Introduction

Gastrointestinal (GI) bleeding poses a significant burden on inpatient care and significant in-patient mortality. Previous audits have demonstrated variation in practice, with patchy adherence to guidelines. In Ireland, information regarding patient outcomes from GI bleeding is scarce.

Aims & Methods

To follow the outcomes of patients admitted with gastrointestinal bleeding in Ireland, monitor trends in patient activity and to identify factors associated with adverse outcomes. A retrospective review of all acute admissions in Ireland between 2017 and 2022 with GI bleeding as the principal diagnosis was performed using the National Quality Assurance and Improvement System Application, an online tool that analyses patient data from discharge summaries. Demographics such as age, gender, admission source was recorded. GI bleeding was stratified into upper GI bleeds (UGIB) and lower GI bleeds (LGIB), with UGIB further classified as variceal and non-variceal GI bleeding based on relevant logged terms. Outcomes including mortality, readmission rates (7-day and 30-day), and hospital length of stay (LOS) were analysed. Regression analysis was performed to identify factors associated with adverse outcomes.

Results

Data from 16,456 emergency admissions was analysed. The median age was 70.5 years (IQR 53-81), 57.2% were male. Median LOS was 4 days (IQR 2-7). Overall mortality was 3.8% (n=625), 6.5% (n=1076) of admissions required high-dependency care and readmission rates within 7- and 30-days were 5% (n=818) and 12.2% (n=2013) respectively. Patient admissions were under a general medical team in 43.8%, a surgical team in 42.4% and gastroenterology in 12.9%.
Weekend admissions (Friday-Sunday) were associated with an increased median LOS (4.0 days vs 3.0 days, p<0.001). Patients admitted under Gastroenterology had a longer average LOS (6.9 days vs 6.3 days, p<0.001) compared to other services but had an overall lower mortality (2.8% vs 4.1%, p=0.013). No significant difference was observed in admission rates, LOS, mortality, 7- and 30-day readmission during the COVID pandemic.
UGIB (n=9546) data demonstrated an overall mortality of 4.0% (n=378) with significantly higher mortality (7.6% vs 3.7% p<0.001), ICU requirements (25.4% vs 7.1%, p<0.001), and 7-day (6.6% vs 4.8%, p=0.039) and 30-day (17.9% vs 12.3%, p<0.001) readmission rates seen in variceal bleeds vs non-variceal bleeds. LGIB (n=1842) admissions had a mortality of 2.1% (n=38), a median LOS of 4 days (IQR2-8) with majority (58.5%) of admissions being under a surgical team.
Older age (overall OR 1.054 [95% CI 1.045-1.062, p<0.001]) and an intensive care unit admission (overall OR 12.8 [95% CI 10.5-15.5, p<0.001]) were found to be independent variables predicting mortality across all types of GI bleed admissions. Older age also predicted 7-day and 30-day readmissions to hospital.

Conclusion

This is the first study to report national outcomes of patients admitted with GI bleeding and highlights variations which could be addressed by a GI bleeding care bundle. Patients with GI bleeding admitted at the weekend have a longer average LOS and suggest potential value of weekend endoscopy.

Introduction

Contemporary studies suggest there are racial disparities in the outcomes of acute presentations. This study aimed to investigate the impact of sex and race on the management and outcomes of patients presenting with upper gastrointestinal bleeding (UGIB).

Aims & Methods

Using International Classification of Diseases 10th Revision Codes, all adults >18 admitted from 2016–2020 with a discharge diagnosis of UGIB were extracted from the National Inpatient Sample.

Results

In over 900,000 hospitalisations for UGIB, 69.4%, 14.1%, 9.6%, 3.6%, 0.9% and 2.4% were for admissions in white, black, Hispanic, Asian/pacific islander, native American and ‘other’ patients respectively. Comorbidity burden varied between racial groups (p<0.001). White patients had higher crude rates of endoscopy, and comparable rates of surgery or interventional radiology to control blood loss, in comparison to other racial groups. Adjusted analysis revealed that black and Asian/pacific islander racial group patients had lower odds of in-hospital all cause mortality compared to white patients, but ‘other’ racial group patients had higher odds of mortality (p<0.001). There was no difference for Hispanic or native American patients. For non-variceal bleeding, these outcomes persisted. However, for variceal bleeds, there were no significant differences in outcomes between each racial group.

Conclusion

There are racial disparities in the management and outcomes of admissions for UGIB. These difference persist despite the aetiology of bleeding. Underlying reasons for differences in outcomes must be investigated to ensure improved outcomes across high-risk patient groups.

