Background and study aims Mallory Weiss tears (MWTs) are relatively uncommon causes of upper gastrointestinal bleeding (UGIB), and patients are generally considered at low risk of poor outcome, although data are limited. There is uncertainty about use of endoscopic therapy. We aimed to describe and compare an international cohort of patients presenting with UGIB secondary to MWT and peptic ulcer bleeding (PUB). Patients and methods From an international dataset of patients undergoing endoscopy for acute UGIB at seven hospitals, we assessed patients with MWT bleeding, including the endoscopic stigmata and endoscopic therapy applied. We compared baseline parameters, rebleeding rate, and 30-day mortality between patients with MWT and PUB. Results A total of 3648 patients presented with UGIB, 125 of whom (3.4 %) had bleeding from a MWT. Those patients were younger (61 vs 69 years, P < 0.0001) and more likely to be men (66 % vs 53 %, P = 0.006) compared to the patients PUB. The most common endoscopic stigmata seen in MWTs were oozing blood (26 %) or clean base (26 %). Of the patients with MWT, 53 (42 %) received endoscopic therapy. Forty-eight of them (90 %) had epinephrine injections and 25 (48 %) had through-the-scope clips. The rebleeding rate was lower in MWT patients compared with PUB patients (4.9 % vs 12 %, P = 0.016), but mortality was similar (5.7 vs 7.0 %, P = 0.71). Conclusions Although patients presenting with MWT were younger, with a lower rebleeding rate, their mortality was similar to that of patients with PUB. Endoscopic therapy was applied to 42 % MWT patients, with epinephrine injection as the most common modality.

is but there are few high-level recommendations on when not to biopsy. Taking a biopsy cost of £103 a potential of £ 10330 could have been saved during our study period. Findings from our study mandate development of such guidance, by training of all endoscopists UK-wide audit of local to ensure compliance with guidelines.

Aims Mallory Weiss tears (MWT) are relatively uncommon causes of upper GI bleeding (UGIB). Patients with these lesions are generally considered at low risk of poor outcome, although data are relatively limited. There is also uncertainty about which patients with MWT require endoscopic therapy and which modality should be applied. We aimed to describe an international cohort of patients presenting with UGIB secondary to MWT.

Introduction Renal failure is associated with poorer outcome following upper gastrointestinal haemorrhage (UGIH) and is a parameter in some pre-endoscopy risk stratification scores which can be used to identify low-risk patients who may avoid admission. We studied the outcome of patients admitted with UGIH in relation to their renal function and risk stratification scores. Methods Prospectively collected data from a 1-year international multi-centre study of consecutive patients presenting with UGIH. Demographics, endoscopic findings, treatment and outcomes were recorded. eGFR was determined retrospectively from admission creatinine. If eGFR was <60 ml/minute, it was recorded whether this was acute kidney injury (AKI) or chronic kidney disease (CKD) by review of electronic patient notes. Glasgow Blatchford (GBS), admission Rockall (aRS), AIMS65 and PNED scores were determined. Need for endoscopic therapy, transfusion, surgery, rebleeding >7days and 30-day mortality rates were recorded. Results Mains findings are shown in table 1 as median or percentage except where indicated. Conclusions Patients admitted with UGIH and renal impairment are older and more likely to be female, than those with normal renal function. Transfusion requirements, need for endoscopic therapy, rebleed rate and mortality (bleed and non-bleed related) and are all increased in this group. GBS identifies low risk patients with AKI or CKD with high sensitivity, although few low risk patients are in this group. No other commonly used pre-endoscopy risk score is accurate in identifying low-risk patients with renal impairment.

Introduction Mallory Weiss tears (MWT) are relatively uncommon causes of upper GI bleeding (UGIB) and patients with these lesions are generally considered at low risk of poor outcome. However there are relatively limited data on this condition. In addition, there is uncertainty about which patients with MWT require endoscopic therapy and which modality should be applied. We aimed to describe an international cohort of patients presenting with UGIB secondary to MWT, including the endoscopic therapy undertaken. We also compared clinical outcomes between patients with MWT and other causes of UGIB. Methods From an international dataset of consecutive patients undergoing endoscopy for acute UGIB at six hospitals in UK, Denmark, USA, Singapore and New Zealand, we assessed those patients with MWT bleeding, including the estimated Forrest classification and endoscopic therapy applied. We also compared baseline factors, rebleeding rates and 30 day mortality between patients with MWT, peptic ulcer bleeding (PUB) and all cause UGIB. Results Patients with MWT bleeding were younger, with higher baseline pulse and Hb compared to those with PUB and all cause UGIB. Although the rebleeding rate was lower in MWT patients compared with PUB patients, mortality was similar (table 1). Most MWT lesions were Forrest 1a or 3 at endoscopy (table 2). 42 (43%) MWT patients received endotherapy. 38 (90%) had adrenaline injection, 21 (50%) clips, and 5 (12%) thermal probe applied. 22 (52%) treated patients had combination therapy. Overall rebleeding rate for MWT patients was 4.1% (1.8% in those not treated and 7.1% in those treated with endotherapy). Conclusions Although patients presenting with MWT were younger, with lower rebleeding rate compared with PUB, their mortality was similar to that of patients with PUB and all cause UGIB. Endoscopic therapy was applied to 43% MWT patients, with adrenaline injection, followed by clips, the most common modalities employed.

