Background & aims: Current estimates of the prevalence of iron deficiency anaemia (IDA) in patients with chronic intestinal failure (CIF) exceed those seen in general population, however, the studies to-date are limited. The aim of this study was to determine the point prevalence of IDA in a large cohort of stable home parenteral nutrition (HPN) dependent adults managed by a specialist Intestinal Failure Unit. Methods: This was a retrospective cohort study of HPN-dependent adults managed by a national UK IF Reference Centre between 01/01/2019 and 31/12/2019. Patients with IDA were followed up until death or the end of the follow-up on 01/05/2024. Results: 241 patients were included in the analysis. 27/241 (11.2 %) were diagnosed with IDA. Previous hypoferritinaemia, previous IDA and not receiving the recommended amount of iron via parenteral nutrition as per ESPEN guidelines were associated with higher likelihood of IDA diagnosis. Only 2/27 patients with IDA at inclusion fulfilled IDA criteria by the end of the follow up. Long-term outcomes in the patient cohort with IDA were good with no patients displaying evidence of malignancy until the end of the study period. Conclusion: Our study shows that while IDA is common in patients with CIF, its clinical implications may differ from those in the general non-IF population. Further larger collaborative multi-centre research is necessary to confirm these findings with a view to develop evidence-based guidelines for the investigation of IDA in CIF. (c) 2025 Published by Elsevier Ltd on behalf of European Society for Clinical Nutrition and Metabolism.

Background Irritable bowel syndrome (IBS) is a common and debilitating disorder manifesting with abdominal pain and bowel dysfunction. A mainstay of treatment is dietary modification, fi cation, including restriction of FODMAPs (fermentable oligosaccharides, disaccharides, monosaccharides and polyols). A greater response to a low FODMAP diet has been reported in those with a distinct IBS microbiome termed IBS-P. We investigated whether this is linked to specific fi c changes in the metabolome in IBS-P. Methods Solid phase microextraction gas chromatography-mass spectrometry was used to examine the faecal headspace of 56 IBS cases (each paired with a non-IBS household control) at baseline, and after four-weeks of a low FODMAP diet (39 pairs). 50% cases had the IBS-P microbial subtype, while the others had a microbiome that more resembled healthy controls (termed IBS-H). Clinical response to restriction of FODMAPs was measured with the IBS-symptom severity scale, from which a pain sub score was calculated. Findings Two distinct metabotypes were identified fi ed and mapped onto the microbial subtypes. IBS-P was characterised by a fermentative metabolic profile fi le rich in short chain fatty acids (SCFAs). After FODMAP restriction significant fi cant reductions in SCFAs were observed in IBS-P. SCFA levels did not change significantly fi cantly in the IBS-H group. The magnitude of pain and overall symptom improvement were significantly fi cantly greater in IBS-P compared to IBS-H (p p = 0.016 and p = 0.026, respectively). Using just fi ve metabolites, a biomarker model could predict microbial subtype with accuracy (AUROC 0.797, sensitivity 78.6% (95% CI: 0.78-0.94), - 0.94), specificity fi city 71.4% (95% CI: 0.55-0.88). - 0.88). Interpretation A metabotype high in SCFAs can be manipulated by restricting fermentable carbohydrate, and is associated with an enhanced clinical response to this dietary restriction. This implies that SCFAs harbour pronociceptive potential when produced in a specific fi c IBS niche. By ascertaining metabotype, microbial subtype can be predicted with accuracy. This could allow targeted FODMAP restriction in those seemingly primed to respond best. Funding This research was co-funded by Addenbrooke's ' s Charitable Trust, Cambridge University Hospitals and the Wellcome Sanger Institute, and supported by the NIHR Cambridge Biomedical Research Centre (BRC-1215-20014). Copyright (c) 2024 The Author(s). Published by Elsevier B.V. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

