Introduction

Acute variceal bleeding is a life-threatening decompensating event in the natural history of cirrhosis. Endoscopic variceal ligation (EVL) along with non-selective beta blockers or carvedilol are current standard of care for patients with acute esophageal variceal bleeding. Use of proton pump inhibitors (PPI) in post EVL period is more of a personal choice as various society guidelines do not recommend continuation of PPI after EVL owing to low quality of evidence to support their use. The literature regarding the benefits of PPI in post EVL re-bleeding and mortality is heterogeneous without any clear answer particularly for mortality.

Aims & Methods

We conducted a single centre, outcome assessor blinded prospective randomized control trial where patients of liver cirrhosis with suspected or documented acute variceal bleeding were screened and those who underwent EVL were randomized into PPI or No-PPI group. Patients in the PPI group received Tab esomeprazole 40 mg once a day in addition to standard of care for all the patients. Both groups were followed up at 2 weeks post index EVL after randomization for occurrence of rebleeding and a repeat upper gastrointestinal endoscopy (UGIE) to document presence or absence of post EVL ulcers, their number and size. All patients were again followed up at 3 months for development of recurrent bleeding, mortality and adverse effect like pain and dysphagia post EVL. Primary outcome was to compare the rate of recurrent bleeding after EVL between the 2 groups. Secondary outcomes were to assess the difference in mortality, number and size of post EVL ulcers and adverse effects in the form of pain and dysphagia post EVL. Association between categorical outcomes was assessed by cross tabulation and comparison of percentages. Chi square test was used to test statistical significance. The association between quantitative variables was assessed by independent sample t-test to assess statistical significance. A p value of <0.05 was considered significant.

Results

A total of 246 patients were screened from June 2023 to April 2024 and 170 patients were randomized to both the groups. Baseline parameters were comparable between the groups. In the primary outcome, number of patients who developed recurrent bleeding episode were 23 (28.05%) in the no-PPI group, which were significantly more in comparison to 9 (11.54%) in the PPI group (p=0.009). Among the secondary outcomes, incidence of mortality was higher in the no-PPI group [16 (19.51%) vs 13 (16.67%) respectively], although statistically non-significant (p=0.640). All 16 (100%) deaths in the no-PPI group were related to rebleeding episode in comparison to only 5 (38.46%) deaths in the PPI group (p=0.035). Incidence of post EVL ulcers was significantly more in the no-PPI group [65 (86.67%) vs 22 (30.99%) respectively; p<0.001]. Median post EVL ulcer number and size were also significantly higher in the no-PPI group [1 (IQR 1,2) vs 0 (IQR 0,1) (p=<0.001); 6 mm (IQR 5,8) vs 5 mm (IQR 5,6) (p=0.0061) respectively]. At 2 weeks, chest pain was reported by 7 (9.33%) patients in the no PPI group vs 2 (2.82%) patients in the PPI group (p=0.167). No patient reported dysphagia at 2 weeks. No patient reported chest pain or dysphagia at 3 months.

Conclusion

Prescription of PPI after EVL in patients of liver cirrhosis with acute esophageal variceal bleeding is beneficial as it significantly decreases the recurrent bleeding episodes as well as mortality in such patients.

Introduction

Colon capsule endoscopy (CCE) or panenteric capsule endoscopy (PCE) offers a promising, non-invasive diagnostic approach for patients with iron deficiency anaemia (IDA). However, high rates of conversion to conventional colonoscopy (CCC) following capsule procedures reduce cost-effectiveness and patient satisfaction. Optimising the faecal immunochemical test (FIT) threshold may improve patient stratification and reduce unnecessary conversions in future applications within the IDA diagnostic pathway.

Aims & Methods

This study aimed to evaluate the accuracy of faecal immunochemical testing (FIT) in predicting colorectal cancer (CRC) and polyp burden in patients with iron deficiency anaemia (IDA), and to extrapolate these findings to assess FIT’s utility in predicting the likelihood of conversion from CCE to conventional colonoscopy (CCC) based on underlying pathology in IDA.
The CLEAR IDA study was a multicentre, retrospective observational study conducted across four UK hospitals. Data were collected over a six-month study period and included patients referred via the two-week-wait (2WW) cancer pathway for iron deficiency, with or without anaemia, over a 12-month timeframe. Colonoscopy findings were analysed and extrapolated using NHS England’s CCE-to-colonoscopy referral criteria to assess the predictive value of FIT for colorectal cancer (CRC), polyp burden, and CCC using ROC curve analysis. The optimal FIT threshold was identified through three complementary approaches: threshold-based analysis, decision curve analysis, and cost-benefit modelling.

Results

A total of 1,531 patients were analysed; only 1.6% underwent small bowel capsule endoscopy. The diagnostic accuracy (AUC) of FIT for predicting CRC, polypoidal lesions, and CCC was 0.78, 0.58, and 0.69, respectively. Threshold-based analysis identified FIT = 15 µg/g as the lowest level at which CCC rates significantly increased (p = 0.02; OR = 1.87; 95% CI: 1.07–3.14). Decision curve analysis showed maximum net benefit at FIT = 17.6 µg/g, while cost-benefit modelling identified 9 µg/g as the most cost-effective. An optimal cost-effective FIT threshold range was identified between 10 and 17.6 µg/g. Threshold selection should be tailored to local service capacity and resource availability.

Conclusion

Significant pathologies in the IDA pathway were uncommon. A FIT threshold range between 10–17 µg/g may enhance cost-effectiveness and guide appropriate PCE use in IDA.

References

1) Snook J, Bhala N, Beales ILP, et al. British Society of Gastroenterology guidelines for the management of iron deficiency anaemia in adults. Gut. 2021 Nov;70(11):2030-2051.
2) (NICE) NIFHACE. PillCam COLON 2 for investigation of the colon through direct visualisation: NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE; August 2024 [cited 2025 23/03/2025]; Diagnostics Assessment Programme]. Available from: https://www.nice.org.uk/guidance/gid-dg10083/documents/final-scope-2
3) Turvill J, Haritakis M, Pygall S, et al. Multicentre Study of 10,369 Symptomatic Patients Comparing the Diagnostic Accuracy of Colon Capsule Endoscopy, Colonoscopy and CT Colonography. Aliment Pharmacol Ther. 2025 Feb 26;0:1–13.
4) Cilona A, Zullo A, Hassan C, et al. Is faecal-immunochemical test useful in patients with iron deficiency anaemia and without overt bleeding? Dig Liver Dis. 2011 Dec;43(12):1022-4.
5) Turvill JL, Turnock D, Cottingham D, et al. The Fast Track FIT study: diagnostic accuracy of faecal immunochemical test for haemoglobin in patients with suspected colorectal cancer. Br J Gen Pract. 2021 Aug;71(709):e643-e651.