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.
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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

1. Hearnshaw et al Gut 2011

Introduction

The prevalence of musculoskeletal disorders (MSD) among gastroenterologists is estimated between 39 to 89%. Factors associated with MSDs among endoscopists include a high number of procedures (over 20/week), prolonged procedure times (over 16 hours/week), the age of the endoscopist (> 40 years vs ≤ 40 years), and female sex.
This study aimed to evaluate the prevalence of MSD among French gastroenterologists and identify risk factors of MSD

Aims & Methods

A computerized, anonymized questionnaire was e-mailed to all members of French society of endoscopy (SFED) over a one-month period. Demographic data were collected, as well as the level of endoscopic activity performed, the quantity and volume of endoscopies performed per week, the presence of pain associated with the practice of endoscopy, and an assessment of stress.

Results

485 gastroenterologists responded to the questionnaires, the majority were male (55%), with a median age of 48 years (IQR 37–60), and 45.6% practiced endoscopy for more than 20 years. 74.3% of respondents worked full-time, mostly in private practice (47% in private practice, 13% in mixed public-private practice). Endoscopy was performed for a median of 15 hours per week (IQR 10–18.8), with 24 procedures per week (IQR 15–30).
76.3% of participants had already experienced joint and/or musculoskeletal pain related to work. Pain complaints mainly concerned the lower back (55%), shoulders (36% left, 37% right%), neck (50%), and wrists (30% both side). More than half of the participants (55.9%) reported that the pain persisted after procedures, with 17.8% experiencing nocturnal pain and about a quarter reporting pain lasting more than 3 months.
The impact of MSD on workload was evaluated. 5.1% of the gastroenterologists reported loss of efficiency, 3,8% adapted their job, 2.4% decreased their activity, and 2.1% had work stoppage. 35% declared to have management of their MSD (28.1% painkiller, 23.2% reeducation, 3.5% surgery). To reduce discomfort, 74.7% of respondents reported using an adjustable-height examination table, and half adjusted the height and distance of the screen.
In multivariate analysis, factors associated with MSD were, femal sexe (OR 1.85 (1.15-3.01) p = 0.012, number of endoscopy (OR 1.05 (1.01-1.11) p=0.03, activity > 20 years (OR 2.42 (0.89, 6.47) p=0.079.) The risk of MSD was higher after 16.5 hours of endoscopy/ week (Se 35%, Sp 83%).

Conclusion

Musculoskeletal pain among French gastroenterologists is common and concerning. Therefore, it is essential to develop preventive programs to support their health and ensure the quality and safety of care.

Introduction

Esophageal varices (EV) are a critical complication of portal hypertension in patients with cirrhosis, and early detection is essential to prevent potentially life-threatening hemorrhage. The Baveno VII consensus recommends performing endoscopy in patients with transient elastography (TE) values exceeding 20 kPa and platelet counts below 150,000/mm³. While endoscopy remains the gold standard for diagnosis, non-invasive tests are gaining importance as a promising alternative for predicting EV(1) .The objective of our study is to predict the grade of varices in cirrhotic patients using a score derived from both their biological blood test results and clinical parameters.

Aims & Methods

The objective of our study was to predict the grade of varices in cirrhotic patients using a score derived from their biological blood test results and clinical parameters. This retrospective study involved patients recruited from Hôtel-Dieu de France, with data collected a few months prior to their gastroscopy for esophageal varices detection.
We calculated the ALBI-PLT score based on the method described by Inoue-Yuri et al.(2). The modified ALBI-PLT (mALBI-PLT) score was derived from the mALBI grade, assigning 1 point for grades 1 or 2a, and 2 points for grades 2b or 3. It also incorporated platelet counts, awarding 1 point for counts greater than 150,000/μL and 2 points for counts of 150,000/μL or lower. In addition to the mALBI-PLT score, we considered various variables, including blood test results and established predictive scores such as Child-Pugh, MELD-Na, FIB-4, and APRI.

Results

This study analyzed 108 cirrhotic patients (mean age: 63.94 years, 64.8% men, 33.03% had hepatocellular carcinoma (HCC)) out of 115 recruited, excluding cases with missing data. Key predictors of varice grades included lymphocyte count (L, β = −0.43, p = 0.011) and sodium (Na^10, β = −3.22 × 10^−22, p = 0.005) as significant negative associations. Positive associations were observed for the modified ALBI-platelet score (β = 0.43, p < 0.001), HCC (β = 0.51, p = 0.005), and gastrointestinal (GI) bleeding (β = 0.48, p = 0.013).
A derived formula for predicting varice grades is: VariceGrade = 3.49 − 0.43×ln(L) + 0.43×mALBI-PLT score − 3.22×10^−22×Na^10 + 0.51×HCC + 0.48×GI Bleeding.
The model showed strong specificity (94.5%) for identifying varices when the score was ≥ 1 and high sensitivity (97.8%) for excluding grade 3 varices when the score was ≤ 2.