Background & aims: The low-FODMAP diet (LFD) has become almost synonymous with IBS care, yet the challenges associated with this rigorous therapeutic approach are often underacknowledged. Despite positive outcomes in RCTs, comparator groups frequently exhibit substantial response rates, raising questions about the de finition of 'response'. Whilst the assessment of response in drug trials has evolved to utilize the more stringent FDA/EMA primary clinical endpoints, trials of the LFD have not yet followed. The aim of this article is to opine whether the current approach to the measurement of clinical response to the LFD in clinical trials should be reconsidered. Methods: A comprehensive literature review of LFD clinical trials from the past decade was conducted, focusing on recorded response metrics for primary clinical endpoints. Results: While response de finitions vary, the 50-point IBS-SSS delta emerged as the predominant metric. Notably, no trials to date have adopted the more stringent primary clinical endpoints used in drug trials. Other response measures included binary response metrics (such as 'adequate clinical response'), changes in visual analogue scales or stool form/output, reductions in abdominal pain, as well as changes the magnitude of the IBS-SSS delta. Whether these metrics correspond to a clinically meaningful improvement for the patient is less clear, and as such aligning patient-clinician expectations can be challenging. Conclusions: A paradigm shift in the conceptualization of 'response' coupled with an emphasis on harder clinical endpoints in the context of clinical trials may serve to better justify the trade-off between symptom-improvement and the inherent challenges associated with this burdensome therapeutic approach. (c) 2024 The Authors. Published by Elsevier Ltd.

BACKGROUND Fungal related catheter related blood stream infection (CRBSI) is less frequent than those induced by bacteria. In the past, a single episode of fungal CRBSI has been used as a marker of home parenteral nutrition (HPN) failure and thus a possible indication for intestinal transplantation (ITx). MATERIALS AND METHODS Survival outcomes were assessed from a prospectively maintained database of patients initiated on HPN for underlying chronic intestinal failure between 1993 and 2018, with a censoring date of 31st December 2020. Cox regression was performed to assess predictors of mortality with univariable and multivariable analysis. RESULTS A total of 1008 patients were included in the study, with a total of 1,364,595 catheter days. There were 513 CRBSI events recorded in 262 patients, equating to a CRBSI rate of 0.38 /1000 catheter days. 38/262 (14.5%) patients had at least one episode of fungal CRBSI, while 216/262 (82.4%) had at least one bacterial but no fungal CRBSI. The median time between HPN initiation and the first CRBSI episode was 20.6 months (95% CI 16.5 - 24.1). Episodes of fungal or bacterial CRBSI and the number of CRBSI episodes were not associated with increased mortality. Overall, 15 CRBSI-related deaths were observed in the observation period (0.01 CRBSI deaths /1000 catheter days), two of these were fungal in origin. CONCLUSION The occurrence of a fungal CRBSI does not increase the risk of death compared to patients who have bacterial CRBSI or those without a CRBSI event. This article is protected by copyright. All rights reserved.

Introduction Intestinal failure (IF) is an uncommon complication of Crohn's disease (CD). The aim of this study was to describe the use of prophylactic medical treatment and identify factors predicting the recurrence of CD in patients with IF (CD-IF), while also investigating their long-term outcomes and IF-related complications. Methods This was a cohort study of adult patients with CD-IF admitted to a national UK IF reference centre between 2000 and 2021. Patients were followed from first discharge with home parenteral nutrition (HPN) until death or follow-up end on 28.02.2021. Data included clinical characteristics, details of medical therapies and long-term outcomes. Results 124 patients were included, 47 (37.9%) of whom had changed the location and 55/124 (44.4%) had changed the behaviour of their CD between the time of CD diagnosis and CD-IF diagnosis, with a significant increase in upper GI involvement (4.0% vs 22.6% patients) between these times, p<0.001. 29/124 (23.4%) patients were initiated on a prophylactic medical therapy for CD following IF diagnosis; 18 (62.1%) of whom had a history of stricturing or penetrating small bowel disease and 9 (31.0%) of whom had ileocolonic phenotype brought back into continuity. The cumulative incidence of disease recurrence was 2.4% at 1 year, 16.3% at 5 years and 27.2% at 10 years. Presence of colon-in-continuity and prophylactic treatment were associated with an increased likelihood of disease recurrence. 45/124 (36.9%) patients ceased HPN. The rate of catheter-related bloodstream infections (CRBSI) was 0.32 episodes per 1,000 catheter days, with no association between medical therapy and CRBSI rate with IRR of 0.63 (95% CI 0.26 to 1.35, p = 0.27) for immunomodulator and 0.49 (95% CI 0.19 to 1.12, p = 0.12) for biologic use. By the censoring date, 33 out of 124 (26.6%) patients had died. 2 (6.1%) deaths were due to IF-associated liver disease. Underlying disease accounted for 9 (27.3%) deaths and 16 (48.5%) deaths were non-HPN/non-IF related. Conclusions This is the largest series reporting disease activity and long-terms outcomes in patients with CD-IF and the first study to explore the use of prophylactic therapies in this patient cohort. The incidence of disease recurrence was low and the immunosuppressive therapy did not increase the risk of CRBSI. Management of patients with CD-IF needs to be tailored to the individual, with consideration of disease phenotype and careful selection of medical treatments aimed at improving long-term outcomes.

