Management Of Variceal Bleeding Research Articles

AASLD Practice Guidance on the use of TIPS, variceal embolization, and retrograde transvenous obliteration in the management of variceal hemorrhage.

AASLD Practice Guidance on the use of TIPS, variceal embolization, and retrograde transvenous obliteration in the management of variceal hemorrhage.

Comprehensive treatment of patients with gastric variceal bleeding

Gastro-oesophageal varices are the major clinical manifestations of cirrhosis and portal hypertension. Bleeding from gastric varices is usually severe and is associated with higher mortality and a higher risk of rebleeding than from esophageal varices. The management of variceal bleeding is complex, often requiring a multidisciplinary approach involving pharmacological, endoscopic, and radiological interventions. In terms of treatment, three stages can be considered: primary prophylaxis, active bleeding, and secondary prophylaxis. The main goal of primary and secondary prophylaxis is to prevent variceal bleeding. However, active variceal bleeding is a medical emergency that requires prompt intervention to stop it and achieve long-term hemostasis. This review describes the features of pharmacological, endoscopic and interventional radiological prophylactic and treatment options in gastric variceal bleeding. We searched the literature in the MedLine database on the PubMed platform.

EGS P12 An audit of local management of upper gastrointestinal bleeds in a UK district general hospital

Abstract Background Acute upper gastrointestinal bleed (AUGIB) is associated with a 10% in-patient mortality and this outcome has not significantly improved over the past 50 years (1). The UK's National Institute for Health and Care Excellence (NICE) has developed guidance for the management of patients presenting with AUGIB, which highlights several priorities that should be addressed such as: a) risk assessment using the Blatchford and Rockall scores, b) the optimal timing of endoscopy, c) management of non-variceal bleeds (NVB's), d) management of variceal bleeds (VB's), and e) guidance on controlling bleeding and preventing re-bleeding in patients on non-steroidal anti-inflammatory drugs, aspirin or clopidogrel (1). Methods This study aimed to assess the compliance of AUGIB management in a district general hospital against the NICE quality standards. In the first cycle, we retrospectively reviewed case notes from 52 patients who presented with AUGIB and were admitted between September 1 and December 31, 2019. A re-audit was performed between December 1, 2020 to March 31, 2021 where we reviewed the case notes of 22 patients. We allowed for a 1-year interval between the first and second cycle where we educated doctors about the NICE quality standards of AUGIB management. The primary outcome of the study was the compliance of local management of AUGIB in a district hospital compared to NICE quality standards. Results Intervention indications in the first cycle were: haematemesis in 26.9% (14/52); melaena in 50% (26/52); both haematemesis and melaena in 23.1% (12/52). Indications in the second cycle were haematemesis in 64% (14/22); melaena in 18% (4/22); both haematemesis and melaena in 8% (4/22). Compliance with discontinuing aspirin during AUGIB was 60% (3/5) in the first cycle, and 80% (4/5) in the second. Blatchford risk score was used in 12.5% (5/40) in the first cycle, and 50% (11/22) in the second. Among haemodynamically unstable patients, endoscopy was performed immediately after resuscitation in 100% in both the first (4/4) and second (3/3) cycles. Among haemodynamically stable patients, 91.4% (32/35) had endoscopy <24 hours in the first cycle, and 53% (10/19) in the second. For NVB's, proton pump inhibitors were used in 74.4% (29/39) in the first cycle and 77% (17/22) in the second. For NVB endoscopy, there was 100% compliance in using clips with/without adrenaline in both cycles. Dual therapy with thermal coagulation and adrenaline was performed in 100% (1/1) of patients in the first cycle, and none in the second. For VB's, 100% of patients in the first (4/4) and second (5/5) cycle were given terlipressin, antibiotics, and band ligation. Conclusions In our district hospital, pre-endoscopic management of AUGIB such as PPI use, and time to endoscopy were adequate, but did not fully meet the quality standards stipulated by NICE. Endoscopic management for AUGIB, however, was fully compliant with NICE standards.

Salvage transjugular intrahepatic portosystemic shunt in patients with cirrhosis and refractory variceal bleeding: Asystematic review with meta-analysis.