Background: Upper gastrointestinal haemorrhage (UGIH) is a common cause of hospital admission.The Glasgow Blatchford score (GBS) accurately identifies patients' risk of requiring hospital-based intervention or death.Patients with GBS of zero are at very low risk of poor outcome and could have out-patient management.Some authors suggest extending the definition of low-risk patients using a higher GBS cut-off value, possibly with an age adjustment.We compared three thresholds of the GBS and two age adjusted modifications to identify the optimal cut-off value or modification and assessed variation of performance across sites.Methods: Data were collected from consecutive patients presenting with UGIH at four centres in Scotland, England, Denmark, and New Zealand.The performance of each version was evaluated using sensitivity, specificity, proportion of identified low-risk patients, and outcome in patients classified as low-risk.Findings: 2305 patients were included.There were differences in age (p=0.0001),need for intervention (p<0.0001),mortality (p<0.015), and GBS (p=0.0001) between sites.The GBS at cut-off ≤1 and ≤2, and both modifications, had higher specificities (40-49%) than the GBS at cut-off zero (specificity 22%; p<0.001).The GBS at cut-off ≤2 had the highest specificity but 3% of classified low-risk patients developed adverse outcomes.There were no differences between the GBS at cut-off 0, ≤1, and the age-adjusted versions with respect to proportion of classified low-risk patients developing adverse outcomes.All scores had low specificity when used in New Zealand (2.5-11%).Interpretation: The GBS at cut-off ≤1, and the age-extended versions, are useful for clinical use and identify almost twice as many low-risk patients as the GBS at cut-off zero.By implementation of a protocol for non-admission of UGIH-patients based on one of these scores we expect that 15-20% of all admissions can be avoided safely.Further studies evaluating these scores outside Europe are needed.

BACKGROUND & AIMS: Upper gastrointestinal hemorrhage (UGIH) is a common cause of hospital admission. The Glasgow Blatchford score (GBS) is an accurate determinant of patients' risk for hospital-based intervention or death. Patients with a GBS of 0 are at low risk for poor outcome and could be managed as outpatients. Some investigators therefore have proposed extending the definition of low-risk patients by using a higher GBS cut-off value, possibly with an age adjustment. We compared 3 thresholds of the GBS and 2 age-adjusted modifications to identify the optimal cutoff value or modification.METHODS: We performed an observational study of 2305 consecutive patients presenting with UGIH at 4 centers (Scotland, England, Denmark, and New Zealand). The performance of each threshold and modification was evaluated based on sensitivity and specificity analyses, the proportion of low-risk patients identified, and outcomes of patients classified as low risk.RESULTS: There were differences in age (P = .0001), need for intervention (P < .0001), mortality (P < .015), and GBS (P = . 0001) among sites. All systems identified low-risk patients with high levels of sensitivity (>97%). The GBS at cut-off values of <= 1 and <= 2, and both modifications, identified low-risk patients with higher levels of specificity (40%-49%) than the GBS with a cut-off value of 0 (22% specificity; P < .001). The GBS at a cut-off value of <= 2 had the highest specificity, but 3% of patients classified as low-risk patients had adverse outcomes. All GBS cut-off values, and score modifications, had low levels of specificity when tested in New Zealand (2.5%-11%).CONCLUSIONS: A GBS cut-off value of <= 1 and both GBS modifications identify almost twice as many low-risk patients with UGIH as a GBS at a cut-off value of 0. Implementing a protocol for outpatient management, based on one of these scores, could reduce hospital admissions by 15% to 20%.

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.

Introduction In developed countries autochthonous hepatitis E infection is caused by hepatitis E virus (HEV) genotype 3 or 4 and mainly affects middle aged/elderly men. Host factors might explain why older men develop clinically overt disease. Methods Retrospective review of 53 patients with symptomatic autochthonous hepatitis E infection to determine putative host risk factors. Patients were compared with 564 controls with adjustment for age and sex. Anti-HEV seroprevalence was determined in controls and 189 patients with chronic liver disease. Results Mean age of the patients was 62.4 years, 73.6% were men. Compared with controls, patients with hepatitis E were more likely to drink at least 22 U alcohol/week (OR=9.4; 95% confidence interval=3.8–25.0; P<0.001). The seroprevalence of anti-HEV IgG in controls increased with age (P<0.001) but was similar in men and women. There was no association between alcohol consumption and anti-HEV IgG seroprevalence in the control group. There was no difference in the anti-HEV IgG seroprevalence between the controls and patients with chronic liver disease of all aetiologies, but seroprevalence was higher in controls (13.8%) than patients with alcoholic liver disease (4.8%, P=0.04). Conclusion Clinically apparent hepatitis E infection is more common in individuals who consume at least 22 U alcohol/week. Patients with established chronic alcoholic liver disease have a low seroprevalence compared with controls. The reason for this observation is uncertain, but patients with alcoholic liver disease have clinically severe disease with a high mortality when exposed to HEV. The low seroprevalence in this group may represent a 'culled' population.

Background The Glasgow Blatchford Score (GBS) is a validated risk assessment tool in primary upper gastrointestinal haemorrhage, which accurately predicts the need for intervention (endoscopic therapy, blood transfusion or surgery) or death. Aims To identify the GBS that predicts lack of intervention or death and to apply this to clinical practice by managing low-risk patients in the community. Methods GBSs prospectively calculated on 232 patients with upper gastrointestinal haemorrhage to identify low-risk score. Patients with low-risk of requiring intervention (GBS ≤2, age <70 years) from a further 304 patients were considered for management in the community. Results Fifty-two of 232 patients in the first cohort had a GBS ≤2 and were aged less than 70 years: none of these required intervention or died. In the second cohort 104 of 304 (34.2%) patients had a GBS ≤2 and were aged less than 70 years, none of whom died or required endoscopic therapy, blood transfusion, surgery or died. Thrity-two of 104 (10.5% of total cohort) were safely managed in the community. Conclusion Using the criteria of a GBS ≤2, aged less than 70 years to define patients at ‘low risk’ allows 10.5% of patients with primary upper gastrointestinal haemorrhage to be safely managed in the community.