IntroductionPregnancy in patients with chronic intestinal failure (CIF) is a relatively rare occurrence but is an important contemporary topic given both the increasing use of home parenteral nutrition (HPN) and the demographics of patients with CIF. MethodAn opinion-based survey was produced in a multidisciplinary manner, which was then distributed internationally, via the European Society for Clinical Nutrition and Metabolism network, using a web-based survey tool for healthcare professionals with a specialist interest in the management of CIF. ResultsSeventy specialists from 11 countries completed the survey. Fifty-four per cent of the respondents reported some experience of managing pregnancy in patients with CIF. However, 60% stated that they did not feel that it was their role to discuss the topic of pregnancy with their patients, with fewer than 10% stating that they routinely did so. Respondents felt that an individualised approach was required when considering alterations to parenteral support prior to conception, during pregnancy and in the postnatal period. Most respondents also felt there was no increased risk of catheter-related blood stream infections, while catheter-related thrombosis was deemed to be the most significant HPN-related complication for pregnant women. ConclusionThis study reports a variable experience, knowledge and confidence of healthcare professionals when considering pregnancy in patients with CIF. The risk of HPN-related complication was felt to be greater during pregnancy, with an individualised approach being the preferred route for most aspects of care. The findings support the need for an international registry and subsequent consensus guidelines for the management of pregnancy in CIF.

Following ileal resection, the combination of severe bile acid (BA) malabsorption, rapid small bowel transit and unrestricted upper gastrointestinal (GI) secretion results in severe diarrhoea that can prove refractory to pharmacological therapies. While established therapies, including BA sequestrants and antidiarrhoeal drugs seek to ameliorate symptoms, they do not target the underlying pathophysiological mechanisms in this patient group. Their use can also be limited by both intolerance and adverse effects. The novel use of glucagon-like peptide-1 (GLP-1) receptor agonists (RAs) in these patients may allow restoration of the physiological negative feedback mechanisms lost in ileal resection and reduce diarrhoea by prolonging small bowel transit time, limiting upper GI secretions and perhaps by inhibiting hepatic BA synthesis. While recent evidence supports the use of GLP-1 RAs as a safe and effective therapy for bile acid diarrhoea (BAD), it remains uncertain whether those with severe BAD and subsequent short bowel syndrome secondary to extensive ileal resection will benefit. Here, we present three cases of severe diarrhoea secondary to extensive ileal resection in which the use of the GLP-1 RA, liraglutide, was well tolerated and resulted in an objective improvement in diarrhoeal symptoms. We further provide a narrative review of the emerging evidence base supporting the use of GLP therapies in this challenging condition.

Background and Aims Intestinal failure [IF] is a recognised complication of Crohn's disease [CD]. The aim of this study was to identify factors predicting the development and recurrence of CD in patients with IF [CD-IF], and their long-term outcomes. Methods This was a cohort study of adults with CD-IF admitted to a national UK IF reference centre between 2000 and 2021. Patients were followed from discharge with home parenteral nutrition [HPN] until death or February 28, 2021. Results In all, 124 patients were included; 47 [37.9%] changed disease location and 55 [44.4%] changed disease behaviour between CD and CD-IF diagnosis, with increased upper gastrointestinal involvement [4.0% vs 22.6% patients], p <0.001. Following IF diagnosis, 29/124 [23.4%] patients commenced CD prophylactic medical therapy; 18 [62.1%] had a history of stricturing or penetrating small bowel disease; and nine [31.0%] had ileocolonic phenotype brought back into continuity. The cumulative incidence of disease recurrence was 2.4% at 1 year, 16.3% at 5 years and 27.2% at 10 years; colon-in-continuity and prophylactic treatment were associated with an increased likelihood of disease recurrence. Catheter-related bloodstream infection [CRBSI] rate was 0.32 episodes/1000 catheter days, with no association between medical therapy and CRBSI rate. Conclusions This is the largest series reporting disease behaviour and long-term outcomes in CD-IF and the first describing prophylactic therapy use. The incidence of disease recurrence was low. Immunosuppressive therapy appears to be safe in HPN-dependent patients with no increased risk of CRBSI. The management of CD-IF needs to be tailored to the patient's surgical disease history alongside disease phenotype.

