Aims Acute upper gastrointestinal bleeding (AUGIB) is a common medical emergency. We present the findings on endoscopic management of AUGIB patients in the UK.

Introduction: The last UK-wide audit of the management of acute upper gastrointestinal bleeding (AUGIB) was conducted in 2007. Re-evaluation of current practice is needed, because since then, there have been several initiatives to improve the management of AUGIB including new guidelines, innovative endoscopic therapy, service delivery improvements and expansion of endoscopy provision. Methods and analysis: Consecutive, unselected presentations with AUGIB across all UK NHS hospitals were prospectively enrolled over a 2-month period between May and July 2022. Data will be collected on patient characteristics, comorbidities, use of anticoagulant drugs, transfusion, timing and type of diagnostic and therapeutic procedure, length of stay and mortality. Clinical practice will be audited against predefined minimum standards of care for AUGIB and compared to the results of the 2007 UK-wide audit. Data will be collected on the availability and organisation of care as well as the provision of training for specialist registrars in endoscopic management of AUGIB.Ethics and dissemination: This audit will be conducted as part of the National Comparative Audit of Blood Transfusion through collaboration with specialists in gastroenterology, haematology, surgery, and interventional radiology. Individual site reports will be provided alongside a UK-wide report disseminated through specialist societies and publications in peer-reviewed journals. The study has been funded by National Health Services Blood and Transplant and the British Society of Gastroenterology and endorsed by the Royal Colleges of Physicians, the British Association for the Study of the Liver, the Association of Upper GI Surgeons, and the British Society of Interventional Radiology.

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. 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. Conclusions 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. Reference Hearnshaw, et al. Gut 2011.

Introduction Acute upper gastrointestinal bleeding (AUGIB) is a common medical emergency. We compare the characteristics and management of variceal vs non-variceal causes of AUGIB in the 2022 UK audit. 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 In this interim analysis, endoscopy was performed for 2315 of the first 2881 patients and a cause identified in 1542. Those identified with varices (14%, 212/1542) were younger than those with non-variceal AUGIB (median age 57 vs 70 yr, respectively). For varices, sites included:87%(185/212) oesophageal;18%(38/212) gastric;3%(7/212) duodenal. 43%(92/212) were on non-selective beta-blocker prophylaxis on admission;32%(68/212) had a history of previous AUGIB and 24%(50/212) were on a variceal band ligation programme. 69%(147/212) had stigmata of recent bleeding;75%(160/212) received endotherapy:62%(132/212) had variceal therapy (banding – 124, glue or thrombin injection – 11) and 6%(12/212) required a Sengstaken tube. 4%(8/212) underwent TIPSS and 58%(123/212) were discharged on a non-selective beta-blocker. For those with non-variceal causes, findings included:58%(777/1330) peptic ulcer disease;26%(353/1330) oesophagitis;5%(69/1330) portal hypertensive gastropathy;7%(96/1330) malignancy and 28%(369/1330) others. 38%(506/1330) had stigmata of recent bleeding;34%(447/1330) received endotherapy:13%(176/1330) had a single modality and 20%(271/1330) ≥1 modality. Different modalities included:23%(105/447) thermal device;60%(270/447) adrenaline injection;48%(215/447) haemostatic clips;24%(109/447) haemostatic powders or gel;14%(64/447) argon plasma coagulation and 8%(37/447) others. Outcomes for patients with variceal vs non-variceal cause of bleeding are shown (table 1). Conclusions Patients with variceal bleeding were younger, with higher therapeutic and transfusion requirements, re-bleeding rates and length of stay. Mortality was not significantly different to non-variceal bleeding.

