• Acute kidney injury is independently associated with death in patients with cirrhosis

      Scott, Robert; Austin, Andrew; Kolhe, Nitin; McIntyre, Christopher; Selby, Nicholas (2013-07)
      BACKGROUND AND AIMS: Current creatine-based criteria for defining acute kidney injury (AKI) are validated in general hospitalised patients but their application to cirrhotics (who are younger and have reduced muscle mass) is less certain. We aimed to evaluate current definitions of AKI (acute kidney injury network (AKIN) criteria) in a population of cirrhotic patients and correlate this with outcomes. METHODS: We prospectively identified patients with AKI and clinical, radiological or histological evidence of cirrhosis. We compared them with a control group with evidence of cirrhosis and no AKI. RESULTS: 162 cirrhotic patients were studied with a mean age of 56.8±14 years. They were predominantly male (65.4%) with alcoholic liver disease (78.4%). 110 patients had AKI: 44 stage 1, 32 stage 2 and 34 stage 3. They were well matched in age, sex and liver disease severity with 52 cirrhotics without AKI. AKI was associated with increased mortality (31.8% vs 3.8%, p<0.001). Mortality increased with each AKI stage; 3.8% in cirrhotics without AKI, 13.5% stage 1, 37.8% stage 2 and 43.2% stage 3 (p<0.001 for trend). Worsening liver disease (Child-Pugh class) correlated with increased mortality: 3.1% class A, 23.6% class B and 32.8% class C (p=0.006 for trend). AKI was associated with increased length of stay: median 6.0 days (IQR 4.0-8.75) versus 16.0 days (IQR 6.0-27.5), p<0.001. Multivariate analysis identified AKI and Child-Pugh classes B and C as independent factors associated with mortality. CONCLUSIONS: The utility of AKIN criteria is maintained in cirrhotic patients. Decompensated liver disease and AKI appear to be independent variables predicting death in cirrhotics.
    • Autoimmune pancreatitis presenting as a pancreatic mass mimicking malignancy

      Lo, Robert; Singh, Rajeev; Austin, Andrew; Freeman, Jan (2011-04)
      Autoimmune pancreatitis is a rare cause of chronic pancreatitis and pancreatic mass. We describe a case of focal autoimmune pancreatitis in a 51-year-old man presenting with obstructive jaundice and pancreatic mass, mimicking malignancy. The immunological test was suggestive of autoimmune pancreatitis, and the patient responded well to a course of steroids, with complete resolution of the pancreatic mass. Autoimmune pancreatitis, therefore, must be kept in mind as a differential diagnosis of pancreatic mass. Recognition of this disease by its typical radiological and serological findings may help to avoid unnecessary surgical resection.
    • Cholestasis and biliary dilatation associated with chronic ketamine abuse: a case series.

      Lo, Robert; Krishnamoorthy, R; Freeman, Jan; Austin, Andrew (2011-03)
      Ketamine is a dissociative anaesthetic agent that is still widely used in veterinary and human medicine. It is increasingly being used as a recreational hallucinogenic drug. Chronic ketamine abuse is known to account for lower urinary tract symptoms and urinary bladder dysfunction. There is now emerging evidence that ketamine misuse is also associated with abnormal liver function tests and biliary tract abnormality. We report three cases of chronic ketamine misuse in three young men who all presented with obstructive jaundice and biliary tract abnormality. We also describe the clinical features, radiological findings and potential underlying mechanisms for this new entity.
    • Evaluation of Liver Function Tests and Risk Score Assessment to Screen Patients for Significant Liver Disease Prior to Bariatric and Metabolic Surgery.