SummaryBackgroundThe COVID‐19 pandemic offered a unique opportunity to understand inflammatory bowel disease (IBD) management during unexpected disruption. This could help to guide practice overall.AimsTo compare prescribing behaviour for IBD flares and outcomes during the early pandemic with pre‐pandemic findingsMethodsWe performed an observational cohort study comprising patients who contacted IBD teams for symptomatic flares between March and June 2020 in 60 National Health Service trusts in the United Kingdom. Data were compared with a pre‐pandemic cohort after propensity‐matching for age and physician global assessment of disease activity.ResultsWe included 1864 patients in each of the pandemic and pre‐pandemic cohorts. The principal findings were reduced systemic corticosteroid prescription during the pandemic in Crohn's disease (prednisolone: pandemic 26.5% vs. 37.1%; p < 0.001) and ulcerative colitis (UC) (prednisolone: pandemic 33.5% vs. 40.7%, p < 0.001), with increases in poorly bioavailable oral corticosteroids in Crohn's (pandemic 15.6% vs. 6.8%; p < 0.001) and UC (pandemic 11.8% vs. 5.2%; p < 0.001). Ustekinumab (Crohn's and UC) and vedolizumab (UC) treatment also significantly increased. Three‐month steroid‐free remission in each period was similar in Crohn's (pandemic 28.4% vs. 32.1%; p = 0.17) and UC (pandemic 36.4% vs. 40.2%; p = 0.095). Patients experiencing a flare and suspected COVID‐19 were more likely to have moderately‐to‐severely active disease at 3 months than those with a flare alone.ConclusionsDespite treatment adaptations during the pandemic, steroid‐free outcomes were comparable with pre‐pandemic levels, although concurrent flare and suspected COVID‐19 caused worse outcomes. These findings have implications for IBD management during future pandemics and for standard practice.

Objective Anti-tumour necrosis factor (TNF) agents are associated with increased infection risk among elderly IBD patients, but little is known about non anti-TNF biologics in this cohort. We examined the safety and effectiveness of ustekinumab in elderly Crohn’s patients. Methods This retrospective multi-centre cohort study included Crohn’s patients ≥60-years old who commenced ustekinumab. We recorded Harvey-Bradshaw index (HBI), concomitant steroid therapy, treatment persistence and new infections or malignancies. Primary outcome was serious infections requiring hospitalisation. Results Seventy patients were included, with median age of 68 years. 43 (61.4%) had prior anti-TNF exposure, and 15 (21.4%) vedolizumab. Median treatment duration was 12 months, totalling 84 patient-years. Nine serious infections were reported, incidence 106.7/1000 patient-years. Systemic steroids were associated with increased risk of serious infections [odds ratio (OR) 7.83, 95% confidence interval (CI): 1.44–44.32, P = 0.02]. There were 27 “non-serious” infections; 321.4/1000 patient-years. Charlson co-morbidity index (OR 1.49, 95% CI: 1.05–2.12, P = 0.03) and steroid exposure (OR 44.10, 95% CI: 1.75–1112.10, P = 0.02) increased non-serious infection risk ( P < 0.05). Mean HBI improved from 8.13 to 4.64 at 6 months and 4.10 at last follow up ( P < 0.0001). 12-month treatment persistence was 55.7% ( N = 39); 34 (48.6%) were steroid-free. Conclusion Ustekinumab was safe and effective in a cohort of elderly Crohn’s disease patients. Infections were mostly mild, not resulting in therapy discontinuation. Serious infection risk was comparable to previously reported rates with anti-TNF agents. Steroid exposure was associated with an increased serious infection risk.

