Summary Background Upper gastrointestinal bleeding (UGIB) remains a common cause of presentation and admission to hospital in the UK, with the incidence in Scotland one of the highest in the world. Aims To investigate the difference in demographics, deprivation quintiles, aetiology of bleeding and clinical outcomes in patients presenting with UGIB to hospitals across Scotland over a 16‐year period Methods Data were collected using the National Data Catalogue and analysed retrospectively using the National Safe Haven. Results We included 129 404 patients. The annual number of patients presenting with UGIB remained similar over the 16‐year period. Mean age at admission increased from 59.2 to 61.4 years. There was a significant drop in variceal bleeding over time from 2.2% to 1.7% ( P < 0.001). The incidence of UGIB was highest in the more deprived quintiles. There was a significant decrease in 30‐day case‐fatality from 10.1% in 2000 to 7.9% in 2015 ( P < 0.001), which was observed across all deprivation quintiles. Mean length of stay fell from 3.9 to 2.1 days. There was no difference in 30‐day case‐fatality or mean length of stay between patients presenting on weekdays or at weekends. Conclusions In this national study, we demonstrated that case‐fatality and mean length of stay after presentation with UGIB in Scotland has fallen over the past 16 years, despite a rise the in mean age of patients. There is a positive correlation between the incidence of UGIB and deprivation. We found no evidence of worse outcomes among patients presenting at weekends.
These updated guidelines on the management of variceal haemorrhage have been commissioned by the Clinical Services and Standards Committee (CSSC) of the British Society of Gastroenterology (BSG) under the auspices of the liver section of the BSG. The original guidelines which this document supersedes were written in 2000 and have undergone extensive revision by 13 members of the Guidelines Development Group (GDG). The GDG comprises elected members of the BSG liver section, representation from British Association for the Study of the Liver (BASL) and Liver QuEST, a nursing representative and a patient representative. The quality of evidence and grading of recommendations was appraised using the AGREE II tool. The nature of variceal haemorrhage in cirrhotic patients with its complex range of complications makes rigid guidelines inappropriate. These guidelines deal specifically with the management of varices in patients with cirrhosis under the following subheadings: (1) primary prophylaxis; (2) acute variceal haemorrhage; (3) secondary prophylaxis of variceal haemorrhage; and (4) gastric varices. They are not designed to deal with (1) the management of the underlying liver disease; (2) the management of variceal haemorrhage in children; or (3) variceal haemorrhage from other aetiological conditions.
Observational studies have consistently shown an increased risk of upper gastrointestinal bleeding in users of selective serotonin receptor inhibitors (SSRIs), probably explained by their inhibition of platelet aggregation. Therefore, treatment with SSRIs is often temporarily withheld in patients with peptic ulcer bleeding. However, abrupt discontinuation of SSRIs is associated with development of withdrawal symptoms in one-third of patients. Further data are needed to clarify whether treatment with SSRIs is associated with poor outcomes, which would support temporary discontinuation of treatment.To identify if treatment with SSRIs is associated with increased risk of: (1) endoscopy-refractory bleeding, (2) rebleeding or (3) 30-day mortality due to peptic ulcer bleeding.A nationwide cohort study. Analyses were performed on prospectively collected data on consecutive patients admitted to hospital with peptic ulcer bleeding in Denmark in the period 2006-2014. Logistic regression analyses were used to investigate the association between treatment with SSRIs and outcome following adjustment for pre-defined confounders. Sensitivity and subgroup analyses were performed to evaluate the validity of the findings.A total of 14 343 patients were included. Following adjustment, treatment with SSRIs was not associated with increased risk of endoscopy-refractory bleeding (odds ratio [OR] [95% Confidence Interval (CI)]: 1.03 [0.79-1.33]), rebleeding (OR [95% CI]: 0.96 [0.83-1.11]) or 30-day mortality (OR [95% CI]: 1.01 [0.85-1.19]. These findings were supported by sensitivity and subgroup analyses.According to our data, treatment with SSRIs does not influence the risk of endoscopy-refractory bleeding, rebleeding or 30-day mortality in peptic ulcer bleeding.
There have been several different methods proposed for image guided radiotherapy in oesophageal cancer patients. One method described recently has been a fiducial solid gold marker sited under direct EUS guidance.1
Methods
This was a single centre, prospective, feasibility pilot study in a tertiary care cancer centre in Glasgow. Patients with oesophageal cancer, in whom radiotherapy was being planned between October 2015 and February 2016, underwent EUS to place solid gold fiducial markers of length 5 mm. 4 of these fiducials, in a new multi-fiducial delivery system (Cook®) with a 22 g delivery needle, were inserted through the channel of a linear EUS scope. The needle was inserted into the tumour and fiducials placed into the tumour under EUS guidance. 2 markers were placed at both the distal and proximal margin of the tumour where possible. The Five-point Likert scale2 was used to determine technical outcomes from EUS placement at both EUS and planning CT. Median Likert scores are reported. Time to place the fiducial at time of EUS and any complications were recorded.
