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URGENT ENDOSCOPY MAY NOT IMPROVE OUTCOME IN ACUTE VARICEAL BLEEDING: A MULTICENTER COHORT STUDY

Stig Borbjerg Laursen 1, Gaurav Nigam 2, Joanna Leithead 3, Sarah Hearnshaw 4, Kathryn Oakland 5, John Grant-Casye 6, Vipul Jairath 7, John Morris 8, Andrew Douds 9, Adrian Stanley 8

Affiliations

1 Odense University Hospital, Odense, Denmark

2 Oxford University NHS Hospitals, Oxford, United Kingdom

3 Glasgow University, UK, Glasgow, United Kingdom

4 Newcastle Hospital, Newcastle, United Kingdom

5 HCA Healthcare UK, Oxford, United Kingdom

6 National Comparative Audit of Blood Transfusion, Bristol, United Kingdom

7 Alimentiv Inc., London, Canada

8 Glasgow Royal Infirmary, Glasgow, United Kingdom

9 Queen Elizabeth Hospital, Fakenham, United Kingdom

Summary

AI Generated

A UK multicenter cohort study of 401 patients with acute variceal bleeding found no independent association between timing of endoscopy and in-hospital mortality after adjusting for patient characteristics and bleeding severity.

Crude mortality rates were highest in patients undergoing endoscopy within 6 hours of presentation (22%) compared to 6-24 hours (11%) or beyond 24 hours (11%), but patients receiving earlier endoscopy had markers of more severe bleeding including lower blood pressure, higher heart rate, lower hemoglobin, and higher lactate levels.
After adjustment for patient characteristics and bleeding severity, no statistically significant association was found between timing of endoscopy and mortality (odds ratio 1.01, 95% CI 0.99-1.03, p=0.17).
Even haemodynamically stable patients with systolic blood pressure above 100 mmHg had 16% mortality when undergoing urgent endoscopy within 6 hours.
The study cohort included 401 patients with mean age 58 years, 75% with known cirrhosis, mean Child-Pugh score 8.2, and overall in-hospital mortality of 12.6%.
The findings suggest that the association between endoscopy timing and outcome may differ between acute variceal bleeding and peptic ulcer bleeding, and may be relevant to clinicians managing upper gastrointestinal bleeding in cirrhotic patients.

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Abstract

Introduction

Optimal timing of endoscopy in patients with acute variceal bleeding (AVB) remains unclear. Studies in patients with peptic ulcer bleeding (PUB) have indicated that urgent endoscopy <6 hours from presentation may be associated with worsened patient outcome. We aimed to analyse the association between timing of endoscopy and mortality in AVB.

Aims & Methods

Prospective multicenter cohort study based on data from the 2022UK Audit on Acute upper gastrointestinal bleeding. The association between timing of endoscopy and in-hospital mortality was evaluated using logistic regression analyses with adjustment for differences in patients’ characteristics and severity of bleeding.

Results

We included 401 AVB patients. Mean age was 58 years, 65% were males, 75% had known cirrhosis at time of presentation, mean Child-Pugh score was 8.2, 31% had other comorbidities, 13% had ongoing bleeding at time of endoscopy, 78% were treated with terlipressin, 75% were treated with antibiotics, and 12.6% died during hospital admission. Mortality rates were 22%, 17%, 11%, and 11% for patients undergoing endoscopy in the periods <6, <12, 6-24 and >24 hours from presentation. Patients undergoing endoscopy < 6 hours had lower blood pressure, higher heart rate, lower haemoglobin, and higher peak-lactate levels than patients undergoing later endoscopy (see table). However, even haemodynamically stable patients with systolic blood pressure above 100mmHg had high mortality rates (16%) when performing urgent endoscopy < 6 hours. When adjusting for differences in patients’ characteristics, and severity of bleeding, we did not find any association between timing of endoscopy and mortality (Odds ratio (95% confidence interval): 1.01 (0.99-1.03); p=0.17).

