Aims Acute upper gastrointestinal bleeding (AUGIB) is a common medical emergency. We present the findings on endoscopic management of AUGIB patients in the UK.
Patients surviving a variceal bleed are at high risk of re-bleeding with a mortality of 25–50% during a 1–2 year follow-up. Several studies and meta-analyses have demonstrated reduced rates of oesophageal variceal rebleeding with the use of β-blockers. However, their use can be limited by contraindications or intolerance to therapy. Other trials have shown that addition of nitrates may improve the efficacy of β-blockers in prevention of variceal re-bleeding. Endoscopic variceal band ligation (VBL) has been shown in meta-analyses to decrease the rates of rebleeding and mortality compared with endoscopic sclerotherapy. Studies comparing combined drug therapy with VBL have shown similar rebleeding rates although there is a suggestion that survival may be higher in those given drug therapy. Recent data suggest that combined VBL and drug therapy reduces the risk of rebleeding from oesophageal varices compared with either therapy alone; however there appears to be no reduction in overall mortality.
1. Beyond an early age (about 3 weeks), the proportion of brown fat within the hamster maintains a relative constancy. In contrast, the ratio of white fat to body weight increases precipitously with age until full maturity of the hamster. 2. Cortisone treatment results in a prompt hypertrophy of brown fat in hamsters and mice, reflected microscopically by measurable expansion of cell diameter. White fat is possibly somewhat reduced in weight. 3. The reactive hypertrophy of brown fat in cortisone-treated hamsters diminishes with increasing age, apparently caused in part by the increasing numbers of unresponsive white fat cells within the borders of brown fat masses.
Introduction Trainees report inadequate exposure and training barriers in acute upper gastrointestinal bleed (AUGIB) endoscopic management. This UK-wide survey evaluated the experiences of trainees and trainers in AUGIB endoscopy training. Methods A questionnaire was distributed to UK upper GI endoscopy trainees and trainers in 2022–2023. Results We received responses from 137 trainees (23%) and 115 trainers (76%). Trainees reported higher exposure to diagnostic oesophagogastroduodenoscopies (OGDs) than AUGIB endoscopy (median 300, IQR 203–441 vs 15, IQR 2.5–35.5 lifetime procedures), with variations among grades and regions. Among trainees, 55% were specialist trainee (ST)3–5 and 28% ST6–7; 73% had Joint Advisory Group (JAG) certification for OGDs, and 32% attended a JAG-approved haemostasis course. For ST6–7 trainees, the highest lifetime procedure counts were for band ligation (median 20, IQR 8.5–39) and injection therapy (median 10, IQR 6.5–29.5); the lowest counts were for glue, over-the-scope clip and Danis stent (median 0). ≤41% of ST6–7 trainees felt confident in independent haemostatic procedures. Most trainees (68%) and trainers (64%) reported difficulties in AUGIB endoscopy training. Key barriers included lack of structured training (94% trainees), not being part of the AUGIB on-call rota (78% trainees and 72% trainers) and intensive acute-take commitments (75% trainees and 85% trainers). Suggested improvements included mandatory AUGIB on-call rota participation (89% trainees and 85% trainers), access to JAG-approved haemostasis courses (85% trainees and 84% trainers), simulation-based training (83% trainees and 72% trainers) and reduced acute-take commitments (80% trainees and trainers). Conclusion This survey highlights limited exposure to haemostasis procedures and low perceived competence among UK trainees. Addressing these challenges provides an opportunity for targeted improvements, ensuring a more comprehensive training experience.
Rebleeding after an initial oesophageal variceal haemorrhage remains a significant problem despite therapy with band ligation ± non-selective ß-blockers. Carvedilol is a vasodilating non-selective ß-blocker with alpha-1 receptor and calcium channel antagonism. It has a greater portal hypotensive effect than propranolol and has been shown to be effective in the prevention of a first variceal bleed. Our aim was to compare oral carvedilol with band ligation in the prevention of rebleeding following a first variceal bleed.
Methods
Patients who were stable 5 days after presentation with a first variceal haemorrhage and had not been taking (or had contraindications to) ß-blockers, were randomised to oral carvedilol (6.25 mg daily then 12.5 mg daily after one week if tolerated) or a band ligation programme. Patients were followed up at clinic after one week, monthly, then 3-monthly. The primary end-point was variceal rebleeding, on intention-to-treat analysis.
