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This is the first UK national guideline to concentrate on acute lower gastrointestinal bleeding (LGIB) and has been commissioned by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG). The Guidelines Development Group consisted of representatives from the BSG Endoscopy Committee, the Association of Coloproctology of Great Britain and Ireland, the British Society of Interventional Radiology, the Royal College of Radiologists, NHS Blood and Transplant and a patient representative. A systematic search of the literature was undertaken and the quality of evidence and grading of recommendations appraised according to the GRADE(Grading of Recommendations Assessment, Development and Evaluation) methodology. These guidelines focus on the diagnosis and management of acute LGIB in adults, including methods of risk assessment and interventions to diagnose and treat bleeding (colonoscopy, computed tomography, mesenteric angiography, endoscopic therapy, embolisation and surgery). Recommendations are included on the management of patients who develop LGIB while receiving anticoagulants (including direct oral anticoagulants) or antiplatelet drugs. The appropriate use of blood transfusion is also discussed, including haemoglobin triggers and targets.

ObjectiveTo describe the patient characteristics, diagnoses and clinical outcomes of patients presenting with acute upper gastrointestinal bleeding (AUGIB) in the 2007 UK Audit.DesignMulti-centre survey.SettingAll UK hospitals admitting patients with AUGIB.ParticipantsAll adults (>16 years) presenting in or to UK hospitals with AUGIB between 1 May and 30 June 2007.ResultsData 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%).ConclusionsAUGIB 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.

ObjectivesTo 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.DesignMulti-centre cross sectional clinical audit.SettingAll UK hospitals accepting admissions with AUGIB.PatientsAll adults (≥16 yrs) presenting with AUGIB between 1st May and 30th June 2007.Data CollectionA 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.ResultsData 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.ConclusionsThis 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.

Objective To carry out a systematic review of recently published large-scale observational studies assessing the effects of red blood cell transfusion (RBCT) on mortality, with particular emphasis on the statistical methods used to adjust for confounding. Given the limited number of randomised trials of the efficacy of RBCT, clinicians often use evidence from observational studies. However, confounding factors, for example, individuals receiving blood generally being sicker than those who do not, make their interpretation challenging. Design Systematic review. Information sources We searched MEDLINE and EMBASE for studies published from 1 January 2006 to 31 December 2010. Eligibility criteria for included studies We included prospective cohort, case–control studies or retrospective analyses of databases or disease registers where the effect of risk factors for mortality or survival was examined. Studies must have included more than 1000 participants receiving RBCT for any cause. We assessed the effects of RBCT versus no RBCT and different volumes and age of RBCT. Results –32 studies were included in the review; 23 assessed the effects of RBCT versus no RBCT; 5 assessed different volumes and 4 older versus newer RBCT. There was a considerable variability in the patient populations, study designs and level of statistical adjustment. Overall, most studies showed a higher rate of mortality when comparing patients who received RBCT with those who did not, even when these rates were adjusted for confounding; the majority of these increases were statistically significant. The same pattern was observed in studies where protection from bias was likely to be greater, such as prospective studies. Conclusions Recent observational studies do show a consistently adverse effect of RBCT on mortality. Whether this is a true effect remains uncertain as it is possible that even the best conducted adjustments cannot completely eliminate the impact of confounding.