Table: Patient characteristics in relation to time of endoscopy (n=401)

Characteristics	<6hrs (n=60)	6-24hrs (n=181)	>24hrs (n=160)	P
Age (mean, 95%CI)	56 (34-78)	58 (37-77)	58 (36-83)	NS
Child Pugh score (mean, 95%CI)	8.4 (6-12)	8.2 (5-12)	8.2 (5-11)	NS
SBP (mean, 95%CI)	106 (69-140)	118 (85-160)	120 (90-156)	<0.001
Heart Rate (mean, 95%CI)	101 (66-142)	99 (67-134)	94 (64-131)	0.008
Hemoglobin (mean, 95%CI)	83 (40-122)	87 (52-127)	93 (57-128)	0.014
Peak blood lactate (mean, 95%CI)	5.8 (1.4-14)	5.0 (1.0-13)	3.3 (1.0-9.2)	<0.001
Oesophageal varices	55 (92)	166 (92)	144 (90)	NS
Treatment with EDS, SBT or TIPS	9 (15%)	11 (6%)	11 (7%)	NS
Mortality (overall)	13 (21.7)	20 (11.2)	17 (10.8)	NS

Reported values represent n(%) unless otherwise stated.
CI: Confidence Interval; EDS: Ella Danis Stent; NS: Not Significant; SBP: Systolic Blood Pressure; SBT: Sengstaken-Blakemore Tube; TIPS: Transjugular Intrahepatic Portosystemic Shunt

Conclusion

AVB is associated with significant mortality, in particular in patients undergoing urgent endoscopy <6 hours from presentation, which may be explained by more severe bleeding. When taking differences in patients characteristics and severity of bleeding into consideration, endoscopy within 6-12 hours appears to be associated with similar outcomes to endoscopy undertaken 6-24 hours from presentation, despite less time to patient optimization before endoscopy. Thus, the association between timing of endoscopy and outcome may differ between patients with AVB and patients with PUB.

Disclosure

No conflicts of interest.

Conference

UEG Week Vienna 2024

Topics

Oesophagus

Submission format

Abstract

Session

Upper GI bleeding (Posters)

Citation

United European Gastroenterology Journal 2024; 12 (Supplement 8)

Published

2024

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GOING DEEP: THE EFFECT OF ULTRA-PROCESSED FOODS ON THE SMALL INTESTINE, A PILOT STUDY ON ILEOSTOMY PATIENTS

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Alessandra Zilli

UEG Presentation

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GOING DEEP: THE EFFECT OF ULTRA-PROCESSED FOODS ON THE SMALL INTESTINE, A PILOT STUDY ON ILEOSTOMY PATIENTS

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GOING DEEP: THE EFFECT OF ULTRA-PROCESSED FOODS ON THE SMALL INTESTINE, A PILOT STUDY ON ILEOSTOMY PATIENTS

Haggai Bar-Yoseph 1,2, Zohar Leshinsky 1, Yuval Molcho 1, Jonathan Sahar 2, Julia Belansky 2, Neta Milman 2, Tal Gefen 2, Alexandra Blatt 1, Sigal Pressman 1, Tarek Arraf 1, Rabiaa Fared 1, Inbar Kesten 1, Haim Gilshtein 1, Timothy Cooper 2, Maria Postnikov 1, Naama Geva-Zatorsky 2, Shai Shen-Orr 2, Yehuda Chowers 3

Affiliations

1 Rambam Health Care Campus, Haifa, Israel

2 Technion - Israel Institute of Technology, Haifa, Israel

3 CytoReason, Tel Aviv, Israel

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Abstract

Introduction

Epidemiological and clinical studies suggest that the consumption of ultra-processed foods (UPFs) is associated with an increased incidence of metabolic and immune-mediated diseases, including inflammatory bowel disease (IBD). However, little is known about the specific effects of UPF consumption on the human small intestine-the primary site of nutrient-host interactions and the major location of Crohn’s disease involvement.

Aims & Methods

Our aim was to comprehensively characterize the dynamic microbial and host transcriptional changes that occur in the human small intestine during exposure to a high-UPF (h-UPF) diet.
Patients with an ileostomy were recruited into a crossover study involving alternating 10-day periods of a nutritionist-guided high-UPF (h-UPF) or low-UPF (l-UPF) diet. At the end of each period, clinical samples including blood, ileostomy effluent, and mucosal biopsies were collected. Participants subsequently received a challenge meal representing the opposite diet, with repeat sampling performed 6 hours later to capture acute responses. Analysis included deep shotgun metagenomic sequencing of effluent and mucosal specimens, alongside mucosal transcriptomic profiling using both bulk RNA sequencing and spatial transcriptomics (CosMx platform). Paired statistical analyses were performed to identify significant differences between dietary conditions.

