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TRENDS IN MANAGEMENT AND OUTCOMES OF CIRRHOTIC PATIENTS WITH VARICEAL BLEEDING IN THE UNITED KINGDOM – 15 YEARS APART: A COMPARATIVE ANALYSIS OF 2007 AND 2022

Gaurav Nigam 1, John Grant-Casye 2, Kathryn Oakland 3, Sarah Hearnshaw 4, Vipul Jairath 5, Simon Travis 6, Mike F. Murphy 2, Lise Estcourt 2, Andrew Douds 7, Joanna Leithead 8, Adrian Stanley 9

Affiliations

1 Oxford University NHS Hospitals, Oxford, United Kingdom

2 NHS Blood and Transplant, Oxford, United Kingdom

3 HCA Healthcare UK, Oxford, United Kingdom

4 Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, United Kingdom

5 Alimentiv Inc., London, Canada

6 John Radcliffe Hospital, Oxford, United Kingdom

7 Queen Elizabeth Hospital, Fakenham, United Kingdom

8 Forth Valley Royal Hospital, Larbert, United Kingdom

9 Glasgow Royal Infirmary, Glasgow, United Kingdom

Summary

AI Generated

A 2022 UK-wide audit of 307 cirrhotic patients with variceal bleeding shows improved pre-endoscopy treatment, increased endotherapy use, reduced rebleeding, and shorter hospital stays compared to a 2007 audit.

Pre-endoscopic treatment improved significantly between 2007 and 2022: antibiotic use increased from 27% to 61%, vasopressor use from 57% to 70%, and PPI use from 50% to 62% (all p<0.05).
Endotherapy application increased from 64% in 2007 to 78% in 2022 (p<0.05), with 70% receiving variceal therapy (93% banding, 12% injection) and TIPSS use rising from 0.8% to 2% (p<0.05).
Further in-patient bleeding after index endoscopy decreased from 26% to 18% (p<0.05) and median length of stay fell from 9 days to 7 days.
In-hospital mortality showed a numerical decrease from 15.2% to 13% (p=0.32, not statistically significant).
The authors suggest that further improvements in pre-endoscopic management and provision of TIPSS are required; this material is most relevant to gastroenterologists and hepatologists managing variceal bleeding in cirrhotic patients.

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Abstract

Introduction

This study revisits the management and outcomes of acute upper gastrointestinal bleeding (AUGIB) in cirrhotic patients across the United Kingdom, allowing comparisons with the last UK wide audit undertaken in 2007 .¹

Aims & Methods

Focusing on cirrhotic patients with variceal bleeding, we analyze patient profiles, investigations, treatments, and outcomes, drawing comparisons with the 2007 study. A prospective multi-center observational study of adults (>16 years) presenting to 152 UK hospitals with AUGIB between 3 May - 2 Jul 2022.

Results

744/5101 (15%) presenting with AUGIB had known cirrhosis (Child-Pugh categories: A:1%, B: 47%, C: 11%.)with median age of 59yrs (IQR 49.7-69). 73%(547/744) were new admissions. Glasgow-Blatchford score(GBS), stratified patients into, 22% medium-risk(GBS 2-6),47% high-risk(7-11),and 30% very high-risk(≥12). For pre-endoscopy management: 58%(433) received proton pump inhibitors(PPI), 50%(371) terlipressin/vasopressor and 44%(326) antibiotics. An endoscopy was performed for 91%(679/744). Time to endoscopy from presentation was: 0-12 hrs in 25%, 12-24 hrs in 25%, & 24-48 hrs in 21%. 45% (307/679) were identified to have varices (91% - oesophageal, 15% - gastric and 2% - duodenal) and 33%(224/679) had non-variceal findings. Median age of patients with varices (n=307) was 57 yrs (IQR 49-68). Stigmata of recent bleed were noted for 72%(222) - 45% blood in the upper GI tract and 65% high risk markings on varices and endotherapy was applied for 78%(241). Variceal therapy applied in 70%(214 – 93% banding, 12% injection therapy), Danis stent 2%(5) and Sengstaken tube 6%(14). 18% (55) had evidence of further in-patient bleeding after index endoscopy. During inpatient stay, 26%(81) needed >1 endoscopy, and 2%(6) underwent transjugular intrahepatic portosystemic shunt(TIPSS). 67%(206) were transfused ≥1 packed red blood cells, 17%(53) platelets and 22%(68) fresh frozen plasma for AUGIB. Median length of stay was 7days (IQR 5-11) and in-hospital mortality was 13%(40). Comparisons with the 2007 audit for patients with varices revealed an increased average age (58yrs vs 54.5 yrs), increased pre-endoscopic use of PPI (62% vs 50%),vasopressors (70% vs 57%) and antibiotics (61% vs 27%). There was a significant increase in those receiving endotherapy (78% vs 64%) and undergoing TIPSS (2% vs .8%), along with a lower likelihood of further in-patient bleeding after an index endoscopy (18% vs 26%), and numerically lower in-hospital mortality (13% vs 15.2%).Comparisons with the 2007 audit are presented in table 1.