Introduction

Upper gastrointestinal bleeding (UGIB) is a major cause of mortality in the United States (US). This study aimed to investigate the contemporary trends in the management and outcomes of these patients as well as factors associated with in-hospital mortality, using national data.

Aims & Methods

The US National Inpatient Sample was queried from 2016-2020. Using International Classification of Diseases 10th Revision Codes, all adults >18 admitted with a principal discharge diagnosis of UGIB were extracted along with data about demographics, management and outcomes. Categorical variables were compared using chi-squared and expressed as percentages (%). Logistic regression was performed, adjusting for variables associated with adverse outcomes and reported as adjusted odds ratios (aOR) with 95% confidence intervals (CI). Data were considered significant if p<0.001.

Results

There were 918,925 hospitalizations for UGIB in the study period. Variceal bleeding occurred in 36,050 (3.9%) of admissions. Endoscopy was performed in 451,450 (49.1%) of admissions, with 10,160 (1.1%) of admissions and 9,355 (1.0%) of admissions requiring interventional radiology and gastrointestinal surgery to control blood loss respectively. The crude rate of all-cause in-hospital mortality was 1.9%. Factors associated with death included variceal bleed (aOR 2.84 CI 2.67-3.02), age (aOR 1.03 CI 1.03-1.03), history of cancer (aOR 2.45 CI 2.35-2.56), ulcer disease (aOR 1.44 CI 1.39-1.49), chronic renal failure (aOR 1.34 CI 1.29-1.37), chronic obstructive pulmonary disease (aOR 1.29 CI 1.24-1.34), receipt of endoscopy (aOR 1.33 CI 1.29-1.38), surgery (aOR 3.92 CI 3.63-4.24) and interventional radiology (aOR 3.33 CI 3.09-3.58).

Conclusion

UGIB remains a significant cause of hospitalisation in the US. Knowledge of the contemporary trends and outcomes of this patient group is important to improve management in this at-risk patient group.

Introduction

Colorectal cancer (CRC) remains a major cause of mortality and morbidity worldwide. Projected increases in CRC cases pose a significant challenge to the capacity of colonoscopy programs. Referrals for symptomatic colonoscopy exceed capacity in Ireland and most European nations. Fecal Immunochemical Test (FIT) with a lower cut-off (50ng/ml) has been proposed as a tool to aid triage of referrals which do not meet criteria for urgent colonoscopy, potentially allowing colonoscopy to be avoided.

Aims & Methods

The aim of this study was to evaluate FIT testing outcomes when combined with an endoscopy nurse delivered clinical triage and evaluate suitability as a ‘rule out’ test for serious gastrointestinal pathology.
This multi-centre study included symptomatic patients from sixteen hospitals across Ireland who were referred for colonoscopy from 2023-2024. All patients received ‘FIT testing at the front door’. Using an advanced endoscopy nurse triage approach, assessing patient clinical characteristics and FIT result (positive result determined as FIT≥50ng/mL), patients were triaged into urgent colonoscopy or remained on the routine (P2) colonoscopy list.
Among 7,808 patients sent for FIT testing, 408 were excluded on the basis of missing FIT results (n = 407) or incomplete data (n = 1). The remaining 7,400 patients were included in an analysis assessing FIT positivity rates (FIT≥50 ng/mL) as well as factors associated with positive results. A subset of 1,815 patients from five hospitals, who had lower endoscopy outcomes available, were further analysed to determine frequencies of endoscopy findings (ex: normal, CRC, and IBD) and to evaluate the sensitivity, specificity and negative predictive value of FIT-centered endoscopy nurse clinical triage. IBM SPSS Statistics 29.0.1.0 was used for statistical analysis.

Results

Of 7,400 patients who underwent FIT testing across sixteen sites, 16.4% (n=1,215) had a positive result (FIT≥50ng/mL). Multivariate analysis showed that increased age (OR = 1.029; 95% CI = 1.025-1.033; p-value<0.001) and male sex (OR = 1.44; 95% CI = 1.273-1.63; p-value<0.001) were significantly associated with positive FIT results.
At five sites, 1,815 patients who underwent FIT testing were referred for colonoscopy. At these sites, 79.0% (n=1,433) had a FIT<50ng/mL of whom 0.14% (n=2) had CRC and 1.5% (n=21) had significant findings at colonoscopy (ex: CRC or IBD). In contrast, 21.0% (n=382) had a FIT≥50ng/mL of whom 6.8% (n=26) had CRC and 19.1% (n=73) had significant findings at colonoscopy (ex: CRC or IBD).
The proportion of patients with CRC was significantly greater when FIT≥50ng/mL compared to FIT<50ng/mL (Fisher’s Exact Test, p-value <0.001). The sensitivity, specificity, and negative predictive value of FIT≥50ng/mL for CRC at subsequent colonoscopy is 92.9% (95%CI=75.0-98.8%), 80.1% (95%CI=78.1-81.9%), and 99.9% (95%CI=99.4-99.9%), respectively.