Results

Eleven participants (including 9 with stable IBD and 2 non-IBD) completed the study with high dietary compliance. No significant differences in macronutrient composition or fiber intake were observed between dietary periods. Luminal and mucosal small intestine microbiome communities were found to be distinct (Beta diversity, PERMANOVA q=0.001). Both niches were primarily composed of Bacillota (62-69%), Proteobacteria (20-22%), Actinomycetota (3-8%), and Bacteroidata (4-5%) phyla. While community dynamics were highly individual, differential abundance analysis using ANCOM-BC identified a significant enrichment of species from the Enterobacterales order following the h-UPF period (q<0.1). Specifically, enriched taxa included Escherichia albertii, Klebsiella variicola, Enterobacter cloacae, Salmonella enterica, and Citrobacter freundii. Concurrently, mucosal transcriptomic profiling revealed an increase in immune-related and inflammatory pathways after h-UPF consumption. These effects remained significant even after adjustment for cell composition using spatial data from the CosMx platform, suggesting that UPF consumption directly influences both cell migration and host regulatory pathways.

Conclusion

UPF consumption is associated with rapid and reproducible microbial and host transcriptional changes in the human small intestine. Using a unique ileostomy-based model, we demonstrate that these changes involve an enrichment of potentially pro-inflammatory bacteria and the activation of mucosal immune pathways previously linked to IBD activity. These findings provide mechanistic insights into how dietary UPFs may drive intestinal inflammation and underscore the need for further large-scale studies.

Disclosure

None

Event

UEG Week Barcelona 2026

Topics

Mechanisms & Personalised Medicine Small Intestine & Nutrition Immunology Endoscopy

Submission format

Abstract

Session

Decoding the upper GI tract using biomarkers

Citation

2026: United European Gastroenterology Journal 2026; 14 (S1)

Published

2026

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Alessandra Zilli

UEG Presentation

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Make IBD patients surgery ready

Stéphane Schneider 1

Affiliations

1 CHU de Nice - Archet, Nice, France

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Abstract

Event

UEG Week Barcelona 2026

Topics

Surgery Small Intestine & Nutrition IBD

Session

IBD nutrition matters

Citation

2026: United European Gastroenterology Journal 2026; 14 (S1)

Published

2026

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Surviving upper GI adverse events (Complete Session)

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Surviving upper GI adverse events (Complete Session)

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Abstract

Event

UEG Week Barcelona 2026

Session

Surviving upper GI adverse events

Citation

2026: United European Gastroenterology Journal 2026; 14 (S1)

Published

2026

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Yehuda Chowers

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Reena Sidhu

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Bas Groot Koerkamp

APPLICATION AND VALIDATION OF MILAN ULTRASOUND CRITERIA IN A LARGE COHORT OF 181 PATIENTS WITH ULCERATIVE COLITIS: A MULTICENTER REAL WORLD ITALIAN STUDY

Alessandra Zilli

UEG Presentation

New

Share via Email Share on Facebook Share on X Share on LinkedIn Share on Bluesky

Impact of quality measurements in upper, lower and small bowel endoscopy on patient outcomes?

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Impact of quality measurements in upper, lower and small bowel endoscopy on patient outcomes?

Reena Sidhu 1

Affiliations

1 Royal Hallamshire Hospital , Sheffield Teaching Hospitals, Sheffield, United Kingdom

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Abstract

Event

Postgraduate Teaching Programme Barcelona 2026

Topics

Endoscopy

Session

Quality in endoscopic practice

Citation

2026: United European Gastroenterology Journal 2026; 14 (S1)

Published

2026

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Alessandra Zilli

UEG Presentation

New

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PRIMARY PERCUTANEOUS STENTING VERSUS ENDOSCOPIC DRAINAGE FOR UNRESECTABLE MALIGNANT HILAR BILIARY OBSTRUCTION: A MULTICENTER RANDOMIZED CONTROLLED TRIAL, THE TESLA RCT