BackgroundTransjugular intrahepatic portosystemic shunt (TIPS) may be used as a salvage treatment in patients with cirrhosis and refractory variceal bleeding.AimTo synthesize the available evidence on the efficacy of TIPS in patients with cirrhosis and refractory variceal bleeding.MethodsMeta‐analysis of trials evaluating TIPS in patients with cirrhosis and refractory variceal bleeding, including subgroup analysis to assess the impact of recent changes in the management of variceal bleeding (i.e., the use of Polytetrafluoroethylene‐covered TIPS and the availability of pre‐emptive TIPS as a first‐line treatment for acute variceal bleeding).ResultsTwenty‐three studies with 1430 patients were included. The pooled estimate rates were 0.33 (95% CI = 0.29–0.37) for death at 1 month–6 weeks, 0.46 (95% CI = 0.40–0.52) for death at 1 year, and 0.09 (95% CI = 0.06–0.11) for death due to rebleeding in the follow‐up. The pooled estimate rates for death at 1 month or 6 weeks were similar in subgroup analyses including studies that did not use covered TIPS or that did not include patients after the pre‐emptive TIPS area compared to the ones that did (pooled estimate rate 0.33 [95% CI = 0.28–0.38] and 0.32 [95% CI = 0.25–0.39], respectively). The pooled estimate rates were 0.16 (95% CI = 0.13–0.18) for rebleeding, 0.25 (95% CI = 0.17–0.36) for occurrence of hepatic encephalopathy, and 0.08 (95% CI = 0.05–0.13) for access to liver transplantation after TIPS insertion.ConclusionsOne third of patients with cirrhosis and refractory variceal bleeding treated with salvage TIPS died within the first 6 weeks. Recent improvements in the management of variceal bleeding did not improve the survival of patients presenting with refractory variceal bleeding.

Management variköser Blutungen

Variceal bleeding is a complication of portal hypertension that is still associated with high mortality. Therefore, variceal bleeding is still one of the most dreaded complications in gastroenterology. Management is challenging and is based on rapid cardiorespiratory stabilization of the patient, pharmacological reduction of portal pressure by vasoconstrictors and prevention of infection using antibiotics, as well as endoscopic treatment. The implantation of a transjugular intrahepatic portosystemic shunt (TIPS) within 72 h can improve survival and rebleeding rates in selected cases. Adequate pharmacological (non-selective β‑blocker or carvedilol) and/or endoscopic treatment are recommended for primary and secondary prophylaxis, respectively. This article reviews state-of-the-art management of variceal bleeding.

Variceal Hemorrhage: Decompression, Obliteration, or Both?

AbstractVariceal hemorrhage is a morbid condition that frequently mandates the involvement of interventional radiology to achieve successful and sustained hemostasis. Primary image-guided therapies for variceal hemorrhage include a transjugular intrahepatic portosystemic shunt and transvenous obliteration. Knowledge of variceal pathophysiology and anatomy, current techniques, and the evidence supporting therapeutic selection is paramount to successful patient outcomes. The purpose of this review is to provide the reader a framework of the available literature on image-guided management of bleeding varices to assist in clinical management.

MORTALITY ASSOCIATED WITH VARICEAL BLEED IN CIRRHOSIS PATIENTS ATTENDING A TERTIARY CARE CENTRE IN SOUTH KERALA.

Background : Acute variceal bleeding is a most common complication of portal hypertension. Despite advancement in management of variceal bleeding still carries a very high morbidity and mortality. The present study was undertaken to study mortality associated with variceal bleed in cirrhotic patients attending a tertiary care hospital. Method : This prospective study was conducted between June 2016 to may 2018. Total 60 patients included in the study who admitted with acute variceal bleeding episode with underlying cirrhosis. Results : Majority of patients were male ( 76 %). The mean age of patients was 54 +/- 13.7. Most common etiology of cirrhosis was Alcohol related liver disease (51.7% ). Most common presenting symptom was hematemesis with melena(41.7%). Majority of patients presented with recurrent bleeding episodes (61.7% ). 18.3% Patients had rebleeding episode within 5 days of admission. Total 21 (35 % ) patients died during study period. Univariate analysis showed advance age, presence of ascites, Encephalopathy, high creatinine, bilirubin and INR were important predictors of mortality. In multivariate analysis only signicant predictors was serum creatinine (OR 43.1 (CL3.05 to 608.64)). Conclusion: Patients with cirrhosis are always at risk of variceal bleeding. The survival after a bleeding episode was inuenced by age, comorbidities, in hospital complications, ascites, high CTPand MELD score , beta blocker therapy