      Austin, Andrew; Awad, Sherif; Hughes, D (2020-03)
      Bariatric and metabolic surgery is associated with significant improvement in obesity-related comorbidities, but for patients with non-alcoholic fatty liver disease (NAFLD), clinical outcomes are dependent on the severity of liver disease, i.e. improvement of NAFLD in most patients but increased risks of fulminant hepatic failure and/or bleeding varices in patients with more advanced cirrhosis. Our study showed that absolute values of liver enzymes were poor indicator of risk of liver fibrosis. The use of AST/ALT ratio, Fib 4 or NAFLD scores were appropriate screening tools, with each risk score appearing to pick out a certain phenotype of patients based on age, BMI or individual values of ALT, AST or platelet count. There is lack of agreement in some cases between FIB-4 scores and NAFLD scores when ruling out patients at high risk of liver fibrosis. Meticulous screening of patients at risk of liver fibrosis is crucial in order to reduce the risk of liver-related complications following bariatric and metabolic surgery.
    • Experience in the use of self-expandable metal stents for the management of variceal haemorrhage

      Pick, Harry; Ososanya, A; Kayani, J; Austin, Andrew; Salmon, Claire; Taylor, Nick; Lawson, Adam (2015-06)
      Introduction Self-Expandable Metal Stents (SEMS) have been reported in small case series to be effective in controlling bleeding from oesophageal varices. A NICE technology appraisal published in 2008 (updated 2011) approved their use, providing arrangements were in place to audit practice. We describe our experience of SEMS in patients presenting with variceal haemorrhage. Method The Royal Derby Hospital has 24/7 provision of emergency endoscopy by a consultant gastroenterologist and TIPSS insertion available within normal working hours. A SEMS (SX- ELLA Danis) was inserted in 15 patients (M:F 12:3, mean age 56, range 29-73) presenting with variceal haemorhage between 2009 and 2014. All stents were inserted under endoscopic guidance. Portal hypertension was due to alcohol induced cirrhosis (n = 14) and Budd Chiari (n = 1). The median Child Pugh score was 11 (B=2/ C =13) and MELD 21 (range 12-35). All patients had band ligation therapy prior to SEMS insertion, with 6 patients having two attempts at endoscopic treatment and 8 patients having a Sengstaken-Blakemore Tube (SBT). The indication for SEMS insertion was ongoing variceal haemorrhage (n = 4), bleeding from band ligation ulceration (n = 7), a combination of the above (n = 2) or complication of SBT insertion (n = 2). SEMS was used as a bridge to TIPSS in 3 patients (though unsuccessful in 2), but TIPSS was felt to be contraindicated in 11 patients due to the severity of hepatic decompensation and in 1 patient due to portal vein thrombosis. Results SEMS insertion was successful and immediate haemostasis achieved in all 15 patients. One patient developed aspiration pneumonia, but patients were subsequently nursed at 45degree and received a prokinetic, without further incidence of aspiration. Stent migration into the stomach was observed in 3 patients, with partial slip across the gastro-oesophageal junction seen in a further 2 patients. The SEMS were removed from 9 patients after a median of 11 days (range 1-18) without complication. The remaining 6 patients died prior to removal. No patients had evidence of ongoing bleeding while SEMS in situ, but 33% had rebleeding within 30 days of removal. A median of 7 units of blood were transfused pre-SEMS insertion and 2 units post. Patient survival was 40% at 30 days and 27% at 1 year. Amongst survivors at 1 year the median Child Pugh/ MELD score at SEMS insertion was 8.5/ 14 compared to 11/ 24 in those who died. Conclusion Our experience shows that SEMS can be safely inserted and effectively achieve haemostasis in patients with refractory haemorrhage from oesophageal varices and in those with bleeding from band ligation induced ulceration. Patient survival was poor, however, due to the severity of hepatic decompensation in the study population.
    • In Patients With Severe Alcoholic Hepatitis, Prednisolone Increases Susceptibility to Infection and Infection-Related Mortality, and Is Associated With High Circulating Levels of Bacterial DNA.