BackgroundAcute upper gastrointestinal bleeding (AUGIB) is a common medical emergency with evolving demographics and management strategies, particularly in medical/endoscopic therapy and transfusion strategies.ObjectiveTo provide key data of the most recent 2022 UK audit and compare it with the preceding audit in 2007.DesignProspective multicentre audit conducted from 3 May to 2 July 2022, including adults (≥16 years) with AUGIB across 147 UK hospitals (response rate 86% vs 84% in 2007). AUGIB was defined by clinical symptoms (haematemesis, haematochezia, coffee ground vomiting or melaena confirmed by medical personnel). Patients were followed until discharge, death or 28 days, with re-admissions during the study period counted as new episodes.ResultsAmong 5141 patients (59% male; median age 69), 15% had cirrhosis, 19% reported excess alcohol use, 7% used non-steroidal anti-inflammatory drugs (NSAIDs) and 46% were on antithrombotics. Most (77%) were new admissions, who were younger with fewer comorbidities, while the remainder bled during hospitalisation. Peptic ulcer disease accounted for 32% of cases, varices for 10% and no abnormality was found in 33%. Pre-endoscopic risk stratification was not performed in 42%.Compared with 2007, patients in 2022 had higher comorbidity (67% vs 50%), more cirrhosis (15% vs 9%), greater anticoagulant use (31% vs 13%) and higher transfusion rates (50% vs 43%). In 2022, among early transfusions (pre-endoscopy or within first 24 hrs; 38%), 43% were given at haemoglobin (Hb)>70 g/L, with 24% classified as inappropriate due to haemodynamic stability. A signal of harm was observed: while inappropriate transfusion was not associated with rebleeding at either 70 or 80 g/L, at 80 g/L it was linked to higher adjusted mortality (adjusted OR (aOR) 1.60, 95% CI 1.00 to 2.56).Inpatient endoscopy was more common (83% vs 74%), though endotherapy use remained modest (27% vs 23%). Salvage therapy rates were unchanged (3.3% vs 3.1%) but shifted from surgery to interventional radiology. Outcomes improved, with lower rebleeding (9.7% vs 13.3%), reduced in-hospital mortality (8.8% vs 10.0%) and shorter median stay (5 vs 6 days). In multivariate analysis, mortality was independently predicted by older age (≥80 years: aOR 2.32, 95% CI 1.64 to 3.30), shock (aOR 2.22, 95% CI 1.53 to 3.17) and comorbidity, while lower Hb at presentation increased risk (≤70 g/L: aOR 1.56, 95% CI 1.15 to 2.11). Anticoagulant use was associated with increased mortality (aOR 1.43, 95% CI 1.11 to 1.85), whereas NSAID use (aOR 0.49, 95% CI 0.25 to 0.96) and antiplatelet use (aOR 0.68, 95% CI 0.54 to 0.87) were associated with lower mortality.ConclusionsDespite a higher-risk case mix and incomplete adherence to guidelines (notably in transfusion thresholds and risk stratification), outcomes in AUGIB have improved. The observation of increased mortality with liberal transfusion above 80 g/L in stable patients reinforces the importance of restrictive transfusion practice. Quality improvement initiatives focused on risk stratification, endoscopic training and multidisciplinary care could further enhance outcomes in the UK and internationally.

IntroductionTrainees 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.MethodsA questionnaire was distributed to UK upper GI endoscopy trainees and trainers in 2022–2023.ResultsWe 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).ConclusionThis 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.

Introduction Intracranial haemorrhage (ICH) is one of the most serious side-effects of severe thrombocytopenia in haematology patients. ICH is rare, but can have devastating consequences (death or major morbidity). It is unknown why some patients with severe thrombocytopenia bleed and others do not. Study aims Primary aim was to identify risk factors for ICH in patients with haematological malignancies. Secondary aims were to identify short-term outcomes for these patients at 30 days (major morbidity and mortality) and produce a more accurate estimate of ICH incidence in this population. This information is key to identifying means to improve treatment and quality of care. Methods/analysis This is a UK-wide case–control study of ICH nested within a 4-year prospective surveillance study set up specifically for the case–control study. Each case will be matched to one control. Cases will be adult haematology patients (≥16 years) who have had any type or severity of ICH who are receiving, about to receive or have just received myeloablative chemotherapy (defined as chemotherapy expected to cause a significant thrombocytopenia <50×109/L for >5 days) or a haemopoietic stem cell transplant. Only patients being treated with curative intent will be included. Controls will be patients who fulfil the same inclusion criteria as cases (apart from ICH) and were treated at the same hospital immediately before the index case. Cases and controls will be matched to type of treatment (myeloablative chemotherapy or haemopoietic stem cell transplant). Hospitals across the UK will participate in a monthly email reporting strategy (started June 2011), as to whether a case of ICH occurred during the preceding calendar month. Case and control forms will be sent to any hospital reporting an eligible case. Conditional logistic regression will be used to calculate ORs. Denominator data for incidence estimates will use national registry data. Study Registration ISRCTN05026912 (prospective registration). NIHR Portfolio (UKCRN ID 10712).