Pathophysiology and Management of Variceal Bleeding

Cirrhosis is the fifth leading cause of death in adults. Advanced cirrhosis can cause significant portal hypertension (PH), which is responsible for many of the complications observed in patients with cirrhosis, such as varices. If portal pressure exceeds a certain threshold, the patient is at risk of developing life-threatening bleeding from varices. Variceal bleeding has a high incidence among patients with liver cirrhosis and carries a high risk of mortality and morbidity. The management of variceal bleeding is complex, often requiring a multidisciplinary approach involving pharmacological, endoscopic, and radiologic interventions. In terms of management, three stages can be considered: primary prophylaxis, active bleeding, and secondary prophylaxis. The main goal of primary and secondary prophylaxis is to prevent variceal bleeding. However, active variceal bleeding is a medical emergency that requires swift intervention to stop the bleeding and achieve durable hemostasis. We describe the pathophysiology of cirrhosis and PH to contextualize the formation of gastric and esophageal varices. We also discuss the currently available treatments and compare how they fare in each stage of clinical management, with a special focus on drugs that can prevent bleeding or assist in achieving hemostasis.

A126 GIST – GLUE IN STROMAL TUMOR

Abstract Background Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract and typically located in the stomach. Gastrointestinal bleeding is a frequent complication of GISTs with surgery being the treatment of choice. Managing GIST bleeding endoscopically can be challenging by an underlying friable neovascularization. The use of cyanoacrylate basis glue has well-established utility in the endoscopic management of variceal bleeding. However, the role of cyanoacrylate basis glue in the management of GIST bleeding is exceptionally rare. Aims We present a case of a bleeding GIST that was successfully managed through the utilization of cyanoacrylate basis glue allowing for elective surgical resection. Methods A chart review was undertaken. Also, a literature review of the topic was also conducted using the terms “GIST, Cyanoacrylate Glue, Bleeding” Results A 75-year-old male presented with a four week history of exertional chest pain. He had noticed persistent black stools for the previous two weeks. His past medical history was relevant for coronary artery disease; two years earlier he had drug eluting stents placed. His medications included ASA 81mg PO OD and Pantoprazole 40mg OD. Physical examination revealed stable vital signs, a soft abdomen and melena on rectal examination. Laboratory investigations showed a hemoglobin of 75 g/L, and 2 weeks prior his hemoglobin had been 120 g/L. Platelets were 149. His liver enzymes and liver function tests were unremarkable. His BUN was 9.9 mmol/L and creatinine of 96.0 umol/L. An esophagogastroduodenoscopy (EGD) revealed a 5cm smooth mass with a central deep depression, in the antrum, that was actively bleeding. Attempts to clip were unsuccessful due to the width of the central depression which was the source of bleeding. (See image 1). The endoscopist chose to inject 1cc of cyanoacrylate basis glue directly into the bleeding site. A subsequent CT scan revealed a 5.2cm polypoid mass in the gastric antrum, favored to be a GIST with no evidence of metastatic disease. Surgery and Cardiology were involved in the care of this patient, and emergency surgery was delayed due to the patient having an intercurrent acute coronary syndrome. Post EGD, the patient underwent an angiogram and the culprit coronary artery was stented and patient was started on dual antiplatelet therapy. Patient then successfully underwent a laparoscopic gastric wedge resection for his GIST, this was completed 1 week after EGD. The pathology of the resected area was in keeping with a GIST. Of note, the patient’s hemoglobin had been stable from the time of EGD until surgical intervention. Conclusions Managing GIST bleeding endoscopically can be challenging, and surgical resection is the recommended treatment modality. In situations where surgical intervention is contraindicated, endoscopic therapy with cyanoacrylate basis glue can be considered to achieve hemostasis in GIST bleeding. Funding Agencies None

Thrombin Is an Effective and Safe Therapy in the Management of Bleeding Gastric Varices. A Real-World Experience.

