Underwent Emergency Endoscopy Research Articles

Evaluating the Efficacy of a Novel Hemostatic Powder Compared to Traditional Treatments in Non-Variceal Upper Gastrointestinal Bleeding: A Multicenter, Randomized Non-inferiority Study

Hemostatic powders have been rapidly developed and used to treat gastrointestinal bleeding. We aimed to investigate the non-inferiority of the newly developed hemostatic powder (CEGP-003) compared to conventional endoscopic treatments for non-variceal upper gastrointestinal bleeding (NVUGIB). This prospective, multicenter, randomized, open-label, controlled trial was conducted at four referral institutions. We enrolled consecutive patients who underwent emergency endoscopy for NVUGIB. The patients were randomly assigned to either the CEGP-003 or the conventional treatment group. In the CEGP-003 group, the hemostatic powder was applied as a spray. Conventional endoscopic treatments included electrical coagulation and hemoclipping. Between November 2019 and June 2022, 218 patients were enrolled (CEGP-003, 108; conventional, 110). Initial hemostasis was achieved in 104 of 108 patients (96.3%) in the CEGP-003 group and 101 of 110 patients (91.8%) in the conventional treatment group. The CEGP-003 group exhibited a significantly higher re-bleeding rate than the conventional treatment group. Multivariate analysis that age, duodenum and middle 1/3 of stomach, and CEGP-003 use as the initial hemostatic treatment were independent risk factors for re-bleeding. No adverse events were associated with CEGP-003. CEGP-003 demonstrates promise as an initial endoscopic therapy for NVUGIB, however close monitoring is warranted due to the risk of re-bleeding (Cris.nih.go.kr, number: KCT0004655).

Management of Antithrombotic Agents During Emergency Endoscopy for Upper Gastrointestinal Bleeding: A Propensity Score Matching Analysis

Background/Aims: This study is aimed at comparing the outcomes of upper gastrointestinal bleeding (UGIB) during emergency endoscopy between patients taking and not taking antithrombotic agents to inform antithrombotic management.Methods: We conducted a retrospective analysis of 389 patients who underwent emergency endoscopy for UGIB from 2016 to 2021. The patients were categorized into group A (taking antithrombotic agents) and group NA (not taking antithrombotic agents). The clinical characteristics, types of antithrombotic agents, patient status upon admission, and causes of UGIB were examined. Treatment outcomes and adverse events were assessed by propensity score matching (PSM).Results: Group A was significantly older and the primary antithrombotic agent was low‐dose aspirin, with multiple antithrombotics taken by 38 patients (29.0%). Peptic ulcers were the most common cause of UGIB in both groups. PSM generated 83 matched pairs. The success rate of endoscopic hemostasis in group A was significantly higher than in group NA (96.4% vs. 84.3%, P = 0.02). Despite promptly resuming antithrombotic agent posthemostasis, there was no significant difference in the rebleeding rate or 30‐day mortality.Conclusion: The high success rate of endoscopic hemostasis and no difference in adverse events made the prompt resumption of antithrombotic medications after emergency endoscopy for UGIB acceptable.Trial Registration: ClinicalTrials.gov identifier: UMIN000053561

A Comparison between Traumatic and Atraumatic Over-The-Scope-Clips in patients with Duodenal Ulcer Bleeding: a Retrospective Analysis with Propensity-Score-based Matching.