BackgroundAcute upper gastrointestinal bleeding (AUGIB) is a common medical emergency globally. We report endoscopic management of AUGIB in a large UK multicentre study.MethodsA prospective audit in 152 UK hospitals from May 3 to July 2, 2022, included 5101 AUGIB cases in adults (>16 years).ResultsOf 5101 cases, 83% (4228) underwent endoscopy, median age of 69 yrs & in-patient mortality of 7.7%. Glasgow-Blatchford score (GBS) stratified patients: 4% low-risk (GBS 0–1), 21% medium-risk (2–6), 36% higher-risk (7–11), & 26% very high-risk (≥12). 32% were on anticoagulants at presentation. Time to endoscopy from presentation: 0–6 hrs: 6%, 6–24 hrs: 33%, & 24–48 hrs: 25%. Bleeding aetiology identified at endoscopy included peptic ulceration(30%),oesophagitis(16%),varices(10%:90% oesophageal, 16% gastric, & 2% duodenal), malignancy(4%),& other(20%). Stigmata of recent bleeding were observed in 30%(1273) cases – 41% with blood in the upper GI tract, 5% Forrest 1a, 31% 1b, 15% 2a, 21% 2b, & 16% with high-risk markings on varices. Endotherapy was applied in 27%(1135), with 54% receiving a single modality. Therapies applied included adrenaline injection (46% - with median volume of 8 mls; IQR: 5.5–10), haemostatic clips(37% - with 96% endoclips & 4% over the scope clips), variceal banding/injection therapy(25%), haemostatic powder/gel(19%), thermal coagulation(16%), argon plasma coagulation(11%), Sengstaken tube(2%), & Danis stent(1%). Endotherapy with only adrenaline injection &/or haemostatic powder/gel was applied in 16%. Among those receiving endotherapy, 4% (46/1135) did not achieve adequate haemostasis. 17%(199/1135 - 43% with blood in the upper GI tract, 7% Forrest 1a, 26% 1b, 18% 2a, 22% 2b, & 20% with high-risk markings on varices) experienced in-patient re-bleeding, leading to repeat endoscopy in 71%, interventional radiology in 14%, & surgery in 6%. Multivariable logistic regression analyses revealed predictors for in-patient rebleeding & mortality (figure 1).ConclusionsThis prospective UK study identified an increased risk of rebleeding & mortality in very high-risk GBS patients & those with high-risk endoscopic stigmata. Endoscopic therapy showed a trend towards reducing mortality. Adherence to clinical guidelines on endoscopic management in AUGIB, endoscopists’ skills training, & 24/7 access to therapeutic modalities are crucial to improve outcomes.Abstract O61 Figure 1

Introduction With the evolving landscape of acute upper GI bleeding (AUGIB) management, a comprehensive understanding of changing clinical outcomes becomes imperative. This report presents findings from the 2022 UK-wide AUGIB audit, comparing them to the 2007 study.MethodsProspective multi-centre observational study of adults (≥16 years) presenting UK hospitals with AUGIB between 3 May and 2 July 2022.ResultsData on 5101 patients (median age 69yr) from 152 participating hospitals are reported. New admissions with AUGIB (n=3905) were younger than inpatients developing AUGIB (median age 67.5 vs 74 yrs, respectively) with fewer comorbidities (63% vs 80%, respectively). At presentation, 16% (802) had chronic liver disease (CLD), 30% (1528) a history of regular alcohol use, 7% (371) were taking non-steroidal anti-inflammatory drugs and 46% (2339) antiplatelets and/or anticoagulants. 83% (4228) patients had an inpatient endoscopy; 30% had peptic ulcer disease (PUD), 9% had varices, and 27% received endoscopic therapy. Reasons for no endoscopy (n=873) were: 56% not clinically indicated/27% outpatient procedure/18% not for active treatment/7% self-discharged/1% transferred to other hospital/6% death. 10% (416/4228) had evidence of further in-patient bleeding after index endoscopy. 9% (440) underwent >1 endoscopy during inpatient stay; 0.8%(42) underwent surgery, 2.6%(134) had interventional radiology (IR) and 49%(2511) were transfused ≥1 packed red blood cells; 4%(212) platelets; and 5%(282) fresh frozen plasma for AUGIB. Median length of stay was 5 days (IQR 3–9). In-hospital mortality was 9%(461); 5.7% in new admissions and 18.4% in inpatients. Comparisons with the 2007 audit revealed significant differences in patient profiles in 2022, including an increase in comorbid patients (67% vs 50%), higher prevalence of anticoagulant use (31% vs 13%), and a greater proportion with underlying CLD (16% vs 9%). A higher percentage of patients underwent inpatient endoscopy (83% vs 74%) in 2022, with reductions in PUD (30% vs 36%) and varices (9% vs 11%). There was a significant increase in those receiving endotherapies (27% vs 24%) and undergoing IR procedures (2.6% vs 1.2%), along with a lower likelihood of further in-patient bleeding after an index endoscopy (10% vs 13%), surgery (0.8% vs 1.9%), and in-hospital mortality (9% vs 10%). All differences were statistically significant (p<0.05).ConclusionsDespite a more co-morbid population, there was reduced recurrent bleeding, need for surgery and in-hospital mortality for AUGIB since 2007. These are possibly linked to improved management and better endoscopic therapy.ReferenceHearnshaw, et al. Gut 2011.