Introduction

The last UK audit of the management of acute upper gastrointestinal bleeding (AUGIB) was conducted in 2007.¹ We report patient characteristics, investigations, treatments, and clinical outcomes from an interim analysis of the 2022 UK audit.

Aims & Methods

Prospective multi-centre observational study of adults (≥16 years) presenting in or to UK hospitals with AUGIB between 3 May and 2 July 2022.

Results

Data on the first 2881 patients (median age 70yr) from 158 participating hospitals are reported. New admissions with AUGIB (n=2205) were younger than inpatients developing AUGIB (median age 68 vs 75 yrs, respectively) with fewer comorbidities (63% vs 79%, respectively). At presentation, 17%(490/2881) had chronic liver disease(CLD), 28%(n=815) a history of alcohol excess, 7%(n=294) were taking non-steroidal anti-inflammatory drugs (NSAID) and 44%(n=1268) antiplatelets or anticoagulants. 80%(n=2315) patients had an inpatient endoscopy; 32%(742/2315) had peptic ulcer disease (PUD), 9%(212/2315) had a variceal bleed, and 27%(622/2315) received endoscopic therapy. Reasons for no endoscopy (n=566) were: 47%(n=265) not clinically indicated/25%(n=139) outpatient procedure /18%(n=102) not for active treatment /6%(n=37) self-discharged /0.5%(n=3) transferred to other hospital /5%(n=28) death. 9%(202/2315) had evidence of further bleeding after index endoscopy. 0.6%(n=19) underwent surgery, 3%(n=72) had interventional radiology (IR) and 47%(n=1367) were transfused ≥1 packed red blood cells (PRC); 4%(n=113) platelets; and 5%(n=137) fresh frozen plasma (FFP) for AUGIB. Median length of stay (LOS) was 5 days. In-hospital mortality was 8.2%(n=636); 5.3% in new admissions and 19% in inpatients. Comparisons with the full 2007 audit are presented in table 1.

Table 1

Conclusion

Despite an older and more co-morbid population, there is an indication of reduced recurrent bleeding, need for surgery and in-hospital mortality for AUGIB since 2007. This improvement may correlate with improved management and better endoscopic therapy.

References

1. Hearnshaw et al Gut 2011

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.

Introduction

Idiopathic gastroparesis (IG) remains a challenging condition, with few effective therapeutic options available. Despite recent European and international consensuses, some management modalities are still different in the French practice (1).

Aims & Methods

We aimed to develop French recommendations on the diagnosis and management of IG in adults and paediatric patients, highlighting the similarities and differences with recent consensuses. A Delphi process was conducted among a panel of 16 French neurogastroenterology experts, including gastroenterologists and paediatricians. A first list of statements was drafted with a literature summary. After revisions and clarifications, 3 voting rounds were conducted and consensus statements were identified (defined as ≥ 80% agreement).

Results

Consensus was reached for 39 out of 46 statements. Definition and diagnostic modalities were similar to recent guidelines. IG was defined as symptoms associated with delayed gastric emptying (GE), in the absence of a mechanical obstruction. The panel agreed that nausea and vomiting are cardinal symptoms, with postprandial distress symptoms frequently overlapping. Variable presentations according to age were highlighted in paediatric patients.
Delayed GE can be confirmed by either scintigraphy or a GE breath test, using a solid meal, and a 4-hour measurement. Food retention at endoscopy was not considered a diagnostic criterion. Pyloric EndoFlip was not considered a diagnostic or pretherapeutic tool. A blood test and screening for Helicobacter pylori were supported before diagnosing IG.
Regarding the management, like in recent guidelines, the panel supported a first-line therapy using dietary advice and dopamine antagonists (metoclopramide or domperidone). The panel supported the efficacy of intravenous erythromycin, but not oral erythromycin. Agreement on the efficacy of other drugs, including prucalopride, antiemetics, or neuromodulators, was not reached. The use of nutritional support was recommended if deemed necessary for refractory vomiting and malnutrition, with enteral post-pyloric nutrition recommended as the first option.
The consensus supported different strategies for the management of refractory gastroparesis. Stopping opioids, or drugs inducing delayed GE, and the treatment of associated constipation were recommended before considering more invasive procedures. The efficacy of pyloric toxin injection was not agreed upon. Gastric endoscopic pyloromyotomy and gastric electrical stimulation were considered effective therapies for refractory IG. Finally, surgical procedures were not supported.

Conclusion

This consensus shows that the diagnostic modalities for IG are similar in France as compared to international guidelines, but highlights differences in the management of refractory gastroparesis, supporting endoscopic pyloromyotomy or the implantation of gastric electrical stimulation.

References

1. Schol J, Wauters L, Dickman R, Drug V, Mulak A, Serra J, et al. United European Gastroenterology (UEG) and European Society for Neurogastroenterology and Motility (ESNM) consensus on gastroparesis. United European Gastroenterol J. 2021 Apr;9(3):287–306.
2. Schol J, Huang IH, Carbone F, Fernandez LMB, Gourcerol G, Ho V, et al. Rome Foundation and international neurogastroenterology and motility societies’ consensus on idiopathic gastroparesis. Lancet Gastroenterol Hepatol. 2025 Jan;10(1):68–81.

Disclosure

HS received lecture fees from Enterra Medical, and Viatris.