Conclusion

This study introduces a non-invasive scoring system to accurately stratify esophageal varices severity, optimizing clinical decision-making and endoscopic screening in cirrhotic patients.

References

(1) de Franchis R, Bosch J, Garcia-Tsao G, Reiberger T, Ripoll C, Baveno VII Faculty. Baveno VII—Renewing consensus in portal hypertension. J Hepatol. 2022;76:959–974. doi: 10.1016/j.jhep.2021.12.022.
(2) Inoue-Yuri M, Enomoto H, Wakabayashi I, Yuri Y, Aizawa N, Ikeda N, Takashima T, Fujiwara A, Yoshioka R, Kawata S, Yoshihara K, Ota S, Nakano R, Shiomi H, Nishimura T, Nishiguchi S, Iijima H. Modification of the ALBI-PLT Score for the Prediction of High-risk Varices. In Vivo. 2022 May-Jun;36(3):1360-1366. doi: 10.21873/invivo.12839. PMID: 35478164; PMCID: PMC9087093.

Introduction

​​​​​PSC is chronic infammatory disease of bile ducts leading to strictures of bile duct and eventually to liver cirrhosis. Chronic inflammation is associated with markedly increased risk of cholangiocancer (CCA). In addition, gall bladder abnormalities are common in patients with PSC¹ such as cholecystitis, gallstones, polys and gallbladder carcinoma (GBCA). Increased fasting gallbladder volume has been reported with normal gallbladder emptying². Due to the increased risk of GBCA³ cholecystectomy is recommended in PSC with gallbladder polyps ≥8 mm and smaller polyps growing⁴. However, cholecystectomy has been associated with impaired PSC outcome. A study consisting of 11 PSC patients with cholecystectomy suggested protective role of gallbladder based on MRCP changes and elevated AST levels in patients with cholecystectomy. No significant difference in serum bile acids was observed in patients with or w/o cholecystectomy⁵. Another small study including five PSC patients with cholecystectomy showed that cholecystectomy was associated with worse Mayo scores and an elevated FIB4⁶. More than 50% of PSC have enlarged gallbladder which is suspected to be caused by hyperpressure in the biliary tract⁵. Cholecystectomy may thus eliminate this reserve function and lead to progression of bile duct strictures.

Aims & Methods

To evaluate the impact of cholecystectomy on liver enzyme levels, biliary bile acid composition, bile duct disease progression, and overall outcomes in a large PSC patient cohort, we analyzed data from 1,009 individuals enrolled in the prospective Helsinki PSC registry. Of these, 114 patients (11.3%) had undergone cholecystectomy—34 prior to and 80 following the PSC diagnosis. Patients with gallbladder cancer were excluded. Clinical and laboratory parameters were collected, along with data on disease progression based on sequential ERC examinations scored by the Helsinki ERC score⁷. Additionally, bile composition was analyzed in a subgroup of 157 patients receiving UDCA therapy, 32 of whom had undergone cholecystectomy.

Results

Demographics, liver function tests, and outcomes stratified by cholecystectomy, are presented in the table. We found no differences between the three groups (no cholecystectomy, cholecystectomy done prior or after PSC dg) regarding the progression of bile duct disease or its severity, liver function tests, development of biliary dysplasia or need for dilatation, Mayo- and MELD-scores. The cumulative incidence of the composite end point (= transplantation, liver related death, HCC or CCA) did not differ between groups. The molar-% of phospholipids were lower and cholic acid and deoxycholic acid (mg) elevated in bile in patients with cholecystectomy, whereas no differences were found in UDCA content.

Conclusion

In this large study investigating the impact of cholecystectomy on PSC outcomes, we found no effect on liver enzyme levels, prognostic indices, bile duct disease progression, or overall prognosis, regardless of whether the procedure was performed before or after the PSC diagnosis.

References

1. Said K, eta al. Journal of Hepatology 2008; 48:598–605
2. Said K, et al. World J Gastroenterol 2009; 15: 3498-3503
3. van Erp LW, et al. Liver Int 2020; 40:382–92.
4. Chazouilleres O et al. EASL Clinical Practice Guidelines on sclerosing cholangitis. J Hepatol 2022; 77:761–806
5. Cazzagon N, et al. JHEP Reports 2023. https://doi.org/10.1016/j.jhepr.2022.100649
6. Miyake N, et al. Cureus 17(3): e80184. DOI 10.7759/cureus.80184
7. Boyd S, et al. Endoscopy. 2016;48:432-9.