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PRIMARY PERCUTANEOUS STENTING VERSUS ENDOSCOPIC DRAINAGE FOR UNRESECTABLE MALIGNANT HILAR BILIARY OBSTRUCTION: A MULTICENTER RANDOMIZED CONTROLLED TRIAL, THE TESLA RCT

Merve Rousian 1, Jessica Holster 1, Victorien M. T. van Verschuer 2, Stijn Franssen 3, Andries E. Braat 2, Joep de Bruijne 3, Marc C. Burgmans 2, Otto M. van Delden 4, Maxime Dewulf 5, Joris I. Erdmann 6, Jeroen Hagendoorn 3, Akin Inderson 2, Christiaan van der Leij 5, Jan Werner Poley 5, Maarten L. J. Smits 3, Rogier P. Voermans 6, Ijsbrand A. J. Zijlstra 4, Bronno van der Holt 1, Diederik C. Bijdevaate 1, Behnam Mohseny 1, Lydi van Driel 7, Bas Groot Koerkamp 8

Affiliations

1 Erasmus MC Cancer Institute, Rotterdam, Netherlands

2 Leiden University Medical Center, Leiden, Netherlands

3 University Medical Center Utrecht, Utrecht, Netherlands

4 Academic Medical Center (AMC), Amsterdam, Netherlands

5 Maastricht University Medical Center, Maastricht, Netherlands

6 Amsterdam University Medical Center, Amsterdam, Netherlands

7 Erasmus Medical Center, Schiedam, Netherlands

8 Erasmus MC University Medical Center, Rotterdam, Netherlands

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Abstract

Introduction

Endoscopic biliary drainage (EBD) is the standard of care for patients with malignant hilar biliary obstructions (MHBO) but is associated with a high risk of complications, such as pancreatitis or cholangitis. In a phase II trial of primary percutaneous stenting (PPS) for unresectable MHBO, the risk of severe drainage-related complications was 18% and none of 67 patients developed cholangitis or pancreatitis.(1)

Aims & Methods

The aim of this randomized controlled trial (RCT) was to compare PPS with EBD for patients with suspected unresectable MHBO. We performed an investigator-initiated, open-label phase III RCT in five Dutch academic centers.(2) Eligible patient presented with metastatic disease, locally advanced disease, or resectable disease with a poor performance status precluding surgery. Patients were randomly assigned 1:1 to PPS or EBD. PPS consisted of one or more uncovered self-expandable metal stents placed above the ampulla without leaving an external drain. EBD was performed according to international guidelines by experienced endoscopists. The primary endpoint was major complications within 90 days after randomization, defined as any complication with prolonged hospital stay (>72 hours), readmission, invasive reintervention, or death (including death due to disease progression). Secondary endpoints included technical success of initial stent placement, clinical success (i.e., bilirubin below 51 µmol/L or a reduction of >=50% within 14 days after the initial drainage procedure), severe drainage-related complications within 90 days, reinterventions within 90 days, palliative systemic treatment, and overall survival. Analyses were performed according to the intention-to-treat principle.

Results

Between August 2023 and June 2026, 148 patients were randomized to PPS (n=72) or EBD (n=76). This preliminary analysis of 143 patients (PPS 69, EBD 74) excluded five patients who have not yet reached 90-day follow-up. The median age was 71 years (IQR, 63-79) and 32 patients (22%) were ≥ 80 years. Patients had perihilar cholangiocarcinoma (n=73, 51%), intrahepatic cholangiocarcinoma (n=42, 29%), gallbladder cancer (n=11, 8%), liver metastases (n=12, 8%), or other tumors causing MHBO (n=5, 3%). The median bilirubin before drainage was 339 µmol/L in the PPS arm and 226 µmol/L in the EBD arm.
Major complications within 90 days occurred in 28 patients (41%) in the PPS arm versus 50 (68%) in the EBD arm (p=0.001). Technical success of stent placement at initial drainage was achieved in 66 patients (96%) after PPS versus 62 (84%) after EBD (p=0.021); clinical success after the initial drainage procedure was reached in 52 patients (75%) after PPS versus 49 (66%) after EBD (p=0.23). Severe drainage-related complications occurred in 13 patients (19%) after PPS versus 37 (50%) after EBD (p<0.001), including cholangitis in 2 (3%) versus 24 (32%, p<0.001), pancreatitis in 5 (7%) versus 0 (p=0.059), hemorrhage in 2 (3%) versus 1 (1%), and bile duct perforation in 5 (7%) versus 5 (7%). Reinterventions were performed in 10 patients (15%) after PPS versus 42 (57%) after EBD (p<0.001). Crossover was never performed in the PPS arm versus in 15 patients (20%) in the EBD arm. Palliative systemic treatment was initiated in 28 patients (41%) after PPS versus 22 (30%) after EBD (P=0.22). Survival at six months was 62% after PPS versus 44% after EBD (p=0.75).