Results
A total of 25 fiducials have been placed in 7 patients. In 2 patients the tumour limited the passage of the EUS scope distally; therefore only proximal placement of the fiducials was undertaken. The median EUS accuracy of fiducial placement was within 5 mm from the outer rim of the target (Likert 2) and fiducials were deployed with minimal difficulty (Likert 2). The needle was clearly seen and easy to distinguish from surrounding tissue (Likert 1) and the fiducial markers were easy to see with minimal adjustments to the scope (Likert2). Mean time for fiducial deployment at EUS was 345 seconds. Mean time from EUS to planning CT scan was 28 days. At the planning CT fiducials were visualised in the tumour region in 6 of 7 patients. In these 6 patients they were visible in the tumour areas where placement was undertaken. The total number of fiducials identified was 15 out of 25 sited and they were easy to distinguish from surrounding tissue (Likert 2). There have been no complications reported.
Conclusion
EUS guided solid gold marker fiducial deployment is safe and feasible in patients with oesophageal cancer. There appears to be good correlation between fiducial position at EUS and subsequent radiotherapy planning CT. This may help to better target radiotherapy delivery.
References
1 Endoscopy/EUS-guided fiducial marker placement in patients with esophageal cancer. GastrointestEndosc. 2015 Oct;82(4):641–9. doi:10.1016/j.gie.2015.03.1972. 2 Evaluation of a new endoscopic ultrasound-guided multi-fiducial delivery system: Digestive Endoscopy, 25:615–621. doi:10.1111/den.12046
Anti-thrombotics (antiplatelets and anticoagulants; ATs) have been identified as risk factors for upper gastrointestinal bleeding (UGIB). However few international studies have evaluated their effect on patient outcome. We aimed to assess the effects of AT use on outcome in patients with high-risk UGIB requiring endoscopic therapy.
Methods
Patients presenting with UGIB who required endoscopic therapy at eight centres (Scotland, England, USA, Canada, Denmark, Italy, Singapore & New Zealand) were prospectively included over 12 months. Data recorded included the full Rockall score (FRS); AT use (Aspirin, Adenosine Diphosphate Receptor Inhibitors (ADP-RI), Vitamin-K Antagonists (VKA), Low Molecular Weight Heparin (LMWH), Thrombin inhibitors and Factor Xa inhibitors); endoscopic findings; blood transfusion; interventional radiology; surgery; rebleeding; 30 day mortality and length of hospital stay.
Results
Out of 3154 patients, 619 required endotherapy (44% for ulcer bleeding and 21% for varices). 187 (30%) patients were on aspirin, 61 (11%) ADP-RI, 57 (9%) VKA, 8 (1%) LMWH, 7 (1%) factor Xa-inhibitor and 1 patient a thrombin-inhibitor. 63 (11%) patients were treated with >1 type of AT. Patients treated with ATs were older (p < 0.0001), had higher ASA-score (p = 0.001), lower haemoglobin (P = 0.04), higher FRS (p < 0.0001), more frequently had ischaemic heart disease (IHD; p < 0.001), less frequently had cirrhosis (P < 0.001), more frequently bled from ulcers (p < 0.001) but less frequently from varices (p < 0.001) compared with those not taking ATs. There were no differences in sex, systolic blood pressure, frequency of malignancies, need for surgery/embolisation or rebleeding rate. Patients taking ATs had lower mortality than those not taking these drugs: all cause (11/253 [4%] vs 37/315 [12%]; p = 0.006) and bleeding-related (3/253 [1%] vs 19/315 [6%]; p = 0.01). However, when excluding patients with liver cirrhosis (n = 151) there were no differences in mortality between groups.
Conclusion
Patients with UGIB who require endoscopic therapy whilst on ATs do not experience a higher rate of rebleeding or mortality compared with UGIB patients who do not use ATs. We observed excess mortality in patients not taking ATs, which is likely due to the high rates of cirrhosis (40%) and variceal bleeding (33%) in these patients. Further studies are needed to clarify the risk of adverse outcome following UGIB in patients taking novel ATs.
We examined the association of serum alanine aminotransferase (ALT) with features of the metabolic syndrome and whether it predicted incident diabetes independently of routinely measured factors in 5,974 men in the West of Scotland Coronary Prevention Study. A total of 139 men developed new diabetes over 4.9 years of follow-up. ALT, but not aspartate aminotransferase, levels increased progressively with the increasing number of metabolic syndrome abnormalities from (means ± SD) 20.9 ± 7.6 units/l in those with none to 28.1 ± 10.1 units/l in those with four or more (P < 0.001). In a univariate analysis, men with ALT in the top quartile (ALT ≥29 units/l) had an elevated risk for diabetes (hazard ratio 3.38 [95% CI 1.99–5.73]) versus those in the bottom quartile (<17 units/l). ALT remained a predictor with adjustment for age, BMI, triglycerides, HDL cholesterol, systolic blood pressure, glucose, and alcohol intake (2.04 [1.16–3.58] for the fourth versus first quartile). In stepwise regression, incorporating ALT and C-reactive protein (CRP) together with metabolic syndrome criteria, elevated ALT (≥29 units/l), and CRP (≥3 mg/l) predicted incident diabetes, but low HDL cholesterol and hypertension did not. Thus, elevated ALT levels within the “normal” range predict incident diabetes. The simplicity of ALT measurement and its availability in routine clinical practice suggest that this enzyme activity could be included in future diabetes prediction algorithms.
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