      Austin, Andrew (2017-04)
      BACKGROUND & AIMS: Infections are common in patients with severe alcoholic hepatitis (SAH), but little information is available on how to predict their development or their effects on patients. Prednisolone is advocated for treatment of SAH, but can increase susceptibility to infection. We compared the effects of infection on clinical outcomes of patients treated with and without prednisolone, and identified risk factors for development of infection in SAH. METHODS: We analyzed data from 1092 patients enrolled in a double-blind placebo-controlled trial to evaluate the efficacy of treatment with prednisolone (40 mg daily) or pentoxifylline (400 mg 3 times each day) in patients with SAH. The 2 × 2 factorial design led to 547 patients receiving prednisolone; 546 were treated with pentoxifylline. The trial was conducted in the United Kingdom from January 2011 through February 2014. Data on development of infection were collected at evaluations performed at screening, baseline, weekly during admission, on discharge, and after 90 days. Patients were diagnosed with infection based on published clinical and microbiologic criteria. Risk factors for development of infection and effects on 90-day mortality were evaluated separately in patients treated with prednisolone (n = 547) and patients not treated with prednisolone (n = 545) using logistic regression. Pre treatment blood levels of bacterial DNA (bDNA) were measured in 731 patients. RESULTS: Of the 1092 patients in the study, 135 had an infection at baseline, 251developed infections during treatment, and 89 patients developed an infection after treatment. There was no association between pentoxifylline therapy and the risk of serious infection (P = .084), infection during treatment (P = .20), or infection after treatment (P = .27). Infections classified as serious were more frequent in patients treated with prednisolone (odds ratio [OR], 1.27; 95% confidence interval [CI], 1.27-2.92; P = .002). There was no association between prednisolone therapy and infection during treatment (OR, 1.04; 95% CI, 0.78-1.37; P = .80). However, a higher proportion (10%) of patients receiving prednisolone developed an infection after treatment than of patients not given prednisolone (6%) (OR, 1.70; 95% CI, 1.07-2.69; P = .024). Development of infection was associated with increased 90-day mortality in patients with SAH treated with prednisolone, independent of model for end-stage liver disease or Lille score (OR, 2.46; 95% CI, 1.41-4.30; P = .002). High circulating bDNA predicted infection that developed within 7 days of prednisolone therapy, independent of Model for End-Stage Liver Disease and white blood cell count (OR, 4.68; 95% CI, 1.80-12.17; P = .001). In patients who did not receive prednisolone, infection was not independently associated with 90-day mortality (OR, 0.94; 95% CI, 0.54-1.62; P = .82) or levels of bDNA (OR, 0.83; 95% CI, 0.39-1.75; P = .62). CONCLUSIONS: Patients with SAH given prednisolone are at greater risk for developing serious infections and infections after treatment than patients not given prednisolone, which may offset its therapeutic benefit. Level of circulating bDNA before treatment could identify patients at high risk of infection if given prednisolone; these data could be used to select therapies for patients with SAH. EudraCT no: 2009-013897-42; Current Controlled Trials no: ISRCTN88782125.
    • Introduction of Transjugular Intrahepatic Portosystemic Shunt (TIPSS) service for refractory ascites in a non-transplant liver unit