Variceal haemorrhage is a severe complication of liver disease with high mortality. Human recombinant thrombin has gained popularity in the management of variceal haemorrhage. We report on the use of thrombin for gastric and ectopic varices at a regional tertiary care centre. This was a retrospective observational study. Patients with portal hypertension who received endoscopic injection of recombinant thrombin were identified and data collected on haemostasis and rebleeding rates, complications and mortality. Patients were grouped by indication for thrombin injection: gastric/oesophageal/ectopic varices and endoscopic band ligation (EBL)-induced ulceration. 155 patients (96M/59F, mean age 58.3 years) received endoscopic thrombin injection. Mean volume of thrombin injected at index endoscopy was 9.5 ml/2375IU. Initial haemostasis was achieved in 144 patients (92.9%). Rebleeding occurred in a total of 53 patients (36.8%) divided as follows: early rebleeding (<5 days from index endoscopy)—26 patients (18%); rebleeding within 30 days—42 patients (29.1%); delayed rebleeding (> 30 days)—11 patients (7.6%). There was statistically significant difference in rate of initial haemostasis between Child-Pugh A/B patients vs Child-Pugh C (p = 0.046). There was no significant difference in rebleeding rates between different indication groups (p = 0.78), by presence of cirrhosis or by Child-Pugh Score. All-cause mortality at 6 weeks was 18.7%; 1-year mortality 37.4% (median follow-up 48 months). There was no significant difference in mortality between groups (p = 0.37). No significant adverse events or complications were reported. Thrombin is effective and safe for gastric varices and other portal-hypertension-related bleeding including oesophageal varices, ulcers secondary to EBL and ectopic varices.

Comparative Efficacy of Terlipressin and Octreotide along with Endoscopic Band Ligation in the Management of Esophageal Variceal Bleeding

Esophageal variceal bleeding is a medical emergency that carries a high mortality rate despite appropriate management. Terlipressin and Octreotide are two common agents used as adjuvant agents in the management of variceal bleeding. The objective of this study is to compare the effectiveness of Terlipressin with Octreotide along with endoscopic band ligation in the management of esophageal variceal bleeding in cirrhotic patients. This randomized control study was carried out at the Department of General Medicine, Fatima Memorial Hospital, Lahore, for six months extending from February 2019 to July 2019. A total of 100 cirrhotic patients were selected /based on predetermined inclusion and exclusion criteria. The patients were randomly divided into two groups of equal strength. Hence, 50 patients were included in Group A and 50 patients were included in Group B along with banding. Group A received Terlipressin whereas Group B received Octreotide. The two groups were monitored for variceal bleeding for 72 hours. The mean age of the patients in Group A was 55.9±7.3 years and for the patients in Group B it was 56.8±7.4 years. In Group A, 36 (72.0%) male and 14 (28.0%) female patients were included. In Group B, there were 34 (68.0%) male and 16 (32.0%) female patients. In Group A, the treatment was effective for 46 (92.0%) patients and in Group B, 36 (72.0%) patients had an effective treatment. It is concluded from this study that Terlipressin is statistically more effective than Octerotide in terms of preventing esophageal variceal bleeding.

