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Objective To compare the predictive accuracy and clinical utility of five risk scoring systems in the assessment of patients with upper gastrointestinal bleeding.Design International multicentre prospective study.Setting Six large hospitals in Europe, North America, Asia, and Oceania.Participants 3012 consecutive patients presenting over 12 months with upper gastrointestinal bleeding.Main outcome measures Comparison of pre-endoscopy scores (admission Rockall, AIMS65, and Glasgow Blatchford) and post-endoscopy scores (full Rockall and PNED) for their ability to predict predefined clinical endpoints: a composite endpoint (transfusion, endoscopic treatment, interventional radiology, surgery, or 30 day mortality), endoscopic treatment, 30 day mortality, rebleeding, and length of hospital stay. Optimum score thresholds to identify low risk and high risk patients were determined.Results The Glasgow Blatchford score was best (area under the receiver operating characteristic curve (AUROC) 0.86) at predicting intervention or death compared with the full Rockall score (0.70), PNED score (0.69), admission Rockall score (0.66, and AIMS65 score (0.68) (all P<0.001). A Glasgow Blatchford score of ≤1 was the optimum threshold to predict survival without intervention (sensitivity 98.6%, specificity 34.6%). The Glasgow Blatchford score was better at predicting endoscopic treatment (AUROC 0.75) than the AIMS65 (0.62) and admission Rockall scores (0.61) (both P<0.001). A Glasgow Blatchford score of ≥7 was the optimum threshold to predict endoscopic treatment (sensitivity 80%, specificity 57%). The PNED (AUROC 0.77) and AIMS65 scores (0.77) were best at predicting mortality, with both superior to admission Rockall score (0.72) and Glasgow Blatchford score (0.64; P<0.001). Score thresholds of ≥4 for PNED, ≥2 for AIMS65, ≥4 for admission Rockall, and ≥5 for full Rockall were optimal at predicting death, with sensitivities of 65.8-78.6% and specificities of 65.0-65.3%. No score was helpful at predicting rebleeding or length of stay.Conclusions The Glasgow Blatchford score has high accuracy at predicting need for hospital based intervention or death. Scores of ≤1 appear the optimum threshold for directing patients to outpatient management. AUROCs of scores for the other endpoints are less than 0.80, therefore their clinical utility for these outcomes seems to be limited.Trial registration Current Controlled Trials ISRCTN16235737.

BackgroundClinical guidelines recommend continuing antiplatelet monotherapy with aspirin and, in certain situations, other antiplatelet agents in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy.AimsGiven the scant evidence supporting this recommendation, our primary objective was to determine if the risk of post-sphincterotomy bleeding was increased in patients on antiplatelet monotherapy.MethodsWe performed a systematic search of Cochrane Library, Ovid Embase, Ovid Medline, Pubmed, Scopus, and Web of Science Core Collection databases. Inclusion criteria were adult patients undergoing ERCP and sphincterotomy on antiplatelet monotherapy with the comparator of no antithrombotic therapy. Our primary outcome was post-sphincterotomy bleeding. Methodological quality was assessed with the ROBINS-I tool and the Newcastle–Ottawa Scale. Meta-analysis with random-effects model was performed.ResultsThe search identified 4676 unique citations, with six cohort studies meeting our inclusion criteria. Post-sphincterotomy bleeding was increased in patients on antiplatelet monotherapy: OR = 1.53 (95% CI 1.03–2.28) without substantial heterogeneity (I2 = 0%). The number needed to harm (the number of patients who would have to receive antiplatelet monotherapy for one additional patient to have a post-sphincterotomy bleeding episode) was 185(95% CI 80–2272). All included studies had methodological shortcomings.ConclusionAntiplatelet monotherapy was associated with a modestly increased risk of post-sphincterotomy bleeding in our systematic review and meta-analysis. More high-quality studies are needed to improve certainty regarding the estimated effect size.RegistrationPROSPERO CRD42020153019.

The management of Barrett’s esophagus and early esophageal adenocarcinoma has shifted away from esophagectomy and toward endoscopic techniques, including endoscopic resection and ablative therapies. The most commonly used ablative therapies are radiofrequency ablation and cryotherapy. Radiofrequency ablation has risen to the top of the management algorithm due to its favorable safety profile and established track record of efficacy in patients with dysplastic Barrett’s. Cryotherapy offers early promise as an alternatively safe and effective ablative modality. We review radiofrequency ablation and cryotherapy techniques, and updated data regarding their efficacy and safety as well as their roles in the management of Barrett’s esophagus.

Adjustments for lead and length time bias has been used when examining apparent survival advantages from screening procedures. However, these estimates depend on several assumptions and are modeled from malignancies that are fairly common and large cohorts are available. In smaller retrospective cohorts, adjustments themselves may be based on estimates that may not be biological nor statistically accurate, which can lead to divergent results as has been found in several recent studies of screening in Barrett’s esophagus. Only a prospective randomized controlled trial can really determine the benefit though this may not feasible.