      Salmon, Claire; Austin, Andrew (2016)
      Introduction TIPSS has been shown to be an effective treatment for patients with refractory ascites (RA).The majority of TIPSS procedures in the UK are performed in a transplant centre. In 2009, Derby Teaching Hospitals introduced TIPSS service. The aim of our study was to evaluate our experience and assess its impact on the care of this patient group. Methods 56 successful TIPSS procedures were performed between May 2009 and August 2015, 32 for RA were included in this analysis.Data on patient demographics, aetiology of liver disease, inpatient bed days (6 months before and after the procedure), Model for End-Stage Liver Disease (MELD) scores, Child-Pugh score, procedure details, clinical outcomes, mortality and complications were collected retrospectively from our centres clinical results database.Complete response was defined as no further need for paracentesis and partial if frequency reduced to >50%. Results 25/32 (78%) patients were male with a median age of 58 years (range, 39-77 years). 30 patients were Child-Pugh class B, 2 Child-Pugh C, with a median MELD and MELD Na of 11 (range, 6-16) and 14 (range, 6-22) respectively. Alcoholic Liver Disease was most common aetiology of cirrhosis (86.5%) followed by non-alcoholic fatty liver disease (6.45%). Pre-TIPSS and post-TIPSS hepatic venous pressure gradients (HVPG) were 20 mmHg (range, 10-30) and 8 mmHg (range, 1-21) respectively. Cumulative mortality at 1, 3, and 12 months was 3%, 9%,and 18% (n = 28) respectively. One early death (within 30 days) was secondary to pneumonia. Ascites resolved completely after the first procedure in 66% and partially in 6% of patients.Cummulative response rate was 24, 62 and 90 percent at 30,60 and 90 days respectively. Five patients (16%) showed no improvement in RA, of whom 2 underwent liver transplantation. 9 patients (28%) developed hepatic encephalopathy (HE), 5 of whom (16%) developed refractory HE, with 3 patients requiring TIPSS reduction. The number of inpatient days reduced from 23 (range, 4-52) days in the 6 months pre-TIPSS to 8 (range 0-48) in the 6 months post TIPSS. The main reason for hospital admission was elective admission for ascites drainage. Conclusion A safe and effective TIPSS service for patients with refractory ascites can be successfully introduced into a comprehensive secondary care liver service by careful patient selection and technical proficiency. Excellent outcomes with acceptable complication rates can be achieved for patients with a significant reduction in resource utilisation (inpatient bed days and paracentesis). An established elective service is an important precursor for the provision of early and rescue TIPSS for variceal bleeding.
    • Is there a role for probiotics in liver disease?

      Lo, Robert; Austin, Andrew; Freeman, Jan (2014-11)
      Intestinal microbiota plays an important role in health and disease. Alteration in its healthy homeostasis may result in the development of numerous liver disorders including complications of liver cirrhosis. On the other hand, restoration and modulation of intestinal flora through the use of probiotics is potentially an emerging therapeutic strategy. There is mounting evidence that probiotics are effective in the treatment of covert and overt hepatic encephalopathy, as well as in the prevention of recurrence of encephalopathy. The beneficial effect of probiotics also extends to liver function in cirrhosis, nonalcoholic fatty liver disease, and alcoholic liver disease. On the other hand, data associating probiotics and portal hypertension is scanty and conflicting. Probiotic therapy has also not been shown to prevent primary or secondary spontaneous bacterial peritonitis. Larger clinical studies are required before probiotics can be recommended as a treatment modality in liver diseases.
    • Non-invasive Diagnosis of Oesophageal Varices Using Systemic Haemodynamic Measurements by Finometry: Comparison with Other Non-invasive Predictive Scores.

      Rye, Kara; Mortimore, Gerri; Austin, Andrew; Freeman, Jan (2016-09)
      BACKGROUND/AIMS: Cirrhosis and portal hypertension are characterised by a hyperdynamic circulation, which is independently associated with variceal size. Non-invasive techniques for measurement of systemic haemodynamics are now available. The aim of the study was to prospectively assess the accuracy of systemic haemodynamics measured non-invasively for the detection of oesophageal varices in cirrhotic patients as compared to other currently available non-invasive methods. METHODS: In a study of 29 cirrhotic patients, systemic haemodynamics were studied non-invasively using the Finometer(®) (mean arterial pressure (MAP), cardiac output (CO)/index, heart rate (HR), peripheral vascular resistance) and portal pressure was assessed by hepatic venous pressure gradient. Sensitivity, specificity, predictive values and area under the receiver operating characteristic (ROC) curves were assessed for predicting presence of varices and large oesophageal varices. Results were compared to child's classification, platelet/spleen ratio and ALT/AST ratios as predictors of the presence of large varices. RESULTS: Using finometry large oesophageal varices were correctly predicted in 83% of patients compared to other non-invasive techniques (range 66-76%). CONCLUSIONS: Non-invasive assessment of systemic haemodynamics using finometry could aid the identification of patients who do not immediately require variceal surveillance reducing the numbers of endoscopies and ensuring services are provided to those most likely to benefit.
    • Patients With Severe Alcoholic Hepatitis Given Prednisolone Therapy Who Have High Circulating Levels Of Bacterial DNA are at Increased Risk for Developing Infections.