Results
63 patients were randomised, 32 to carvedilol and 31 to banding. Fifty-six (89%) patients had alcohol related liver disease. There was no difference in baseline mean age (51 yrs ± 10.9 and 50 yrs ± 13.0) or median Childs Pugh score (9, IQR 6–11 and 9, IQR 8–11) for patients randomised to carvedilol or banding respectively. Mean follow-up was 29 months. Compliance was 72% and 90% for carvedilol and banding respectively (p = 0.14) and there was no difference in the number of serious adverse events between the two groups. Variceal rebleeding occurred during follow-up in 12 (37.5%) and 9 (29.0%) patients in the carvedilol and banding groups respectively (p = 0.72), with mortality 25.0% and 51.6% respectively (p = 0.058). The differences in outcome the between groups were similar using per protocol analysis. This interim analysis indicates that to show a significant difference in rebleeding, 482 patients would be required in each group.
Conclusion
Carvedilol is not clearly superior to band ligation in the prevention of variceal rebleeding. However there appears to be a survival benefit for patients taking this drug compared with those undergoing banding, which requires further exploration.
EUS+/-FNA has been regarded as a standard investigation for T and N staging of oesophageal and oesophagogastric junctional (OGJ) cancer. The increased availablility of PET-CT has led to many centres reducing their use of EUS and relying more on non-invasive assessment of lymph node involvement. The aim of this study was to retrospectively analyse the outcomes from EUS following the introduction of PET-CT into a single regional unit.
Methods
The computerised records of all patients diagnosed with oesophageal or OGJ cancer and discussed at a regional MDM between March 2009 and February 2011 were analysed. Patients felt to be suitable for radical treatment based upon initial endoscopy, CT scan and review of referral letter underwent a combination of PET-CT +/- EUS. The final staging pathway and management of this group of patients were analysed retrospectively.
Results
593 patients were diagnosed and presented to the regional MDM. 412 (69%) were directed towards palliative treatment following initial assessment. Of the remaining 181 (31%), PET-CT was undertaken in 180 and EUS in 99 (55%). FNA was undertaken in 31 (31%) of those undergoing EUS. One patient (1%) had a perforation related to dilatation prior to planned EUS. A covered stent was inserted and he was discharged from hospital. The findings on PET-CT directly changed management to a palliative approach in 30 patients (17%). A further 75 patients (42%) required further investigations based upon PET-CT including EUS (n=52), colonoscopy (n=9), review by other specialities (n=6), lymph node excision biopsy (n=2), radiological guided FNA/core biopsy (n=3) and MRI liver (n=2). EUS was performed to investigate nodal status in 51 (52%), to confirm the presence or depth of tumour invasion in 21 (21%) and to investigate other organ involvement in 3 (3%). 24 EUS procedures were performed routinely due to protocols used at that time. EUS+/-FNA directed patients to a palliative approach in 22 (22%). Management was directed to a radical approach in 72 (73%), and to endoscopic treatment (EMR/PDT) in 5 (5%). In the 98 patients who had both PET-CT and EUS, there was concordance of lymph node status in 79 (85%). Ten (11%) patients with negative nodes on PET-CT had positive nodes on EUS (of which 5 were suspicious at the time of staging CT), and 4 (4%) with positive nodes on PET-CT had negative nodes on EUS. Five had incomplete EUS due to stricturing.
Conclusion
These results demonstrate that EUS has a complementary role in the staging process, with EUS playing an essential role in 11% of patients where confirmation of lymph node status, not identified on PET-CT, guided appropriate management.
'%3e%3ccircle r='20' fill='%23008'/%3e%3ccircle r='17.5' fill='%23fff'/%3e%3ccircle r='3.5' fill='%23008'/%3e%3cg id='d'%3e%3cg id='c'%3e%3cg id='b'%3e%3cg id='a' fill='%23008'%3e%3ccircle r='.875' transform='rotate(7.5 -8.75 133.5)'/%3e%3cpath d='M0 17.5.6 7 0 2l-.6 5L0 17.5z'/%3e%3c/g%3e%3cuse xlink:href='%23a' transform='rotate(15)'/%3e%3c/g%3e%3cuse xlink:href='%23b' transform='rotate(30)'/%3e%3c/g%3e%3cuse xlink:href='%23c' transform='rotate(60)'/%3e%3c/g%3e%3cuse xlink:href='%23d' transform='rotate(120)'/%3e%3cuse xlink:href='%23d' transform='rotate(-120)'/%3e%3c/g%3e%3c/svg%3e)
'%3e%3cpath fill='%23012169' d='M0 0v30h60V0z'/%3e%3cpath stroke='%23fff' stroke-width='6' d='m0 0 60 30m0-30L0 30'/%3e%3cpath stroke='%23C8102E' stroke-width='4' d='m0 0 60 30m0-30L0 30' clip-path='url(%23b)'/%3e%3cpath stroke='%23fff' stroke-width='10' d='M30 0v30M0 15h60'/%3e%3cpath stroke='%23C8102E' stroke-width='6' d='M30 0v30M0 15h60'/%3e%3c/g%3e%3c/svg%3e)