The over-the-scope-clip (OTSC) substantially improved the endoscopic armamentarium for the treatment of severe gastrointestinal bleeding and can potentially overcome limitations of standard clips. Recent data indicated a superiority of OTSC in hemostasis as first and second line therapy. However, the impact of the OTSC design (traumatic (-t) or atraumatic (-a) type) in particular in duodenal ulcer bleeding has not been analyzed so far. Retrospective analysis of a prospective collected database from 2009 until 2020 of six German endoscopic centers. All patients who underwent emergency endoscopy and were treated by an OTSC for duodenal ulcer bleeding were included. OTSC-t and OTSC-a patients were compared by Fisher's exact test, chi-square- or Mann-Whitney U-test as appropriate. A propensity-score based 1:1 matching was performed to obtain equal distribution of baseline characteristics in both groups. The entire cohort comprised 173 patients (93 OTSC-a, 80 OTSC-t). Age, gender, anticoagulant therapy, Rockall-Score and treatment regimen had similar distributions in the two groups. However, OTSC-t group showed significantly more active bleeding ulcers (Forrest Ia/b). Matching identified 132 patients (66 in both groups) with comparable baseline characteristics. Initial bleeding hemostasis (OTSC-a: 90.9%, OTSC-t: 87.9%, p=0.82) or 72h-mortality (OTSC-a: 4.5%, OTSC-t: 6.0%, p>0.99) were not significantly different but the OTSC-t group revealed a clearly higher rate of rebleeding (34.9% vs. 7.6%, p<0.001) and necessity of red blood cell transfusions (5.1±3.4 vs. 2.5±2.4 concentrates, p<0.001). OTSC-a should be the preferred option for duodenal ulcer bleeding if the endoscopist aims for an over-the-scope-clip.

Safety and Efficacy of Sedation During Emergency Endoscopy for Upper Gastrointestinal Bleeding: A Propensity Score Matching Analysis

Background and AimThis study aimed to compare patients with and without sedation during emergency endoscopy for upper gastrointestinal bleeding (UGIB) and to clarify the safety and efficacy of sedation in emergency endoscopy.MethodsWe retrospectively collected 389 patients who underwent emergency endoscopy for UGIB at Ureshino Medical Center from 2016 to 2021. Patients were divided into two groups: sedation group during emergency endoscopy and nonsedation group. Clinical characteristics, patient status on admission, and UGIB etiology were evaluated. Treatment outcomes and adverse events were evaluated using propensity score matching (PSM), and risk factors for mortality from UGIB were investigated using Cox multivariate analysis.ResultsThe sedation group was significantly younger, composed of a higher proportion of males, and had chronic liver disease. Blood pressure and hemoglobin level on admission were significantly higher in the sedation group. The main cause of bleeding was peptic ulcer, which was significantly higher in the nonsedation group. PSM created 133 matched pairs. The success rate of endoscopic hemostasis was similar in both groups, and procedure time was significantly shorter in the sedation group than in the nonsedation group (17.6 ± 10.0 versus 20.2 ± 10.2 min, P = 0.04). There were no significant differences in adverse events between groups. Cox multivariate analyses revealed that red blood cell transfusion [hazard ratio (HR) 4.45, P < 0.02] and rebleeding (HR 3.30, P = 0.03) were associated with increased risk of 30-day mortality from UGIB.ConclusionsSedation reduced the procedure time during emergency endoscopy for UGIB. Sedation during emergency endoscopy for UGIB is acceptable for safe endoscopic procedures.

Application of endoscopic purse-string sutures in high-risk peptic ulcer hemorrhage: preliminary experience of 38 cases

Objective This study is a prospective study to explore the therapeutic effect of endoscopic purse-string sutures in high-risk peptic ulcer hemorrhage. Patients and methods We prospectively collected and analyzed data from July 2018 to December 2020 from patients in Jinshan hospital, Fudan University, who underwent emergency endoscopy for acute severe high-risk non-variceal upper gastrointestinal hemorrhage (NVUGIB) and were treated with endoscopic purse-string sutures. Results We included 38 patients whose median age was 64 years (interquartile range: 57.2 − 71.2 years). All patients were high risk gastric ulcer larger than 1 cm, including Forrest Ia (n = 4, 10.5%), Forrest Ib (n = 13, 34.2%) and Forrest IIa (n = 21, 55.3%). All patients were treated with endoscopic purse-string sutures. The clinical success rate reached 89.5%. Three patients suffered from rebleeding within seven days, and were treated with surgery or arterial embolization, respectively, all of which successfully stopped bleeding. One patient died of myocardial infarction. All other patients were followed up for 30 days without bleeding. Conclusions We conclude that endoscopic purse-string sutures seem to be safe and effective in the treatment of patients at high risk of ulcer bleeding.