      Austin, Andrew (2016-12)
      BACKGROUND & AIMS: Infections are common in patients with severe alcoholic hepatitis (SAH), but little information is available on how to predict their development or their effects on patients. Prednisolone is advocated for treatment of SAH, but may increase susceptibility to infection. We compared the effects of infection on clinical outcomes of patients treated with and without prednisolone, and identified risk factors for development of infection in SAH. METHODS: We analyzed data from 1092 patients enrolled in a double-blind placebo-controlled trial to evaluate the efficacy of treatment with prednisolone (40 mg daily) or pentoxifylline (400 mg 3 times each day) in patients with SAH. The 2-by-2 factorial design led to 547 patients receiving prednisolone; 546 were treated with penotxifylline. The trial was conducted in the United Kingdom from January 2011 through February 2014. Data on development of infection were collected at evaluations performed at screening, baseline, weekly during admission, on discharge, and after 90 days. Patients were diagnosed with infection based on published clinical and microbiologic criteria. Risk factors for development of infection and effects on 90-day mortality were evaluated separately in patients treated with prednisolone (n=547) and patients not treated with prednisolone (n=545) using logistic regression. Pre-treatment blood levels of bacterial DNA (bDNA) were measured in 731 patients. RESULTS: Of the 1092 patients in the study, 135 had an infection at baseline, 251 developed infections during treatment, and 89 patients developed an infection after treatment. There was no association between pentoxifylline therapy and the risk of serious infection (P=.084), infection during treatment (P=.20), or infection after treatment (P=.27). Infections classified as serious were more frequent in patients treated with prednisolone (odds ratio [OR], 1.27; 95% CI,1.27-2.92; P=.002). There was no association between prednisolone therapy and infection during treatment (OR, 1.04; 95% CI, 0.78-1.37; P=.80). However, a higher proportion of patients receiving prednisolone developed an infection after treatment (10%) than of patients not given prednisolone (6%) (OR, 1.70; 95% CI, 1.07-2.69; P=.024). Development of infection was associated with increased 90-day mortality in patients with SAH treated with prednisolone, independent of model for end-stage liver disease or Lille score (OR, 2.46; 95% CI, 1.41-4.30; P=.002). High circulating bDNA predicted infection that developed within 7 days of prednisolone therapy, independent of MELD and white blood cell count (OR, 4.68; 95% CI, 1.80-12.17; P=.001). In patients who did not receive prednisolone, infection was not independently associated with 90-day mortality (OR, 0.94; 95% CI, 0.54-1.62; P=.82) or levels of bDNA (OR, 0.83; 95% CI, 0.39-1.75; P=.62). CONCLUSIONS: Patients with SAH given prednisolone are at greater risk for developing serious infections and infections after treatment than patients not given prednisolone, which may offset its therapeutic benefit. Level of circulating bDNA before treatment could identify patients at high risk of infection if given prednisolone; these data could be used to select therapies for patients with SAH. EudraCT no: 2009-013897-42; current controlled trials no: ISRCTN88782125.
    • Prednisolone or pentoxifylline for alcoholic hepatitis