Introduction Initiatives to improve the management of acute upper gastrointestinal bleeding (AUGIB) include service delivery improvements and expansion of endoscopy provision. We report the organisational capabilities of UK hospitals in management of AUGIB from the 2022 national audit. Methods An electronic questionnaire on the availability and organisation of care in management of AUGIB was sent to sites enrolled for the UK 2022 AUGIB audit. Results Data on the first 81/158 participating hospitals are reported in this interim analysis. Annual case load of AUGIB patients: <100 (12%,n=10); 100–200 (35%,n=28); 201–300 (18%,n=15);>300 (35%,n=28). 93%(n=75) had high dependency unit/level 2 care; 95%(n=77) intensive therapy unit/level 3 care; 57%(n=46) a lead clinician responsible for pathways and governance of GI bleeding. All hospitals but one had an endoscopy unit on site. 26%(n=21) had provision for 7 days protected endoscopy slots; 84%(n=68) for weekday emergency slots; 42%(n=34) had weekend slots, with all offering Saturday slots and 62%(21/34) Sunday slots. 85%(n=69) had access to interventional radiology (24/7 on site access for 36%,n=29; on site access for transjugular intrahepatic portosystemic shunt for 22%,n=18); 95%(n=77) to emergency surgery; and 97%(n=79) had a transfusion lab on site. 79%(n=64) had a written policy on AUGIB management – separate variceal and non-variceal for 67%(43/64); transfusion management for 94%(60/64), but 11%(7/64) still included use of tranexamic acid. 38%(n=31) routinely used an AUGIB care bundle. AUGIB audit was carried out by 93%(n=75), with 83%(62/75) within the last 1 year. Out of hours (OOH) endoscopy was offered by 90%(n=73) with 95%(69/73) having a formal OOH endoscopy rota. There were a total of 725 endoscopists on OOH rota across the included hospitals (median 10, IQR 7–12 per site). Comparisons with the 2007 audit are shown (table 1). Conclusions There is improvement in OOH endoscopy rota and staffing provisions compared to 2007. Weekend list availability, use of AUGIB care bundles and written policies merit improvement.

Introduction Biologic treatment has been associated with 5-fold increased risk of tuberculosis (TB). Latent TB infection (LTBI) screening should be performed on all inflammatory bowel disease (IBD) patients prior to initiating biologic treatment. We analysed cases of active TB after receiving biologic treatment in IBD patients. Methods All TB patients were identified from Leicester, Leicestershire and Rutland (LLR) TB database case notification between January 2007 to July 2022. All IBD patients who received biologic treatment during this time period were identified from the University Hospitals of Leicester high-cost funding pharmacy database. Those who developed active TB while on biologic treatment were identified after data matching. Clinical and electronic notes were reviewed. LTBI biologic screening utilises full history, CXR, QuantiFERON or T-spot TB assay since 2007 and Mantoux testing in selected cases prior to that. Results During this 15-year period, 3089 cases of TB notifications were recorded in the LLR TB database. 1508 IBD patients were treated with biologics during the study period, and of those, 6 (3 Crohn's Disease and 3 Ulcerative Colitis) (0.4%) subsequently developed active TB after the biologic treatment. Four were male and the age range was 27–45 years. Four were Caucasian of UK origin, the other 2 were from Slovakia and India. BCG vaccination status was only known for 2 out of 6 (1 vaccinated). Four had negative QuantiFERON assays on biologic screening. One case was started on biologic treatment in the private sector and screening information was limited. One was treated prior to the availability of IGRA assays. All patients had a normal CXR prior to anti-TNF and none of them had received LTBI treatment. Three patients each were on Adalimumab or Infliximab at the time of TB diagnosis. Time from initiation of anti-TNF to TB diagnosis ranged from 3 to 108 months. All active cases had fully sensitive culture confirmed TB. The disease site was pulmonary in 4 cases and miliary in 2 cases. Two of the pulmonary cases had pericardial or peritoneal involvement, respectively. TB treatment duration was between 6–12 months depending on the site and severity of TB. Conclusion The overall incidence of active TB was low and the majority of the identified 6 cases were considered low epidemiological risk for LTBI. None had abnormal chest imaging and of those tested, none had a positive QuantiFERON assay before the start of the anti-TNF treatment. It is unknown if the cases represented de novo infection or reactivation of remotely acquired LTBI. Re-screening may have informed opportunities for prevention treatment. Ongoing surveillance for LTBI is imperative in biologic treated IBD patients, particularly following travel to endemic countries, high-risk exposures and in the context of drug therapy escalation. Active collaboration with the TB service, especially for those requiring urgent immunosuppression, is of critical value for comprehensive care.