Summary Background In developed countries, hepatitis E is a porcine zoonosis caused by hepatitis E virus ( HEV ) genotype 3. In developing countries, hepatitis E is mainly caused by genotype 1, and causes increased mortality in patients with pre‐existing chronic liver disease ( CLD ). Aim To determine the role of HEV in patients with decompensated CLD . Methods Prospective HEV testing of 343 patients with decompensated CLD at three UK centres and Toulouse France, with follow‐up for 6 months or death. IgG seroprevalence was compared with 911 controls. Results 11/343 patients (3.2%) had acute hepatitis E infection, and three died. There were no differences in mortality (27% vs. 26%, OR 1.1, 95% CI 0.28–4.1), age ( P = 0.9), bilirubin ( P = 0.5), alanine aminotransferase ( P = 0.06) albumin ( P = 0.5) or international normalised ratio ( P = 0.6) in patients with and without hepatitis E infection. Five cases were polymerase chain reaction ( PCR ) positive (genotype 3). Hepatitis E was more common in Toulouse (7.9%) compared to the UK cohort (1.2%, P = 0.003). HEV IgG seroprevalence was higher in Toulouse ( OR 17, 95% CI 9.2–30) and Truro ( OR 2.5, 95% CI 1.4–4.6) than in Glasgow, but lower in cases, compared to controls ( OR 0.59, 95% CI 0.41–0.86). Conclusions Hepatitis E occurs in a minority of patients with decompensated chronic liver disease . The mortality is no different to the mortality in patients without hepatitis E infection. The diagnosis can only be established by a combination of serology and PCR , the yield and utility of which vary by geographical location.

Background Forty percent of patients with autoimmune hepatitis (AIH) present with acute jaundice/hepatitis. Such patients, when treated promptly, are thought to have a good prognosis. Objectives The objective of this study was to describe the natural history of AIH in patients presenting with jaundice/hepatitis and to determine whether the diagnosis could have been made earlier, before presentation. Methods This study is a retrospective review of 2249 consecutive patients who presented with jaundice to the Jaundice Hotline clinic, Truro, Cornwall, UK, over 15 years (1998–2013) and includes a review of the laboratory data over a 23-year period (1990–2013). Results Of the 955 patients with hepatocellular jaundice, 47 (5%) had criterion-referenced AIH: 35 female and 12 male, the median age was 65 years (range 15–91 years); the bilirubin concentration was 139 &mgr;mol/l (range 23–634 &mgr;mol/l) and the alanine transaminase level was 687 IU/l (range 22–2519 IU/l). Among the patients, 23/46 (50%) were cirrhotic on biopsy; 11/47 (23%) died: median time from diagnosis to death, 5 months (range 1–59); median age, 72 years (range 59–91 years). All 8/11 patients who died of liver-related causes were cirrhotic. Weight loss (P=0.04) and presence of cirrhosis (P=0.004) and varices (P=0.015) were more common among those who died. Among patients who died from liver-related causes, 6/8 (75%) died less than 6 months from diagnosis. Cirrhosis at presentation and oesophageal varices were associated with early liver-related deaths (P=0.011, 0.002 respectively). Liver function test results were available in 33/47 (70%) patients before presentation. Among these patients, 16 (49%) had abnormal alanine transaminase levels previously, and eight (50%) were cirrhotic at presentation. Conclusion AIH presenting as jaundice/hepatitis was mainly observed in older women: 50% of the patients were cirrhotic, and liver-related mortality was high. Some of these deaths were potentially preventable by earlier diagnosis, as the patients had abnormal liver function test results previously, which had not been investigated.

Background Acute upper gastrointestinal haemorrhage is a common medical emergency, initially managed with inpatient care. Bleeding stops spontaneously in over 80% of cases, indicating that patients with low-risk upper gastrointestinal haemorrhage may be more optimally managed in the community, without the need for admission to hospital. Aim To assess the safety of managing patients with low-risk upper gastrointestinal haemorrhage without admission to hospital. Methods Prospective/retrospective study of all patients presenting to a UK teaching hospital with low-risk upper gastrointestinal haemorrhage who were managed without admission to hospital over 5 years. Low risk was defined as Glasgow Blatchford Score of 2 or less, age below 70 years, no other active medical problems, not taking warfarin and suspected nonvariceal bleed. Outcome measures were the need for intervention (blood transfusion, endoscopic therapy or surgery) and death. Results One hundred and forty-two patients fulfilled the inclusion criteria, and were managed without admission to hospital. No patients required endoscopic intervention, blood transfusion or surgery. The 28-day mortality was nil. Forty-one patients had normal endoscopic examination and 11 had significant endoscopic findings (peptic ulceration=10, oozing Mallory–Weiss tear=1) but did not require intervention. Conclusion Patients presenting with a primary upper gastrointestinal haemorrhage aged below 70 years with a Glasgow Blatchford Score of 2 or less are at a low risk, and can be safely managed in the community.

Introduction Acute upper gastrointestinal haemorrhage is a common medical emergency, initially managed with in-patient care. Bleeding stops spontaneously in over 80% of cases indicating patients with low-risk upper gastrointestinal haemorrhage may be more optimally managed in the community, without the need for admission to hospital. We have previously shown that using the Glasgow Blatchford Score (GBS) is an accurate method of identifying low risk cases.1 2 Aims To assess the safety of managing patients with low risk upper gastrointestinal haemorrhage without admission to hospital. Methods Prospective/retrospective study of all patients presenting to a UK teaching hospital with low risk upper gastrointestinal haemorrhage who were managed without admission to hospital over 5 years. Low risk was defined as: GBS ≤2, age <70 years, no other active medical problems, not taking warfarin, suspected non-variceal bleed. Outcome measures were the need for intervention (blood transfusion, endoscopic therapy or surgery) and death. Results 142 patients fulfilled the inclusion criteria, and were managed without admission to hospital. Upper GI endoscopy was preformed at a median of 1 day (range 0–18 days). No patients required endoscopic intervention, blood transfusion or surgery. The 28-day mortality was nil. 41 patients had a normal endoscopy. 11 had significant endoscopic findings (peptic ulceration =10, oozing Mallory Weiss tear =1) but did not require intervention. Significant endoscopic findings were unrelated to age (p=0.547), and four patients <30 years had significant findings (peptic ulceration n=3, Mallory Weiss tear n=1). Conclusion Patients presenting with a primary upper gastrointestinal haemorrhage aged <70 years with a GBS of ≤2 are at low risk, and can be safely managed in the community. All such patients should have an upper GI endoscopy. The findings in this paper were presented to the NHS Innovation Challenge Prize Final, London, 29th September 2011. Competing interests None declared. References 1. Stanley AJ, et al. Lancet 2009;373:42–7. 2. Stephens J. Eur J Gastro Hepatol 2009;21:1340–6.