      Austin, Andrew (2015-04)
      Background: Alcoholic hepatitis is a clinical syndrome characterized by jaundice and liver impairment that occurs in patients with a history of heavy and prolonged alcohol use. The short-term mortality among patients with severe disease exceeds 30%. Prednisolone and pentoxifylline are both recommended for the treatment of severe alcoholic hepatitis, but uncertainty about their benefit persists. Methods: We conducted a multicenter, double-blind, randomized trial with a 2-by-2 factorial design to evaluate the effect of treatment with prednisolone or pentoxifylline. The primary end point was mortality at 28 days. Secondary end points included death or liver transplantation at 90 days and at 1 year. Patients with a clinical diagnosis of alcoholic hepatitis and severe disease were randomly assigned to one of four groups: a group that received a pentoxifylline-matched placebo and a prednisolone-matched placebo, a group that received prednisolone and a pentoxifylline-matched placebo, a group that received pentoxifylline and a prednisolone-matched placebo, or a group that received both prednisolone and pentoxifylline. Results: A total of 1103 patients underwent randomization, and data from 1053 were available for the primary end-point analysis. Mortality at 28 days was 17% (45 of 269 patients) in the placebo–placebo group, 14% (38 of 266 patients) in the prednisolone–placebo group, 19% (50 of 258 patients) in the pentoxifylline–placebo group, and 13% (35 of 260 patients) in the prednisolone–pentoxifylline group. The odds ratio for 28-day mortality with pentoxifylline was 1.07 (95% confidence interval [CI], 0.77 to 1.49; P = 0.69), and that with prednisolone was 0.72 (95% CI, 0.52 to 1.01; P = 0.06). At 90 days and at 1 year, there were no significant between-group differences. Serious infections occurred in 13% of the patients treated with prednisolone versus 7% of those who did not receive prednisolone (P = 0.002). Conclusions: Pentoxifylline did not improve survival in patients with alcoholic hepatitis. Prednisolone was associated with a reduction in 28-day mortality that did not reach significance and with no improvement in outcomes at 90 days or 1 year.
    • Response to the NCEPOD report: development of a care bundle for patients admitted with decompensated cirrhosis-the first 24 h.

      Austin, Andrew (2016-01)
      Recently, there has been a significant increase in the prevalence of chronic liver disease in the UK, and as a result, hospital admissions and deaths due to liver disease have also increased. The 2013 National Confidential Enquiry into Patient Outcome and Death (NCEPOD) of patients with alcohol-related liver disease (ARLD) found that less than half the number of patients who died from ARLD received 'good care', and avoidable deaths were identified. In order to improve the care of patients admitted with ARLD, the NCEPOD report recommended that a 'toolkit' for the acute management of patients admitted with decompensated ARLD be developed and made widely available. As a result, we have developed a 'care bundle' for patients admitted with decompensated cirrhosis (of all aetiologies) to ensure that effective evidence-based treatments are delivered within the first 24 h. This care bundle provides a checklist to ensure that all appropriate investigations are undertaken when a patient with decompensated cirrhosis presents and provides clinicians with clear guidance on the initial management of alcohol withdrawal, infection, acute kidney injury, gastrointestinal bleeding and encephalopathy. The first 24 h are particularly important, as early intervention can reduce mortality and shorten hospital stay, and specialist gastroenterology/liver advice is not always available during this period. This review will discuss the care bundle and the evidence base behind the treatment recommendations made.
    • Service provision for liver disease in the UK: a national questionnaire-based survey.

      Scott, Robert; Williams, M; Austin, Andrew; Freeman, Jan (2012-04)
      The National Plan for Liver Services in 2009 called for a review of current liver services across the UK to identify areas of good and poor provision. We present the results of a national questionnaire survey of liver services, which focussed on staffing and training, access to key facilities and clinical management of liver disease. Areas of good practice include the increased proportion of consultants who trained at a liver centre, the introduction of specific liver clinics and the widespread use of terlipressin and antibiotics for variceal bleeding. Areas of poor practice include limited access to alcohol psychiatry services and transjugular intrahepatic portosystemic shunts (TIPS) and limited recording of outcome measures or patient databases. Wide variation in the clinical management of serious liver diseases supports the need for managed clinical networks. These results will help to guide the development of standards of care for liver services across the UK.
    • Towards noninvasive detection of oesophageal varices.