Conclusion

FIT testing is useful in low risk symptomatic patients referred for colonoscopy and when combined with enhanced nurse led clinical triage has a very good negative predictive value for serious gastrointestinal pathology.

Introduction

Endoscopy services in many healthcare systems face increasing demand, and novel approaches to patient triage are needed. Recent research suggests that capsule sponge testing combined with immunohistochemical biomarkers can prioritise patients with Barrett’s oesophagus (BO) and gastro-oesophageal reflux for oesophagogastroduodenoscopy (OGD).^1,2 However, it is not yet widely integrated into clinical practice globally. The capsule sponge is not currently used in South Wales and Northern Ireland, and further investigation into its implementation in these regions is required.

Aims & Methods

This multicentre feasibility study aimed to evaluate whether the capsule sponge could be used in Wales and Northern Ireland to triage patients with gastro-oesophageal reflux or BO for OGD, and to assess feedback from patients and staff. Patients referred to gastroenterology due to gastro-oesophageal reflux and patients with known BO under surveillance were eligible. Patients were recruited from 3 hospital sites in Wales and 2 in Northern Ireland, undergoing the test in nurse-led clinics between December 2024 and March 2025. Pathology samples were processed centrally in an accredited laboratory (Cyted), examining for TFF3 (suggestive of intestinal metaplasia), p53 and atypia (high-risk findings associated with dysplasia). Patient feedback was collected at the clinics, and feedback forms were also sent to patients and staff.

Results

201 patients were recruited, with 196 (97.5%) completing the capsule sponge test: 116 with BO (median age 59, 84% male) and 80 with reflux (median age 49, 56% female). 101 BO samples (87%) were adequate for analysis. Of these, 21 (21%) were positive/equivocal for atypia/p53 and deemed high-risk, and 80 (79%) were negative for both atypia and p53. High-risk patients were prioritised for urgent OGD, with the remainder followed-up as per the British Society of Gastroenterology guidelines. 61 samples (76%) from patients with reflux were adequate for analysis. Of these, 3 (5%) were positive/equivocal for atypia/p53 and prioritised for urgent OGD, 11 (18%) were TFF3 positive but negative for both atypia and p53 and were booked for routine OGD, and 47 (77%) were negative for all 3 biomarkers and were managed as per usual local practice.
148 patients (76%) who completed a capsule sponge test had previously had an OGD, with 78% of these preferring the capsule sponge, 4% preferring the OGD and 9% being unsure. Feedback forms were completed by 52 patients, with response rates varying by question. 92% rated the capsule sponge procedure good/very good, 3% fair and 5% poor/very poor. When asked how likely they would be to recommend the test, on a scale from 1 (least likely) to 10, patients with reflux gave a mean score of 8.7 and patients with BO 9.6. For whether they would be willing to have the test done again, 83% said yes, 14% not sure and 3% no. Patients’ free text comments indicated they found the capsule sponge to be quicker and easier than an OGD, however some experienced discomfort on sponge withdrawal. 14 staff completed feedback forms. 100% agreed the capsule sponge test was easy to deliver, and 100% rated the implementation of the test pathway as good/very good.

Conclusion

This feasibility study showed that the capsule sponge could successfully triage patients under BO surveillance or with reflux for OGD in Wales and Northern Ireland, with positive feedback from patients and staff. These findings support future integration of the capsule sponge into clinical pathways in these regions, with potential transferability to other healthcare systems internationally.

References

1. Chien S, Glen P, Penman I, Cruickshank N, Bryce G, Crumley A, et al. Oesophageal cell collection device and biomarker testing to identify high-risk Barrett’s patients requiring endoscopic investigation. Br J Surg. 2024 May 13;111(5):znae117.
2. Chien S, Glen P, Bryce G, Cruickshank N, Penman I, Robertson K, et al. Clinical application of capsule sponge testing in symptomatic reflux disease: a national prospective cohort study. BMC Gastroenterol. 2024 Nov 26;24:431.

Disclosure

R McNally, B Afinowi, I Aldred and R Hardwick are employed by Cyted Health, who manufacture the capsule sponge device used in this study. The remaining authors have nothing to disclose.