Introduction

Contributing to the on-call Upper Gastrointestinal Bleed (UGIB) rota is a crucial part of a consultant gastroenterologist's role. There is no standardised training in managing UGIB as part of the gastroenterology curriculum in the UK, with wide variation in experience amongst registrars by completion of training. Furthermore, with UK Gastroenterology training now reduced to four years, there are fewer opportunities for trainees to gain experience in UGIB. The Bristol Endoscopy Training Collaborative (BETC) developed an Upper Gastrointestinal Haemostasis Course to provide delegates with formal upper gastrointestinal bleeding training. The JAG pilot Upper GI Haemostasis course developed by BSG EQIP initiative was used as template (1)

Aims & Methods

We ran four 1-day courses at Vesalius Clinical Training Centre, Bristol, between November 2021 and November 2022, with 8 delegates & 4 faculty per course. Each course cost approximately £3000 to deliver, including venue hire and porcine models, and was fully funded by the Southwest Endoscopy Training Academy & Health Education England.
The course programme included small group, hands-on training for use of adrenaline injection, heater probe, clip placement, haemostatic powder, variceal banding and sclerotherapy. Porcine models (MedMeats) with simulated bleeds were used with accessory & equipment support from industry partners. Hands-on training for Sengstaken Tube (Steris) insertion and oesophageal stent (Danis) placement was demonstrated with plastic models.
Non-technical skills were taught using small group discussions covering topics including on-call role play, prioritisation in UGIB, pathology recognition, and report writing. Pre- and post- course confidence surveys were sent to delegates, and comparisons were made with the Mann-Whitney-U test. If quoting a company specific product need to reference company e.g. Hemospray (Cook Medical, Indiana, USA).

Results

31 delegates attended the four courses, with fully completed questionnaires obtained from 23 delegates. Most (21 of 23) participants were gastroenterology registrars; -surgical registrars, consultant gastroenterologists and clinical endoscopists also attended.
All delegates stated they would recommend the course to a colleague. Self-reported improvements were seen for all learning objectives:recognising pathology, technical skills and report writing. Most notably, confidence in holding the out of hours on call phone for UGIBs improved from an average of 4/10 to 8/10, (p value < 0.005).

Conclusion

We describe a cost-effective single-day course to improve training in management of UGIB. This course can be reproduced at other regional centres. Those looking to refresh or up-skill UGIB management would also benefit.

References

1. http://dx.doi.org/10.1136/gutjnl-2019-BSGAbstracts.484

Clinical Case Summary

A 54-year-old male with no significant past medical history presented with a five-year history of chronic gastrointestinal and systemic symptoms. He was initially diagnosed with irritable bowel syndrome (IBS) based on recurrent postprandial bloating, periumbilical abdominal discomfort, alternating diarrhea and constipation, and a persistent sensation of gastric fullness independent of food intake. Despite comprehensive management and a low-FODMAP diet, he reported minimal to no clinical improvement.
In addition to gastrointestinal complaints, the patient described recurrent headaches and chronic fatigue, both temporally associated with the consumption of histamine-rich foods such as red wine, aged cheeses, and processed meats. The neurological evaluation was unremarkable. Laboratory investigations were within normal limits, including complete blood count, inflammatory markers, liver and renal function tests, and celiac serologies. Gastroscopy and colonoscopy excluded structural, neoplastic, and inflammatory gastrointestinal pathology. However, serum diamine oxidase (DAO) activity was significantly decreased (2.8 U/mL; reference >10 U/mL), suggesting histamine intolerance secondary to DAO deficiency as the underlying etiology.
Therapeutic intervention included a strict low-histamine diet, oral DAO supplementation, and intermittent use of H1-antihistamines for symptomatic exacerbations. At a three-month follow-up, the patient reported substantial improvement in gastrointestinal and systemic symptoms, including normalizing bowel habits, resolution of headaches, and alleviating fatigue and bloating.
This case underscores the importance of considering histamine intolerance in patients with persistent IBS-like symptoms, particularly when conventional therapeutic strategies fail and symptom patterns suggest dietary histamine sensitivity. DAO activity testing may aid in diagnosis and guide effective, targeted therapy.

Disclosure

No Conflict of Interest.