Conclusion

PPS substantially reduced major complications and reinterventions within 90 days compared to EBD in patients with unresectable MHBO.

References

1. Franssen S, Rousian M, van Verschuer V, et al. Primary percutaneous stenting for palliative biliary drainage of patients with malignant hilar biliary obstruction: TESLA trial. JHEP Rep. 2025;7(11):101541. Published 2025 Sep 11. doi:10.1016/j.jhepr.2025.101541
2. Rousian M, van Verschuer V, Franssen S, et al. Primary percutaneous stenting above the ampulla versus endoscopic drainage for unresectable malignant hilar biliary obstruction (TESLA RCT): study protocol for a multicenter randomized controlled trial. BMC Cancer. 2025;25(1):849. Published 2025 May 9. doi:10.1186/s12885-025-14158-0

Disclosure

This abstract presents the results of the preliminary analysis on August 18^th. All patients have been randomized and treated. But 5 patients are still within the 90 days follow-up period and therefore not yet evaluable for the primary outcome. On September 24^th, all patients will have at least 90 days follow-up. We will then run the definitive analyses according to the statistical analysis plan. Those results will be available for presentation at UEG. It is unlikely that the results will change in a meaningful way.

Event

UEG Week Barcelona 2026

Topics

Primary Care Oesophagus Hepatobiliary Endoscopy Digestive Oncology Colorectal

Submission format

Late-Breaking Abstract

Session

Late-Breaking: Advances in GI-endoscopy

Citation

2026: United European Gastroenterology Journal 2026; 14 (S1)

Published

2026

More Like This:

GOING DEEP: THE EFFECT OF ULTRA-PROCESSED FOODS ON THE SMALL INTESTINE, A PILOT STUDY ON ILEOSTOMY PATIENTS

Yehuda Chowers

Make IBD patients surgery ready

Stéphane Schneider

Surviving upper GI adverse events (Complete Session)

Impact of quality measurements in upper, lower and small bowel endoscopy on patient outcomes?

Reena Sidhu

PRIMARY PERCUTANEOUS STENTING VERSUS ENDOSCOPIC DRAINAGE FOR UNRESECTABLE MALIGNANT HILAR BILIARY OBSTRUCTION: A MULTICENTER RANDOMIZED CONTROLLED TRIAL, THE TESLA RCT

Bas Groot Koerkamp

APPLICATION AND VALIDATION OF MILAN ULTRASOUND CRITERIA IN A LARGE COHORT OF 181 PATIENTS WITH ULCERATIVE COLITIS: A MULTICENTER REAL WORLD ITALIAN STUDY

Alessandra Zilli

UEG Presentation

New

Share via Email Share on Facebook Share on X Share on LinkedIn Share on Bluesky

APPLICATION AND VALIDATION OF MILAN ULTRASOUND CRITERIA IN A LARGE COHORT OF 181 PATIENTS WITH ULCERATIVE COLITIS: A MULTICENTER REAL WORLD ITALIAN STUDY

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APPLICATION AND VALIDATION OF MILAN ULTRASOUND CRITERIA IN A LARGE COHORT OF 181 PATIENTS WITH ULCERATIVE COLITIS: A MULTICENTER REAL WORLD ITALIAN STUDY

Mariangela Allocca 1, Alessandra Zilli 1, Fulvia Terracciano 2, Giovanni Cataletti 3, Arianna Dal Buono 4, Cristina Bezzio 4, Mirella Fraquelli 5, Emma Calabrese 6, Francesca Zorzi 6, Antonio Rispo 7, Alice De Bernardi 8, Federica Furfaro 1, Cosimo Simone Matichecchia 9, Ilaria Faggiani 1, Ferdinando D'Amico 1, Simona Radice 4, Antonella Marra 10, Simone Saibeni 8, Flavio Caprioli 5, Giovanni Maconi 11, Fabiana Castiglione 7, Alessandro Armuzzi 4, Gionata Fiorino 12, Silvio Danese 1