Gastrointestinal Endoscopy Performed by Gastroenterologists: Opportunistic Screening Strategy for Newly Diagnosed Head and Neck Cancers

AimApproximately 66% of head and neck cancers are diagnosed at an advanced stage. This prospective study aimed to detect newly diagnosed head and neck cancers using regular upper gastrointestinal (UGI) endoscopy with oral-pharynx-larynx examination.MethodsA total of 2,849 patients underwent UGI endoscopy with an additional oral-pharynx-larynx examination. Patients aged < 20 years, those who were pregnant, had a history of head and neck cancers, were undergoing emergency endoscopy, and had a poor laryngopharyngeal view were excluded. The symptoms, incidence, location, pathology, and stage of malignant neoplasms were investigated.ResultsA total of 2,720 patients were enrolled. Endoscopically observable 23 abnormal findings (0.85%) included 18 (0.66%) benign lesions and 5 (0.18%) newly diagnosed malignant neoplasms. Notably, 4 (80%) of 5 patients with malignant neoplasms were diagnosed at an early stage (Stage 0, I, and II).ConclusionsUGI endoscopy with oral-pharynx-larynx examination can achieve opportunistic head neck cancer screening and is recommended for every patient in endoscopy units.

Modified N score is helpful for identifying patients who need endoscopic intervention among those with black stools without hematemesis.

Although black stools are one of the signs of upper gastrointestinal bleeding, not all patients without hematemesis need endoscopic intervention. There is no apparent indicator to select who needs treatment thus far. The aim of this study was to establish a novel score that predicts the need for endoscopic intervention in patients with black stools without hematemesis. We retrospectively enrolled 721 consecutive patients with black stools without hematemesis who underwent emergency endoscopy from two facilities. In the development stage (from January 2016 to December 2018), risk factors that predict the need for endoscopic intervention were determined from the data of 422 patients by multivariate logistic regression analysis, and a novel scoring system, named the modified Nagoya University score (modified N score), was developed. In the validation stage (from January 2019 to September 2020), we evaluated the diagnostic value of the modified N score for 299 patients. Multivariate logistic regression analysis revealed four predictive factors for endoscopic intervention: syncope, the blood urea nitrogen (BUN) level, and the BUN/creatinine ratio as positive indicators and anticoagulant drug use as a negative indicator. In the validation stage, the area under the curve of the modified N score was 0.731, and the modified N score showed a sensitivity of 82.0% and a specificity of 58.8%. Our modified N score, which consists of only four factors, can identify patients who need endoscopic intervention among those with black stools without hematemesis.

Treatment Strategies in Emergency Endoscopy for Acute Esophageal Variceal Bleeding (CHESS1905): A Nationwide Cohort Study.

Background and AimsEmergency endoscopy is recommended for patients with acute esophageal variceal bleeding (EVB) and their prognosis has improved markedly over past decades due to the increased specialization of endoscopic practice. The study aimed to compare outcomes following emergency endoscopic injection sclerotherapy (EIS) and endoscopic variceal ligation (EVL) in cirrhotic patients with acute EVB.MethodsCirrhotic patients with acute EVB who underwent emergency endoscopy were retrospectively enrolled from 2013 to 2020 across 34 university hospitals from 30 cities. The primary outcome was the incidence of 5-day rebleeding after emergency endoscopy. Subgroup analysis was stratified by Child-Pugh class and bleeding history. A 1:1 propensity score matching (PSM) analysis was performed.ResultsA total of 1,017 and 382 patients were included in EIS group and EVL group, respectively. The 5-day rebleeding incidence was similar between EIS group and EVL group (4% vs. 5%, P = 0.45). The result remained the same after PSM (P = 1.00). Among Child-Pugh class A, B and C patients, there were no differences in the 5-day rebleeding incidence between the two groups after PSM (P = 0.25, 0.82, and 0.21, respectively). As for the patients with or without bleeding history, the differences between EIS group and EVL group were not significant after PSM (P = 1.00 and 0.26, respectively).ConclusionThe nationwide cohort study indicates that EIS and EVL are both efficient emergency endoscopic treatment strategies for acute EVB. EIS should not be dismissed as an economical and effective emergency endoscopic treatment strategy of acute EVB. ClincialTrials.gov number NCT04307264.