Objectives:Numerous reviews indicate bloody hematemesis signifies more severe bleeding than coffee-grounds hematemesis. We assessed severity and outcomes related to bleeding symptoms in a prospective study.Methods:Consecutive patients presenting with hematemesis or melena were categorized as bloody emesis (N=1209), coffee-grounds emesis without bloody emesis (N=701), or melena without hematemesis (N=1069). We assessed bleeding severity (pulse, blood pressure) and predictors of outcome (hemoglobin, risk stratification scores) at presentation, and outcomes of bleeding episodes. The primary outcome was a composite of transfusion, intervention, or mortality.Results:Bloody and coffee-grounds emesis were similar in pulse ≥100 beats/min (35 vs. 37%), systolic blood pressure ≤100 mm Hg (12 vs. 12%), and hemoglobin ≤100 g/l (25 vs. 27%). Risk stratification scores were lower with bloody emesis. The composite end point was 34.7 vs. 38.2% for bloody vs. coffee-grounds emesis; mortality was 6.6 vs. 9.3%. Hemostatic intervention was more common (19.4 vs. 14.4%) with bloody emesis (due to a higher frequency of varices necessitating endoscopic therapy), as was rebleeding (7.8 vs. 4.5%). Outcomes were worse with hematemesis plus melena vs. isolated hematemesis for bloody (composite: 62.4 vs. 25.6%; hemostatic intervention: 36.5 vs. 13.8%) and coffee-grounds emesis (composite: 59.1 vs. 27.1%; hemostatic intervention: 26.4 vs. 8.1%).Conclusions:Bloody emesis is not associated with more severe bleeding episodes at presentation or higher mortality than coffee-grounds emesis, but is associated with modestly higher rates of hemostatic intervention and rebleeding. Outcomes with hematemesis are worsened with concurrent melena. The presence of bloody emesis plus melena potentially could be considered in decisions regarding timing of endoscopy.

Introduction: Cryoablation poses an attractive alternative to radiofrequency ablation in patients with Barretts esophagus (BE), particularly those with residual intestinal metaplasia after multiple ablation sessions. The use of spray cryoablation, however, is not without challenges, including the need for simultaneous gastrointestinal venting, potential frosting of the endoscope optics, and dysfunction of the spray catheter. The CryoBalloon focal ablation system (CbFAS) was developed to maintain the advantages of cryoablation, but reduce the limitations of the spray system. We reported a U.S experience regarding the feasibility and safety of CbFAS (C2 Therapeutics, Redwood City, California, USA) in treating BE. Methods: A single-center, retrospective study of patients with dysplastic BE or early esophageal adenocarcinoma (EAC) treated with cryoablation using the CryoBalloon between 2016 and 2017. Our primary outcome was rate of technical success. Secondary outcomes included adverse events, complete remission of intestinal metaplasia (CR-IM), and complete remission of dysplasia (CR-D). Results: Forty-two patients were included and treated with 80 cryoablation sessions. The cohort had a mean age of 69.7±10.2 years (IQR: 66- 77) and was male predominant (83.3%). The majority of patients received prior endoscopic treatment (37/42, 88.1%). The mean length of the BE segment was 4±3.4 cm (IQR: 1-5). The majority of patients had high-grade dysplasia and/or intramucosal EAC 83.3%. Cryoablation was successfully performed in 78/80 (97.5%); one failure was due to device malfunction and another one due to the device not deploying due to a safety mechanism in a narrow esophagus. We did not encounter any major adverse events. Nine patients (21.5%) of patients developed mild adverse events including mild to moderate chest pain, mild esophageal strictures, and self-resolving sinus bradycardia. CR-IM and CR-D were achieved in 9.5% and 54.8%, respectively, during a mean follow-up of 7.5±5.7 months (IQR: 3-12). Conclusion: This is a large western experience with use of the CbFAS in treating BE with dysplasia or EAC. CryoBalloon CbFAS ablation was performed with a high rate of technical success and no signifi- cant adverse events. The CryoBalloon focal ablation system may be considered as a potential alternative to spray treatment when Cryoablation is indicated.

Adjustments for lead and length time bias has been used when examining apparent survival advantages from screening procedures. However, these estimates depend on several assumptions and are modeled from malignancies that are fairly common and large cohorts are available. In smaller retrospective cohorts, adjustments themselves may be based on estimates that may not be biological nor statistically accurate, which can lead to divergent results as has been found in several recent studies of screening in Barrett's esophagus. Only a prospective randomized controlled trial can really determine the benefit though this may not feasible.