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.