Transjugular intrahepatic portosystemic shunt in cirrhosis: An exhaustive critical update

More than five decades after it was originally conceptualized as rescue therapy for patients with intractable variceal bleeding, the transjugular intrahepatic portosystemic shunt (TIPS) procedure continues to remain a focus of intense clinical and biomedical research. By the impressive reduction in portal pressure achieved by this intervention, coupled with its minimally invasive nature, TIPS has gained increasing acceptance in the treatment of complications of portal hypertension. The early years of TIPS were plagued by poor long-term patency of the stents and increased incidence of hepatic encephalopathy. Moreover, the diversion of portal flow after placement of TIPS often resulted in derangement of hepatic functions, which was occasionally severe. While the incidence of shunt dysfunction has markedly reduced with the advent of covered stents, hepatic encephalopathy and instances of early liver failure continue to remain a significant issue after TIPS. It has emerged over the years that careful selection of patients and diligent post-procedural care is of paramount importance to optimize the outcome after TIPS. The past twenty years have seen multiple studies redefining the role of TIPS in the management of variceal bleeding and refractory ascites while exploring its application in other complications of cirrhosis like hepatic hydrothorax, portal hypertensive gastropathy, ectopic varices, hepatorenal and hepatopulmonary syndromes, non-tumoral portal vein thrombosis and chylous ascites. It has also been utilized to good effect before extrahepatic abdominal surgery to reduce perioperative morbidity and mortality. The current article aims to review the updated literature on the status of TIPS in the management of patients with liver cirrhosis.

Comparative Efficacy of Terlipressin and Octreotide along with Endoscopic Band Ligation in the Management of Esophageal Variceal Bleeding

Esophageal variceal bleeding is a medical emergency that carries a high mortality rate despite appropriate management. Terlipressin and Octreotide are two common agents used as adjuvant agents in the management of variceal bleeding. The objective of this study is to compare the effectiveness of Terlipressin with Octreotide along with endoscopic band ligation in the management of esophageal variceal bleeding in cirrhotic patients. This randomized control study was carried out at the Department of General Medicine, Fatima Memorial Hospital, Lahore, for six months extending from February 2019 to July 2019. A total of 100 cirrhotic patients were selected /based on predetermined inclusion and exclusion criteria. The patients were randomly divided into two groups of equal strength. Hence, 50 patients were included in Group A and 50 patients were included in Group B along with banding. Group A received Terlipressin whereas Group B received Octreotide. The two groups were monitored for variceal bleeding for 72 hours. The mean age of the patients in Group A was 55.9±7.3 years and for the patients in Group B it was 56.8±7.4 years. In Group A, 36 (72.0%) male and 14 (28.0%) female patients were included. In Group B, there were 34 (68.0%) male and 16 (32.0%) female patients. In Group A, the treatment was effective for 46 (92.0%) patients and in Group B, 36 (72.0%) patients had an effective treatment. It is concluded from this study that Terlipressin is statistically more effective than Octerotide in terms of preventing esophageal variceal bleeding.

Early Transjugular Intrahepatic Portosystemic Shunt Creation Compared to Endoscopy With Pharmacotherapy in the Management of Variceal Rebleeding in Cirrhotic Patients: A Comprehensive Systematic Review and Meta-Analysis: Presidential Poster Award

Introduction: The use of early or rescue transjugular intrahepatic portosystemic shunt (TIPS) has been evaluated in cirrhotic patients with a history of variceal bleeding. In this study, we aimed to perform a systematic review and meta-analysis of studies investigating the efficacy and safety of early TIPS in the management of variceal bleeding as well as comparing the use of early compared to rescue TIPS. Methods: Medical electronic databases were queried for clinical studies in which TIPS creation was compared with endoscopy and pharmacotherapy treatment in cirrhotic patients with a history of variceal bleeding. Search results were screened against predefined eligibility criteria and data were extracted to a standard data extraction form. Meta-analysis was performed using Comprehensive Meta-Analysis software and the risk of bias of included studies was assessed using the Cochrane tool and modified Newcastle-Ottawa scale Results: Thirty-four studies that enrolled 2876 cirrhotic patients (n=1453 in the TIPS group and n=1423 in the endoscopy with pharmacotherapy group) were included. Overall analysis displayed significantly reduced re-bleeding, odds ratio (OR) = 0.29, 95% confidence interval (CI) [0.22-0.38], p< 0.0001) and bleeding-related death (OR= 0.28, 95% CI [0.18-0.44], p< 0.0001) in the TIPS group. There was no significant difference in all-cause mortality between all TIPS and endoscopy with pharmacotherapy (OR= 0.93, 95% CI [0.74-1.16], p= 0.52) and there was an increased incidence of hepatic encephalopathy (OR= 1.80, 95% CI [1.41-2.28], p< 0.0001) in the TIPS group (pooled analysis of both early and rescue TIPS). Early use of TIPS did not reveal any differences in hepatic encephalopathy (OR= 1.27, 95% CI [0.9-1.7], p= 0.13) and showed a decreased mortality in high risk patients (Child-Pugh class C, Child-Pugh class B with active bleeding at endoscopy, and hepatic venous pressure gradient [HVPG] ≥20 mm Hg) when compared to rescue TIPS. Conclusion: TIPS creation decreases rebleeding at the cost of increased hepatic encephalopathy with no survival benefit. Early TIPS creation may confer better clinical outcomes in terms of comparable hepatic encephalopathy and improved survival in high-risk patients when compared to rescue TIPS.