Affiliations

1 IRCCS Hospital San Raffaele and University Vita-Salute San Raffaele, Milano, Italy

2 Casa Sollievo Della Sofferenza, San Giovanni Rotondo, Italy

3 Department Biomedical and Clinical Sciences, "L. Sacco" University Hospital, Milan, Italy

4 IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy

5 Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milano, Italy

6 University of Rome Tor Vergata, Rome, Italy

7 University ´´Federico II´´of Naples, Naples, Italy

8 ASST Rhodense, Rho, Italy

9 Vita e Salute San Raffaele University, Milan, Italy

10 IRCSS Saverio de BELLIS, Castellana Grotte, Italy

11 Luigi Sacco University Hospital Gastroenterology Unit Biomed and Clinical Sciences, Milan, Italy

12 San Camillo-Forlanini Hospital, Rome, Italy

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Abstract

Introduction

The Milan Ultrasound Criteria (MUC) were developed to assess disease activity in ulcerative colitis (UC) based on bowel wall thickness (BWT) and Colour Doppler signal (CDS), using the formula MUC= 1.4 × BWT (mm) + 2 × CDS (0= absent; 1=present) ¹. A MUC > 6.2 identifies patients with a Mayo endoscopic subscore (MES) >1. Although the MUC have been externally validated, existing studies were limited by small sample size and single-centre design ^2,3.

Aims & Methods

This multicentre prospective study included consecutive UC patients undergoing both intestinal ultrasound and endoscopy. Endoscopic activity was defined as MES > 1, and endoscopic remission as MES 0–1. The original coefficients of BWT and CDS (1.4 and 2.0, respectively), derived from the
multivariable analysis in the derivation study, were applied to calculate the MUC. Diagnostic performance was assessed using receiver operating characteristic (ROC) analysis to determine the area under the curve (AUC), sensitivity and specificity.
We aimed to apply and validate the MUC in a large, multicentre, real-world Italian cohort using endoscopy as the reference standard.

Results

A total of 181 UC patients (median age 41 years, IQR 29-56; 94 males) were enrolled contributing 251 paired intestinal ultrasound and endoscopy assessments. Among these, 214 showed endoscopic activity (MES > 1) and 37 indicated endoscopic remission (MES 0–1). ROC analysis confirmed MUC > 6.2 as the optimal cut-off to discriminate endoscopic activity from remission, with an AUC of 0.911 (95% CI 0.869 - 0.943). In this large validation cohort, a MUC > 6.2 achieved a sensitivity of 87.9% (95% CI 82.7 - 91.9) and a specificity of 83.8% (95% CI 68 - 93.8).

Conclusion

In this large multicentre Italian cohort, the MUC demonstrated excellent diagnostic accuracy in differentiating endoscopic activity from remission, confirming its validity as a non-invasive monitoring tool in UC. These findings support the incorporation of the MUC into routine point-of-care ultrasound assessments and into future clinical trials in UC.

References

1. Allocca M, Dell'Avalle C, Furfaro F, et Al. Early Intestinal Ultrasound Predicts Long-Term Endoscopic Response to Biologics in Ulcerative Colitis. J Crohns Colitis. 2023 Nov 8;17(10):1579-1586;
2. Allocca M, Filippi E, Costantino A, et Al. Milan ultrasound criteria are accurate in assessing disease activity in ulcerative colitis: external validation. United European Gastroenterol J. 2021 May;9(4):438-442;
3. Innocenti T, Rocco C, Scarallo L, et Al. Systematic Review of Available Intestinal Ultrasound Scores for Inflammatory Bowel Disease and Update on Validation Studies. Inflamm Bowel Dis. 2025 Sep 20:izaf183.

Event

UEG Week Barcelona 2026

Topics

Mechanisms & Personalised Medicine Immunology IBD

Submission format

Abstract

Session

Abstract session: Hot topics in IBD

Citation

2026: United European Gastroenterology Journal 2026; 14 (S1)

Published

2026

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