A case of severe acute hemorrhagic duodenitis after administration of immune checkpoint inhibitor

ABSTRACT Case: A 66‐year‐old man started carboplatin + etoposide + atezolizumab therapy for advanced small cell lung cancer. Seventeen days after the start of treatment, the patient presented with hematemesis and underwent emergency endoscopy, which revealed multiple erosions and ulcers in the duodenum. Some ulcers showed pulsating bleeding, which was stopped by clipping and cauterization using hemostats. Biopsy of the mucosal peri‐ulcer showed lymphocyte, eosinophil, and plasma cell infiltration. The patient was suggested to have acute hemorrhagic duodenitis, which was associated with immune checkpoint inhibitors (ICIs), and conservative treatment with blood transfusion and antacids was continued. However, 11 days after hemostasis, bleeding from a new ulcer was observed. Hemostasis was achieved by coagulation and clipping again, but the general condition of the patient deteriorated owing to the rapid progression of the primary disease, and he died 8 weeks after the start of treatment. Discussion: Although there have been several reports of colitis and other adverse events caused by ICIs, there have been very few reports of duodenitis. Endoscopic findings include diffuse erythema, erosions/ulcerations, and villous atrophy, and pathological findings include eosinophilic infiltration and increased levels of CD8‐positive T cells. However, there have been no reports of duodenal mucosal damage caused after administration of atezolizumab nor of severe cases of massive bleeding requiring endoscopic hemostasis and blood transfusion, as in this case.

A novel scoring system to predict therapeutic intervention for non-variceal upper gastrointestinal bleeding.

Various scoring systems have been developed to predict the need for endoscopic treatment in patients with non-variceal upper gastrointestinal bleeding (NVUGIB). However, they have rarely been applied in clinical practice because the processes are complicated. The aim of this study was to establish a simple scoring system that predicts the need for endoscopic intervention in patients with NVUGIB. We retrospectively enrolled 509 consecutive patients with suspected NVUGIB who underwent emergency endoscopy. In the development cohort (from January 2016 to December 2018), risk factors that predict the need for endoscopic intervention were determined from 349 patients' data by multivariate logistic regression analysis. This led to the development of a novel scoring system named the Nagoya University score (N score). In the validation cohort (from January 2019 to September 2020), we evaluated the diagnostic value of the N score, the Hirosaki score, and the Glasgow-Blatchford scores (GBS) by receiver operating characteristic (ROC) curves using another 160 patients' data. Multivariate logistic regression analysis revealed syncope, hematemesis, blood urea nitrogen (BUN), and BUN/Cr as significant predictive factors for endoscopic intervention. In the validation study, the N score was superior to the GBS and equal to the Hirosaki score in predicting the endoscopic intervention (AUC, N score 0.776 [95% CI 0.702-0.851] vs. GBS 0.615 [0.523-0.708], Hirosaki 0.719 [0.636-0.803]). The N score revealed a sensitivity of 84.5% and a specificity of 61.8%. Our N score, which is consisted of only four factors, would select patients who require endoscopic intervention with high probability.