Terlipressin-Induced Ischemic Complications: A Systematic Review of Published Case Reports

Terlipressin is used in the management of variceal bleeding and hepatorenal syndrome. Ischemic complications are rare, but serious adverse effects of terlipressin therapy can be fatal. In this context, we reviewed all the published case reports of terlipressin-induced ischemic complications, and data were collected regarding the part of body affected by ischemic complication, latency, geographical variation, different treatment strategies and their outcome, and other relevant information. After an exhaustive search in different databases, 33 published cases were found. The ischemic complications affected virtually every part of the body. Peripheral gangrene was the most common ischemic complication followed by ischemic complications of more proximal parts such as thigh and abdominal wall. Other parts affected were heart, colon, small intestine, scrotum, etc. Most cases were managed conservatively. Although in few cases, other treatment options were also explored, knowledge of this dreaded complication and different management strategies is necessary for early identification of this adverse effect and early management so as to prevent fatality.

Endoscopic Therapy for Variceal Bleeding: from Patient Preparation to Available Techniques and Rescue Therapies

Gastrointestinal variceal bleeding (VB) is a frequent and severe complication in cirrhosis. Despite improvement in the last decades in the management of VB, the 6-week mortality after bleeding still ranges from 10 to 20%. Here, we review an up-to-date in the global management of VB. The endoscopic hemostatic treatment relies on band ligation for esophageal variceal bleeding and tissue adhesive injection for gastric variceal bleeding. In case of refractory bleeding, self-expanding metal stents or balloon tamponade can both be used as bridge to specific treatment. The use of covered TIPS provided a new step in the management of VB in severe patients, so-called “early-TIPS” in the setting of secondary prophylaxis or in all patients with refractory bleeding. The global management of patients with VB should include volume resuscitation, blood transfusion, and prevention of complications such as renal failure+/-sepsis+/-liver encephalopathy, as they drive the prognosis. Therefore, the rapid control of gastrointestinal bleeding and subsequent organ complications should be performed in specific intensive care units.

Recent advances in the management of variceal bleeding.

Acute haemorrhage from ruptured gastroesophageal varices is perhaps the most serious consequence of uncontrolled portal hypertension in cirrhotic patients. It represents a medical emergency and is associated with a high morbidity and mortality. In those who survive the initial bleeding event, the risks of further bleeding and other decompensated events remain high. The past 30 years have seen a slow evolution of management strategies that have greatly improved the chances of surviving a variceal haemorrhage. Liver cirrhosis is a multi-staged pathological process and we are moving away from a one-size-fits-all therapeutic approach. Instead there is an increasing recognition that a more nuanced approach will yield optimal survival for patients. This approach seeks to risk stratify patients according to their disease stage. The exact type and timing of treatment offered can then be varied to suit individual patients. At the same time, the toolbox of available therapy is expanding and there is a continual stream of emerging evidence to support the use of endoscopic and pharmacological therapies. In this review, we present a summary of the treatment options for a variety of different clinical scenarios and for when there is failure to control bleeding. We have conducted a detailed literature review and presented up-to-date evidence from either primary randomized–controlled trials or meta-analyses that support current treatment algorithms.

Clinical Practice Guidelines on the Management of Variceal Bleeding.

