William Murray

Acute upper gastrointestinal haemorrhage in west of Scotland: case ascertainment study.

Abstract Objectives: To determine the incidence and case fatality of acute upper gastrointestinal haemorrhage in the west of Scotland and to identify associated factors. Design: Case ascertainment study. Setting: All hospitals treating adults with acute upper gastrointestinal haemorrhage in the west of Scotland. Subjects: 1882 patients aged 15 years and over treated in hospitals for acute upper gastrointestinal haemorrhage during a six month period. Main outcome measures: Incidence of acute upper gastrointestinal haemorrhage per 100 000 population per year, and case fatality. Results: The annual incidence was 172 per 100 000 people aged 15 and over. The annual population mortality was 14.0 per 100 000. Both were higher among elderly people, men, and patients resident in areas of greater social deprivation. Overall case fatality was 8.2%. This was higher among those who bled as inpatients after admission for other reasons (42%) and those admitted as tertiary referrals (16%). Factors associated with increased case fatality were age, uraemia, pre-existing malignancy, hepatic failure, hypotension, cardiac failure, and frank haematemesis or a history of syncope at presentation. Social deprivation, sex, and anaemia were not associated with increased case fatality after adjustment for other factors. Conclusions: The incidence of acute upper gastrointestinal haemorrhage was 67% greater than the highest previously reported incidence in the United Kingdom, which may be partially attributable to the greater social deprivation in the west of Scotland and may be related to the increased prevalence of Helicobacter pylori. Fatality after acute upper gastrointestinal haemorrhage was associated with age, comorbidity, hypotension, and raised blood urea concentrations on admission. Although deprivation was associated with increased incidence, it was not related to the risk of fatality. Key messages The incidence of upper gastrointestinal haemorrhage in the west of Scotland was 67% higher than the highest incidence previously reported in the United Kingdom A substantial part of this excess incidence may be attributable to socioeconomic deprivation The overall population mortality from upper gastrointestinal haemorrhage may increase as the elderly population increases because both incidence and case fatality rise steeply with age A reduction in the overall case fatality from acute upper gastrointestinal haemorrhage will be best achieved by reducing case fatality among elderly patients

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.

Multicentre comparison of the Glasgow Blatchford and Rockall scores in the prediction of clinical end-points after upper gastrointestinal haemorrhage

Aliment Pharmacol Ther 2011; 34: 470–475

Botulinum toxin-induced relaxation of the sphincter of Oddi may select patients with acalculous biliary pain who will benefit from cholecystectomy

BackgroundAcalculous biliary pain may be due to gallbladder dyskinesia or sphincter of Oddi (SO) hypertension. These two etiologies are difficult to differentiate because the gallbladder ejection fraction may be low and the SO manometry results may be abnormal in both. Cholecystectomy is advised for patients with biliary dyskinesia, but it often exacerbates biliary pain for patients with SO hypertension. The biliary pain response to relaxation of the SO using botulinum toxin may indicate appropriate treatment for patients with acalculous biliary pain.MethodsThe protocol-based management of 25 patients with acalculous biliary pain and two gallbladder ejection fraction estimations less than 40% who had 100 units of botulinum toxin injected into their SO musculature to relax the sphincter has been audited. Patients whose pain was temporarily relieved after botulinum toxin injection were offered endoscopic biliary sphincterotomy, and patients who failed to experience benefit after botulinum toxin injection were assessed for laparoscopic cholecystectomy.ResultsBotulinum toxin was injected into the SO of 25 patients, with 11 experiencing temporary biliary pain relief. Of these patients, 10 consented to undergo endoscopic biliary sphincterotomy, with relief of biliary pain in all cases. A total of 14 patients had a negative response to botulinum toxin treatment, with 10 of these patients progressing to laparoscopic cholecystectomy, which resulted in biliary pain relief in eight cases.ConclusionBotulinum toxin-induced relaxation of the SO may help to direct appropriate therapy for patients with acalculous biliary pain. The data from this study supports the establishment of a randomized clinical trial.

Botulinum Toxin and the Sphincter of Oddi

Sphincter of Oddi (SO) dysfunction can be physical or functional. Physical dysfunction is referred to as SO stenosis, papillary stenosis, or ampullary stenosis and is most commonly due to post-inflammatory fibrosis thought to be secondary to the passage of small gallstones. Symptoms may be biliary and/or pancreatic, and diagnosis is based on the demonstration of a localized SO stricture or its back pressure effects. Endoscopic sphincterotomy is associated with a >90% cure rate (Bistritz and Bain 2006). Physiological dysfunction of the SO is referred to as SO dysfunction or, more accurately, SO hypertension (SOH). In the resting phase, the SO contracts and relaxes up to seven times per minute. SOH is defined by SO manometry, and the critical measurement has been shown to be the relaxation (basal) pressure exhibited by the resting SO. An abnormal SO pressure profile is said to exist when the SO relaxation pressure is >40 mm Hg. SOH has been associated clinically with acalculus biliary pain, postcholecystectomy right upper quadrant abdominal pain, postprandial pancreatic pain and idiopathic recurrent acute pancreatitis (Sherman and Lehman 2001). Updated (Rome III) diagnostic criteria, investigative algorithms and suggestions regarding management were published in 2006 (Behar et al. 2006).