      Rye, Kara; Scott, Robert; Mortimore, Gerri; Austin, Andrew; Freeman, Jan (2012)
      Current guidelines recommend that all cirrhotic patients should undergo screening endoscopy at diagnosis to identify patients with varices at high risk of bleeding who will benefit from primary prophylaxis. This approach places a heavy burden upon endoscopy units and the repeated testing over time may have a detrimental effect on patient compliance. Noninvasive identification of patients at highest risk for oesophageal varices would limit investigation to those most likely to benefit. Upper GI endoscopy is deemed to be the gold standard against which all other tests are compared, but is not without its limitations. Multiple studies have been performed assessing clinical signs and variables relating to liver function, variables relating to liver fibrosis, and also to portal hypertension and hypersplenism. Whilst some tests are clearly preferable to patients, none appear to be as accurate as upper GI endoscopy in the diagnosis of oesophageal varices. The search for noninvasive tests continues.
    • Trends in variceal bleeding: A single centre experience from 2006-2013

      Grant, C; Kemp, D; Austin, Andrew (2014-06)
      Introduction Over the last decade, the numbers of patients presenting with chronic liver disease has risen. During this period the approach to the treatment of variceal bleeding has undergone important changes both internationally (adoption of early TIPSS in high risk cases), and locally with the development of a 24 h endoscopy service (2006), movement to single site hospital with enlarged intensive care capacity (2009), adoption of the DanisTM stent (2009) and a shift to carvedilol as the primary agent for prophylaxis (2013). We reviewed all episodes of variceal bleeding in the last 8 years to describe patient outcomes. Methods All episodes of bleeding from oesophageal varices managed in the Liver Unit at Royal Derby Hospital from 2005 to mid 2013 were identified from clinical coding data - population served approx. 650,000. A retrospective review of the patient records identified the aetiology and severity of liver disease, morbidity, mortality, endoscopy findings and episodes of rebleeding. Results Each year between 17 and 31 patients presented with variceal bleeding. 5 day mortality fluctuated between 3-22% whereas 30 day mortality fell steadily from a peak in 2006 of 41% to 5% in 2012 (Figure 1). The reduction in mortality was in Child's B/C cirrhosis. Interestingly, the proportion of episodes in Child's A cirrhosis increased from 2009 onwards (7% of all bleeding episodes in 2009 to above 30% in 2013). 30 day mortality rates for Child's A did not improve but remained lower than for those with Child's B/C cirrhosis (mean 9.8% compared to 22.8% (2009-2013)). From 2007, there was a fall in frequency of rebleeding from 35% to below 10% in 2013. Only 3 high risk patients underwent an early TIPSS procedure, all after 2012. (Figure presented) Conclusion Variceal bleeding rates have remained surprisingly constant over 8 years despite the rise in admissions with chronic liver disease. Outcomes for acute variceal bleeding have improved which is likely the result of several organisational changes. Notably, rebleeding rates and 30 day mortality decreased even before the adoption of early TIPSS.
    • U.K. guidelines on the management of variceal haemorrhage in cirrhotic patients.

      Austin, Andrew (2015-11)
      These updated guidelines on the management of variceal haemorrhage have been commissioned by the Clinical Services and Standards Committee (CSSC) of the British Society of Gastroenterology (BSG) under the auspices of the liver section of the BSG. The original guidelines which this document supersedes were written in 2000 and have undergone extensive revision by 13 members of the Guidelines Development Group (GDG). The GDG comprises elected members of the BSG liver section, representation from British Association for the Study of the Liver (BASL) and Liver QuEST, a nursing representative and a patient representative. The quality of evidence and grading of recommendations was appraised using the AGREE II tool.The nature of variceal haemorrhage in cirrhotic patients with its complex range of complications makes rigid guidelines inappropriate. These guidelines deal specifically with the management of varices in patients with cirrhosis under the following subheadings: (1) primary prophylaxis; (2) acute variceal haemorrhage; (3) secondary prophylaxis of variceal haemorrhage; and (4) gastric varices. They are not designed to deal with (1) the management of the underlying liver disease; (2) the management of variceal haemorrhage in children; or (3) variceal haemorrhage from other aetiological conditions.