Clinical Practice Guidelines on the Management of Variceal Bleeding.

PTH-146 Oesophageal Variceal Surveillance - Should Community Hospital Endoscopy Units in Gloucestershire Jump On The ‘Band-Wagon’?

Introduction Patients with liver cirrhosis should engage with a variceal surveillance programme to minimise the risk of variceal bleeding, a major cause of morbidity and mortality. 1 To improve compliance with variceal surveillance it is important to adopt a patient-centred approach and optimise access to endoscopy. Although routine diagnostic upper endoscopy is already established in community hospitals in Gloucestershire safety fears obstruct the provision of variceal surveillance causing potentially unjustified inconvenience to patients. Methods This double-centre, observational study investigated the safety of endoscopic variceal surveillance in adult cirrhotic patients (age range: 29–90 y) and evaluated the feasibility for service expansion into community hospital endoscopy units. Information was collected retrospectively from an electronic database of patients who underwent elective endoscopic variceal surveillance in Gloucester Royal Hospital or Cheltenham General Hospital from February 2013 to August 2014. The medical notes of patients who underwent variceal banding were evaluated for short-term complications of band ligation and length of hospital stay. Results 223 patients underwent endoscopy for variceal surveillance during the 18 month study period. Of these patients 12.1% (n = 27) required endoscopic band ligation including 7 patients with history of variceal haemorrhage. All patients underwent endoscopy as a day-case procedure with same-day discharge regardless of the need for band ligation. Variceal band ligation was not associated with any significant complications within 7 days. Conclusion Endoscopy for variceal surveillance is a safe day-case procedure irrespective of the need for band ligation. The safety concerns obstructing the use of existing endoscopy resources for variceal surveillance in community hospitals in Gloucestershire are unjustified. Broadening access to variceal surveillance represents a cost-effective means to make care more patient-centred. This may improve compliance with variceal surveillance and reduce variceal bleeding in cirrhotics. Reference 1 Tripathi D, et al . UK guidelines on the management of variceal haemorrhage in cirrhotic patients. Gut 2015; 64 (11):1680-1704 doi:10.1136/gutjnl-2015-309262 Disclosure of Interest None Declared

PTH-156 Impact of BSG and BASL Liver Care Bundle Introduction on Clinical Practice: A University Hospital Experience: Abstract PTH-156 Table 1

Introduction The National Confidential Enquiry into Patient Outcome and Death for alcohol related liver disease highlighted the need to improve care of patients with decompensated liver disease. BSG and BASL thereafter developed the Liver Care Bundle toolkit to aid provision of evidence-based care within 24 hours of admission. We performed an audit of care delivered to such patients before and after introduction of the Bundle into clinical practice in our hospital. Methods For the initial audit (August 2014-March 2015), patients presenting with decompensated liver disease were retrospectively identified from ward lists, blood bank data for Human Albumin Solution (HAS), and the endoscopy database. Electronic patient records were reviewed against the toolkit. The results were presented at hospital Grand round alongside presentation of the Liver Care Bundle which was, thereafter, implemented throughout the Trust from July 2015. Re-audit using the same methodology was performed September to December 2015. The significance of impact of the Bundle on clinical practice was evaluated using Fisher’s exact test. Results 45 patients were identified for the first part of the audit. The average length of stay was 11 days. Notes for 20 patients with 25 in-patient episodes were reviewed for the re-audit. Average length of stay was 18 days. Conclusion The introduction of the Liver Care Bundle at our institution led to improvement in several aspects of care- especially in the management of variceal haemorrhage. Recognition of patients with excess alcohol consumption and use of Pabrinex was improved upon too. There, however, remain clear areas for improvement. Experiences with the Liver Care Bundle should continue to be widely reported in an attempt to standardise and improve in-patient morbidity and mortality in liver disease. Reference 1 McPherson S, et al. Response to the NCEPOD report: development of a care bundle for patients admitted with decompensated cirrhosis—the first 24 h. Frontline Gastroenterol. 2016 Jan;7(1):16–23. Epub 2014 Dec 2. Disclosure of Interest None Declared