was superior to both the admission Rockall (AUROC 0.944 vs 0.756, p<0.00005) and the full Rockall score (AUROC 0.935 vs 0.792, p<0.00005) in predicting need for transfusion. Conclusion Despite not incorporating age, the GBS is as effective as the admission and full Rockall scores in predicting death after UGIH. It is superior to both the admission and full Rockall scores in predicting need for transfusion and superior to the admission Rockall score in predicting endoscopic or surgical intervention.

Are patients in the IBD clinic at risk of proctitis secondary to sexually transmitted infections

Objective To gauge the potential risk of sexually transmitted infection (STI) as a cause of proctitis in a cohort of patients with inflammatory bowel disease (IBD) and to gauge whether this cohort could benefit from STI testing in the future. Design Patients attending the IBD clinic were given an anonymous questionnaire recording demographics, sexual behaviour, rectal symptoms, history of receptive anal intercourse (RAI), STIs and attitudes towards sexual health screening. Setting A gastroenterology teaching hospital IBD clinic. Patients 280 consecutive patients attending a teaching hospital IBD clinic over a consecutive 6-week period. All patients had an endoscopic, radiological and/or histological diagnosis of IBD. Results 280 questionnaires were distributed and 274 analysed (3 incomplete, 2 not returned, 1 no sexual activity). 167 female (median: 46 years, range 17–81 years) and 107 males. Two males disclosed RAI and were used as a control. Of the 167 females, 96% were heterosexual, 2.4% were same-sex partners and 1.2% were bisexual. 14% had a history of RAI—this group had more previous STIs (40%) versus those with no history RAI (5%) (p<0.0001; relative risk (RR) 13.41). Chronic rectal pain was more frequent in women with RAI (RR 2.4; p≤0.03). No difference in rectal discharge (RR 1.75; p=0.72) or bleeding (p=0.3). Conclusions This is the first report of sexual behaviours in a non-genitourinary medicine clinic; giving a unique insight into sexual practices in a cohort of patients with IBD. A past history of STI and RAI can identify risk and we propose testing for those with a history of STI, RAI, men who have sex with men and women aged under 25 years.

Su1247 Microscopic Colitis in Tayside - Further Observations on Clinical Features, Outcome and Endoscopic Findings

BACKGROUND: Colitis describes inflammation in the colon and is classified into defined diseases: inflammatory bowel disease (IBD), microscopic colitis, iatrogenic colitis, ischemic colitis, and infectious colitis. Accurate classification helps guide management, but this is often difficult. Nonspecific colitis, or also known as atypical colitis, describes the cases that do not show characteristic features of a specific colitis. The clinical significance of nonspecific colitis is unclear as there are limited studies. Notteghem et al. (1993) showed that out of 104 patients with nonspecific colitis, 52.3% had another episode within 3 years and 54% were diagnosed with ulcerative colitis, 33% with Crohns, and 13% remained unclassified, suggesting that nonspecific colitis could potentially be undiagnosed IBD. PURPOSE: The objective of this study is to understand their clinical course by examining subsequent colonoscopies and determining if any presenting symptom can predict subsequent diagnosis. METHODS: Patients who had colonoscopies from 1/2004-12/2006 with biopsies showing nonspecific colitis were enrolled in this retrospective observational study. The inclusion criteria are biopsies from colonoscopies showing nonspecific colitis, follow up with a physician for at least one year, and no previous diagnosis of a specific colitis based on history or biopsy. A chart review of the electronic record was done from the time of colonoscopy until current time or the last note. RESULTS: 101 patients were included in the study with a mean follow-up period of 5.09 years. The most common indications for colonoscopy were diarrhea (44.6%), abdominal pain (29.7%), blood in stool (36.6%), and anemia (7.9%). 50.5% of patients had at least one subsequent colonoscopy with 68.6% of them with normal biopsies, 33.3% with nonspecific biopsies, and 15.7% with biopsies consistent with IBD. No presenting symptom was predictive of subsequent biopsies with IBD, such as abdominal pain (OR, 2.4, 95% CI, 0.57-10.5, p = 0.23) or blood in stool (OR, 3.2, 95% CI, 0.7114.2, p = 0.13). 19 out of 101 patients with nonspecific colitis biopsies were treated for IBD given symptoms (18.8%), and 6 out of the 19 patients had subsequent biopsies showing IBD (31.6%). CONCLUSIONS: 50.5% of patients who have biopsies with nonspecific colitis had a subsequent colonoscopy, and 68.6% of subsequent colonoscopies were normal while 15.7% had IBD. Therefore, although most commonly nonspecific colitis is self-limited colitis, there is a portion that are undiagnosed IBD. In fact, 18.8% of patients with nonspecific colitis were empirically treated for IBD given symptoms, and 31.6% of these patients showed IBD on subsequent colonoscopies.

Is the Glasgow Blatchford Score useful in the risk assessment of patients presenting with variceal haemorrhage

Introduction The Glasgow Blatchford Score (GBS) is a pre-endoscopic risk assessment tool for patients presenting with upper gastrointestinal haemorrhage (UGIH). It can predict need for intervention or death and identifies low risk patients suitable for out-patient management.1 There are no published data assessing its use in variceal haemorrhage. Our aim was to compare the GBS with both admission and full Rockall scores in assessment of patients with variceal bleeding. Methods Data on consecutive patients presenting to four UK hospitals (Glasgow Royal Infirmary, Royal Cornwall Hospital Truro, University Hospital of North Tees and Ninewells Hospital Dundee) were collected. Admission history, clinical and laboratory data, endoscopic findings, intervention and follow-up were recorded. We compared the ability of GBS and both Rockall scores to predict intervention and death in those patients with a final diagnosis of variceal bleeding. Results 1556 patients presented with UGIH to the four hospitals during the study period. 78 had a final diagnosis of variceal bleeding. The mortality of these patients was higher than the non-variceal patients (18% vs 4%; p < 0.0005). On presentation, no variceal bleeding patient had a GBS <3; however, six had an admission Rockall score of zero. The median(range) GBS, admission Rockall and full Rockall scores for the variceal bleeding group were 10(2–18), 3(0–7) and 5(1–10), respectively. The comparable figures for all other patients were 3(0–19), 1(0–7) and 3(0–9), respectively (all p < 0.00005 vs varices). When comparing variceal bleeding patients with those who required intervention or died from another bleeding source, there was no difference using any of the three scores. In predicting need for intervention in the variceal bleeding group, AUC (95% CI) for GBS, admission Rockall and full Rockall scores were: 0.72 (0.56–0.89), 0.46 (0.30–0.62) and 0.66 (0.51–0.83), respectively. For predicting death, the figures were: 0.58 (0.41–0.75), 0.68 (0.54–0.82) and 0.72 (0.58–0.86), respectively. Conclusion At presentation, the GBS correctly identifies patients with variceal bleeding as being at high risk for requiring intervention and appears superior to the admission Rockall score for this. However, it is a poor predictor of mortality in this patient group.