Introduction Catheter-related bloodstream infections (CRBSIs) remain the commonest complication associated with home parenteral nutrition (HPN). Although the management outcomes of CRBSIs have been extensively reported by specialized intestinal failure (IF) centers, there are minimal data reporting CRBSI outcomes for HPN-dependent patients admitted to nonspecialized hospitals. Method This was an observational study from a prospectively maintained database of CRBSIs in HPN-dependent patients managed outside of a specialized IF center. Results Three hundred and six patients from a total cohort of 1066 HPN-dependent patients suffered from 489 CRBSI events from 2003 to 2021; after 2017, 71 of these events were managed at the patient's local, nonspecialized hospital and the remainder at the specialized IF center. From 2017 to 2021, salvage of the central venous catheter (CVC) with antimicrobial therapy was attempted in 32 out of 71 (45.1%) patients admitted to the nonspecialized hospital, with successful salvage recorded in 23 (71.8%) cases. Notably, CVC salvage was attempted more commonly (77 out of 103 [74.8%]; P = 0.004 vs nonspecialized hospital), with a better salvage success rate (64 out of 77 [83.1%] P = 0.01 vs nonspecialized hospital) in patients who were admitted to the specialized IF center. Conclusion In some instances, CRBSIs can be effectively managed when patients presenting to a nonspecialized hospital; however, overall salvage is more likely to be successful in the specialized setting. Further development of clinical and educational networks between IF centers and patients' local hospitals aimed at standardizing care may lead to improved CRBSI outcomes.

A 56-year-old man presented with a change in bowel habit to seven loose non-bloody stools a day. He had previously had a sigmoid resection for an endoscopic diagnosis of colonic malignancy in 2015. Histology of the resection specimen, however, had only shown inflammatory polyps, attributed to the accompanying diverticular disease. His current colonoscopy showed two malignant looking lesions in the descending colon (figure 1) and the hepatic flexure (figure 2) with multiple additional sub-5 mm polyps in the ascending colon (figure 3). The intervening colonic mucosa was inflamed with appearances suggesting ulcerative colitis. A CT scan showed a 12 cm segment of thickening at the hepatic flexure. Mucosal biopsies showed chronic active inflammation in the intervening mucosa in keeping with ulcerative colitis but there was …

Abstract Background The COVID-19 pandemic continues to pose complex problems across Europe and the world, with rising numbers of infections and the ongoing need for drastic public health interventions. This is difficult for patients with immune-mediated disorders like Inflammatory Bowel Disease (IBD), where immunosuppressive medications may affect susceptibility to serious infection. It was particularly challenging for physicians and patients during the first wave of the pandemic, when it was unclear whether anti-inflammatory flare treatment should be adapted to reduce infection risk, whilst trying to ensure symptomatic control and avoid admission to overwhelmed hospitals. Despite the development of various IBD / COVID-19 databases, the treatment adaptations and outcomes of patients experiencing IBD flares during the COVID-19 pandemic remain undefined. We aimed to compare IBD management and outcomes between pandemic and pre-pandemic cohorts. Methods An observational cohort study was performed, comprising patients who contacted IBD teams for a symptom flare between March – June, 2020 in, 60 National Health Service trusts in the United Kingdom. Data were compared to a pre-pandemic cohort after propensity-matching for age and disease severity. Statistical analyses were performed using R (version, 4.1.0, Vienna, Austria). Results In total, 3728 patients in the pandemic (n=1864) and pre-pandemic (n=1864) cohorts were included. The principal findings were reduced systemic corticosteroid prescription during the pandemic in both Crohn’s disease (prednisolone: pandemic, 199/752, 26.5% vs, 263/708, 37.1%; p<0.001) and ulcerative colitis (UC) (prednisolone: pandemic, 372/1112, 33.5% vs, 470/1156, 40.7%, p<0.001), with increases in poorly bioavailable oral corticosteroids in Crohn’s (pandemic, 117/752, 15.6% vs, 48/708, 6.8%; p<0.001) and UC (pandemic, 131/1112, 11.8% vs, 60/1156, 5.2%; p<0.001). Ustekinumab (Crohn’s and UC) and vedolizumab (UC) treatment also significantly increased during the pandemic. Three-month steroid-free remission was similar in both Crohn’s (pandemic, 175/616, 28.4% vs, 195/608, 32.1%; p=0.17) and UC (pandemic, 312/858, 36.4% vs, 404/1006, 40.2%; p=0.095). The, 65 patients experiencing a flare and COVID-19 were more likely to have moderate-to-severely active disease at three months compared to those with a flare alone. Conclusion Despite several treatment adaptations during the pandemic, steroid-free outcomes were comparable to pre-pandemic levels, though patients with a flare and COVID-19 experienced worse outcomes. These findings have implications for IBD management during future waves or pandemics