Table 1: Comparative analysis with 2007 audit of main outcomes for variceal bleeds
Outcome	2007 (n=526)	2022 (n=307)	p value
Mean age	54.5 yrs	57.7 yrs	-
Pre-endoscopy treatment Proton pump inhibitors Terlipressin/ vasopressor Antibiotics	57% 57% 27%	62% 70% 61%	<0.05 <0.05 <0.05
Endoscopy outcomes Stigmata of recent bleed Endotherapy Further bleeding	65% 64% 26%	72% 78% 18%	<0.05 <0.05 <0.05
TIPSS	0.8%	2%	<0.05
Transfusion >1 unit Packed red cells Fresh frozen plasma Platelets	73% 35% 14%	67% 22% 17%	<0.05 <0.05 0.26
Median LOS	9 days (IQR 5-21)	7 days (IQR 5-11)	-
In-hospital mortality	15.2%	13%	0.32

Conclusion

Compared with 2007 patients presenting with variceal haemorrhage were more likely to receive optimal treatment, had reduced length of stay, reduced rebleeding and a trend towards reduced mortality. Our data suggests that further improvements in pre-endoscopic management and provision of TIPSS are required.

References

Hearnshaw et al Gut 2011

Conference

UEG Week Vienna 2024

Topics

Hepatobiliary

Submission format

Abstract

Session

Complications in end stage liver disease (Posters)

Citation

United European Gastroenterology Journal 2024; 12 (Supplement 8)

Published

2024

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Can surgery be the cure?

Gianluca M Sampietro 1

Affiliations

1 ASST Fatebenefratelli Sacco - Ospedale Luigi Sacco Polo Universitario, Milano, Italy

Summary

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Abstract

Event

UEG Week Barcelona 2026

Topics

Small Intestine & Nutrition Surgery IBD

Session

What’s new in… Managing stricturing Crohn’s disease

Citation

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

Published

2026

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When the acid is gone: Dealing with gastric atrophy

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When the acid is gone: Dealing with gastric atrophy

Marco Vincenzo Lenti 1

Affiliations

1 Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy

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Abstract

Event

UEG Week Barcelona 2026

Topics

Stomach & H. Pylori Mechanisms & Personalised Medicine

Session

Therapy update: Acid-related disorders

Citation

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

Published

2026

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Life after liver transplant

Gonzalo Crespo 1

Affiliations

1 Hospital Clínic de Barcelona, Barcelona, Spain

Summary

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Abstract

Event

UEG Week Barcelona 2026

Topics

Pancreas Surgery Hepatobiliary

Session

After the surgeon: A glimpse behind the survival curves

Citation

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

Published

2026

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Management of pouchitis and Crohn’s disease of the pouch

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Management of pouchitis and Crohn’s disease of the pouch

Bo Shen 1

Affiliations

1 Columbia University Irving Medical Center, New York, United States of America

Summary

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Abstract

Event

UEG Week Barcelona 2026

Topics

Small Intestine & Nutrition Surgery IBD

Session

What’s new in… Managing stricturing Crohn’s disease

Citation

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

Published

2026

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NOT ALL NORMAL POUCHES ARE ALIKE: THE CLINICAL AND MICROBIAL SPECTRUM OF DURABLE NORMAL POUCH BEHAVIOR

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NOT ALL NORMAL POUCHES ARE ALIKE: THE CLINICAL AND MICROBIAL SPECTRUM OF DURABLE NORMAL POUCH BEHAVIOR

Maya Fischman 1, Liat Bilinsky 2, Lihi Godny 1,2, Jacob E. Ollech 2,3, Keren M Rabinowitz 1,2, Ian White 2,4, Nir Wasserberg 2,4, Adi Friedeberg 1, Maor Pauker 1, Irit Avni-Biron 1,2, Hagar Banai Eran 1,2, Yifat Snir 1,2, Henit Yanai 1,2, Leah Reshef 2, Uri Gophna 2, Iris Dotan 1,2

Affiliations

1 Rabin Medical Center, Beilinson Campus, Petah Tikva, Israel

2 Tel Aviv University, Tel Aviv, Israel

3 Meir Medical Center, Kfar Sava, Israel

4 Rabin Medical Center, Petah Tikva, Israel

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Abstract

Introduction

While acute pouchitis develops in up to 80% of patients with ulcerative colitis (UC) after ileal pouch-anal anastomosis (IPAA), little is known about the clinical and microbial features of normal pouches that remain durable over time.

