On call gastroenterology: Bloating, bleeds and batteries RCP Update in medicine – Loughborough 8 February 2018 Peter Wurm Consultant Gastroenterologist University Hospitals of Leicester

Seasonal gastroenterology

Awwooooooooooooooooo Awwooooooooooooooooo! Gavin Francis, London Review of Books 39; 21: 21-22 ‘1995 US study found that 40 per cent of the general public were convinced the moon had an influence on the mind; an earlier survey put the rate for mental health professionals at 74 per cent’ ‘A German study from 2000 recorded a rise in binge-drinking ‘during the five-day full moon cycle’. Another, of inmates at a jail in Leeds in 1998, noticed a rise in violent incidents around the full moon.’

“An endoscopy is the most important intervention in the management of upper gastro-intestinal bleeding”

Out of hour gastroenterology at University Hospitals Leicester Ramiah R, Wurm P Provision of an out-of-hours emergency endoscopy service: the Leicester experience Frontline Gastroenterology 2013;4:288-295

Does urgent endoscopy actually make a difference?

There is very limited evidence that OOH endoscopy for non-variceal bleeding patients improves mortality Asia- Pacific Working Group consensus on non-variceal upper gastrointestinal bleeding. Sung JJ et al; Asia-Pacific Working Group. Gut. 2011 Sep;60(9):1170-7 Relationship between timing of endoscopy and mortality in patients with peptic ulcer bleeding: a nationwide cohort study [Denmark]. Laursen SB, Leontiadis GI et al. gastrointestinal Endosc 2017 85(5): 936- 944 In haemodynamically unstable patients timing of endoscopy appears to lower in hospital mortality [6-24 hours after presentation]

UHL: Dr Foster audit 2015 Review of 34/39 patients 1/4/14-31/3/15 RIP with admission diagnosis upper GI haemorrhage 5 miscoded- rectal bleed, AAA, SB obstruction 12 advanced dementia, disseminated cancer- kept comfortable without endoscopic intervention 8 bleed (had endoscopy)- died of MOF and complications of decompensated LD 6 catastrophic bleeds, cardiac arrest, not fit for further intervention [1 SUI] 3 bleeds (had endoscopy)- died of complications later- stroke, IHD, pneumonia [3 oncology notes missing]

Why? Inadequately resuscitated patients Making stable situations worse Most ulcers heal spontaneously Stress of procedure Most patients die of other pathology

NCEPOD: Time to get control 2015 Recommendation 6: the ongoing management of care for patients with major bleeds should rest with, and be directed by the named consultant responsible for GI bleeds….. Recommendation 8: … all patients with a GI bleed and haemodynamic instability should have 24.7 access to an OGD within 2 hours of optimal resuscitation

NICE QS 38: Acute upper GI bleeding in adults. July 2013 Statement 2. People with severe acute upper gastrointestinal bleeding who are haemodynamically unstable are given an endoscopy within 2 hours of optimal resuscitation. Statement 3. People admitted to hospital with acute upper gastrointestinal bleeding who are haemodynamically stable are given an endoscopy within 24 hours of admission

Special considerations New antiplatelets and anticoagulants Patients post cardiac events- restart as soon as safe. Mehran R, Baber U, Steg PG, et al.  Cessation of dual antiplatelet treatment and cardiac events after percutaneous coronary intervention (PARIS): 2 year results from a prospective observational study. Lancet 2013;382:1714–22 End of life pathway, advanced directives and palliative care Uncooperative patient

Recommendations Discuss at a senior level Stabilise non-variceal bleeds Tube catastrophic variceal bleeds Manage critical bleeds in controlled setting with surgical cover and /or angiographic back up