Introduction Acute severe ulcerative colitis (ASUC) traditionally requires inpatient hospital management for intravenous therapies and/or colectomy. Ambulatory ASUC care has not yet been evaluated in large cohorts. Aims We used data from PROTECT, a UK multicentre observational COVID-19 inflammatory bowel disease study, to report the extent, safety and effectiveness of ASUC ambulatory pathways. Methods Adults (≥18 years old) meeting Truelove and Witts criteria between 1 January 2019–1 June 2019 and 1 March 2020–30 June 2020 were recruited to PROTECT. We used demographic, disease phenotype, treatment outcomes and 3-month follow-up data. Primary outcome was rate of colectomy during the index ASUC episode. Secondary outcomes included corticosteroid response, time to and rate of rescue or primary induction therapy, response to rescue or primary induction therapy, time to colectomy, mortality, duration of inpatient treatment and hospital readmission and colectomy within 3 months of index flare. We compared outcomes in three cohorts: (1) patients treated entirely in inpatient setting; ambulatory patients subdivided into; (2) patients managed as ambulatory from diagnosis and (3) patients hospitalised and subsequently discharged to ambulatory care for continued intravenous steroids. Results 37% (22/60) participating hospitals used ambulatory pathways. Of 764 eligible patients, 695 (91%) patients received entirely inpatient care, 15 (2%) patients were managed as ambulatory from diagnosis and 54 (7%) patients were discharged to ambulatory pathways. Aside from younger age in patients treated as ambulatory from diagnosis, no significant differences in disease or patient phenotype were observed. The rate of colectomy (15.0% (104/695) vs 13.3% (2/15) vs 13.0% (7/54), respectively, p=0.96) and secondary outcomes were similar among all three cohorts. Stool culture and flexible sigmoidoscopy were less frequently performed in ambulatory cohorts. Forty per cent of patients treated as ambulatory from diagnosis required subsequent hospital admission. Conclusions In a post hoc analysis of one of the largest ASUC cohorts collected to date, we report an emerging UK ambulatory practice which challenges treatment paradigms. However, our analysis remains underpowered to detect key outcome measures and further studies exploring clinical and cost-effectiveness as well as patient and physician acceptability are needed. Trial registration number NCT04411784.

Introduction Many patients presenting to hospital with lower gastrointestinal bleeding (LGIB) are elderly and co-morbid. British Society of Gastroenterology (BSG) guidelines recommend LGI endoscopy for all patients admitted with LGIB. As the majority of LGIB ceases spontaneously and risks of endoscopy increase with patient age, a ‘watch and wait’ management approach may be appropriate for older patients. Methods Patients aged ≥75 years presenting with LGIB to seven hospital trusts from June 1st– September 1st 2019 were included. Data on presentation, management and outcomes were recorded, then compared to current BSG guidelines. Results 127 patients were included. 47% were male with a mean age 84 (range 75-96), 73.2% of patients had ≥2 listed co-morbidities. Mean Shock Index (SI) on presentation was 0.69, with a SI >1 being rare (7.0%) and reduced to 2.4% following resuscitation. Of stable patients (SI<1), 94.3% were classified as having a major bleed (Oakland Score >8). 96.1% of presenting patients were admitted, while 3.9% were discharged from A&E. 80% of these discharged patients had an Oakland Score >8. 21 (17.2%) of admitted patients received an inpatient lower GI endoscopy; 19% of which received endoscopic therapy. The most commonly identified cause of LGIB was diverticulosis (23.8%). Overall, 82.8% of admitted patients received no inpatient lower GI endoscopy and were managed conservatively. Comparing those who underwent LGI endoscopy versus a watch and wait approach, there was no difference in inpatient mortality (0% vs 4%, p=1.0) or 30-day re-admission rate (9.5% vs 22.8%, p= 0.24). However, undergoing inpatient LGI endoscopy was associated with greater median length of stay (8 days vs 3 days, p=0.0002) Conclusions Age and co-morbidities complicate risk stratification in the elderly as many will score highly regardless of bleed severity, limiting the role of the Oakland Score. Endoscopic assessment of all elderly patients presenting with LGIB is not performed in real world practice, may not be necessary or even appropriate. Although not in keeping with current guidelines, this watch and wait approach does not appear to be associated with adverse outcomes in the elderly.