Aims & Methods

This study aims to decipher the biology of durable normal pouch phenotype by comparing clinical, endoscopic, and microbial features across pouch phenotypes. Patients undergoing IPAA for UC or familial adenomatous polyposis (FAP) were prospectively followed at a comprehensive pouch clinic. Follow-up included clinical visits; blood and stool sampling; pouch endoscopies with biopsies. The normal spectrum was divided into FAP; ultra normal (UN, ≥10 years from ileostomy closure without pouchitis); and normal with later progression to pouchitis (NLP, normal at sampling with later pouchitis during follow-up), and compared to pouchitis flare sampling. Stool samples underwent shotgun metagenomic sequencing. Analyses included overall comparisons across all four phenotypes and pairwise comparisons between phenotype pairs, using Kruskal-Wallis and Fisher’s exact tests, and mixed linear regression models with patient identity as a random effect. Multiple testing was corrected using false discovery rate (q<0.2).

Results

Sixty patients were included: FAP (n=16), UN (n=20), NLP (n=14), and pouchitis (n=10) (baseline median age 46.7y; pouch age 10.1y; 55% female). Median follow-up was 17.7y; UN was durable for a median of 20.8y. Among patients with UC, pre-IPAA disease extent and IPAA indication were comparable (p>0.9 and p=0.27); UN patients had lower pre-IPAA exposure to immunomodulatory/advanced therapy (p=0.08). Clinical, endoscopic and histologic Pouchitis Disease Activity Index subscores gradually increased across FAP, UN, NLP, and pouchitis; median fecal calprotectin was 51.5, 130, 317.7, and 831 mg/g, respectively. Shannon diversity was comparable, whereas Microbial Dysbiosis Index (MDI) gradually increased across phenotypes (FAP -2.76, UN -1.74, NLP -0.91, pouchitis -0.78). Principal coordinates analysis (Jaccard dissimilarities) showed significant differences in overall microbial community composition across phenotypes (p=0.026). Pairwise differential abundance analysis supported gradual taxonomic shift, from comparable taxa between FAP and UN, to maximal separation (53 taxa) between FAP and pouchitis. Taxa with significant pairwise differences showed a graded distribution across phenotypes: Prevotella copri, Blautia wexlerae and Faecalibacterium prausnitzii were more abundant in FAP and UN; Ruminococcus gnavus was higher in NLP and pouchitis. UN and NLP significantly differed by 9 taxa, including Clostridium perfringens, Veillonella parvula and Fusobacterium animalis. In longitudinal analysis of patients with NLP (27 samples), over a follow-up period from 3,496 to 27 days prior to first pouchitis, MDI gradually increased over serial pre-flare samples before pouchitis onset (p=0.032).

Conclusion

The normal pouch phenotype encompasses a heterogeneous spectrum characterized by distinct clinical, endoscopic and microbial features. Patients with UC post-IPAA who sustain UN pouch for over a decade uniquely demonstrate hybrid phenotype, with clinically intermediate features but taxonomic similarity to FAP and microbial separation from those who later progress to pouchitis, the latter harboring dysbiotic taxa and showing progressive MDI increase towards flare. This restratification of normal pouch phenotype trajectory has mechanistic and clinical implications, potentially guiding intervention and prevention, thus modifying disease course.

Event

UEG Week Barcelona 2026

Topics

IBD Pancreas Gut Microbiota Endoscopy Digestive Oncology Colorectal

Submission format

Abstract

Session

Hot topics in clinical GI research

Citation

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

Published

2026

More Like This:

Can surgery be the cure?

Gianluca M Sampietro

When the acid is gone: Dealing with gastric atrophy

Marco Vincenzo Lenti

Life after liver transplant

Gonzalo Crespo

Management of pouchitis and Crohn’s disease of the pouch

Bo Shen

NOT ALL NORMAL POUCHES ARE ALIKE: THE CLINICAL AND MICROBIAL SPECTRUM OF DURABLE NORMAL POUCH BEHAVIOR

Iris Dotan

After the first biologic failure, the next choice matters: Building confidence beyond conventional targets through deep remission with mirikizumab in CD (Eli Lilly and Company) (Complete Session)

Stefan Schreiber

UEG Presentation

New

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

After the first biologic failure, the next choice matters: Building confidence beyond conventional targets through deep remission with mirikizumab in CD (Eli Lilly and Company) (Complete Session)

This content is part of Gutflix. Log in with your myUEG account, or create one free, to watch it.

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After the first biologic failure, the next choice matters: Building confidence beyond conventional targets through deep remission with mirikizumab in CD (Eli Lilly and Company) (Complete Session)

Alissa Walsh 1, Marc Ferrante 2, Stefan Schreiber 3

Affiliations

1 Translational Gastroenterology Unit, Oxford University Hospital, Oxford, United Kingdom

2 University Hospitals Leuven, Leuven, Belgium

3 Department of Internal Medicine I, University Hospital Schleswig-Holstein, Kiel University, Kiel, Germany

Summary

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Abstract

Publisher

Eli Lilly

Event

UEG Week Barcelona 2026

Session

After the first biologic failure, the next choice matters: Building confidence beyond conventional targets through deep remission with mirikizumab in CD (Eli Lilly and Company)

Citation

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

Published

2026

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