Clinical Impact of Universal Screening for COVID-19 before Therapeutic Endoscopy

Abstract Introduction The Coronavirus pandemic (COVID-19) has led to drastic change in gastrointestinal (GI) endoscopy practice. Endoscopy is an aerosol-generating procedure. COVID-19 testing prior to endoscopy can reduce transmission by delaying non-emergency endoscopies in positive patients. There is scarcity of literature to support such protocols. We aimed to study the clinical impact of universal testing for COVID-19 before therapeutic endoscopy. Methods This is retrospective analysis of prospectively maintained data. All patients requiring therapeutic endoscopy were enrolled between June 15 to July 15, 2020. Clinical profile, indication, endoscopic intervention, and outcome of patients tested positive for COVID-19 real-time polymerase chain reaction (RT PCR) or CT chest suggestive of CO-RADS 3 or more were included for analysis. Results Out of 772 patients scheduled for endoscopic interventions, 26 (3.34%) patients had COVID-19 infection with mean age (range) of 48.19 (3–75) years. Eight (30.8%) were females. Of them, seven (26.9%) patients underwent emergency endoscopy, and another seven (26.9%) patients underwent endoscopy after minimum of 2 weeks waiting period. Two deaths were seen in patients who underwent emergency interventions which were unrelated to endoscopy. One patient, who was planned for endoscopic ultrasound (EUS) for choledocholithiasis, developed acute biliary pancreatitis in the waiting period. Conclusion We suggest use of universal testing for COVID-19 by RT-PCR before endoscopic intervention. Endoscopy can be postponed for 2 weeks with marginal risk of adverse events during the waiting period in nonemergency indications. However, this approach needs to be tailored as per local needs, resources availability, and indication of endoscopy.

The proposed algorithm for emergency endoscopy during the coronavirus disease 2019 outbreak.

Following the coronavirus disease 2019 outbreak in China, more than 10,765 patients tested positive for severe acute respiratory syndrome coronavirus 2 from February 18, 2020 to April 30, 2020 in South Korea. Performing emergency endoscopy is extremely challenging from the clinicians’ viewpoint during the viral outbreak. There are no available guidelines for emergency endoscopy in tertiary hospitals during this pandemic. We set up an algorithm as a guide for emergency endoscopy in patients presenting to the emergency room with bleeding, foreign body, or impending cholangitis. From February 18, 2020 to April 30, 2020 of outbreak, 130 patients underwent emergency endoscopy in our center. Owing to the simple and streamlined algorithm for performing emergency endoscopy, no endoscopy-related infection to other patients or medical workers was reported in our center.

Esophageal foreign bodies: observational cohort study and factors associated with recurrent impaction.

Esophageal foreign bodies, including food bolus impaction, represent a common clinical problem. The prevalence of underlying esophageal disease depends on study design and degree of suspicion of a structural or functional esophageal abnormality. Aim of this study was to analyze factors associated with recurrent impaction. The prospectively collected database at a University Hospital and Swallowing Center was reviewed from January 2012 to June 2019 to identify all patients admitted for esophageal foreign bodies. Patients who underwent an emergency endoscopic procedure represented the final study sample. Patient characteristics, including history of previous esophageal foreign bodies, and type of endoscopic procedure were collected. Sixty-five patients, 41 males and 24 females with a median age of 59 years, underwent emergency endoscopy for esophageal foreign bodies during the study period. Food bolus was the most common foreign body (n = 43, 66%). Flexible endoscopy was successful in retrieving or pushing the foreign bodies in the stomach in 91% of patients. In 54% of patients, impaction was secondary to an underlying esophageal disorder, which was previously unrecognized in half of them. Recurrent impaction was more common in patients with esophageal disease (P < 0.011). Surgical therapy was required in 4 patients (6.1%). Food bolus impaction is a common sentinel event in patients with underlying esophageal disease and is associated with recurrent impaction. Diagnostic endoscopy with biopsies should possibly be performed at the first episode of impaction. Patients with negative biopsies should undergo barium swallow study and high-resolution esophageal manometry.

Characteristics of patients with rectal variceal rupture who underwent emergency endoscopy

Characteristics of patients with rectal variceal rupture who underwent emergency endoscopy

Peptic Ulcer Is the Most Common Cause of Non-Variceal Upper-Gastrointestinal Bleeding (NVUGIB) in China.

BackgroundThis study aimed to discover the common cause of non-variceal upper-gastrointestinal bleeding (NVUGIB) by conducting a multi-center retrospective study from 2008 to 2012.Material/MethodsHospitalized patients ages ≥18 years old, from 8 hospitals in China, diagnosed with NVUGIB by endoscopy from 1 January 2008 to 31 December 2012 were enrolled. Questionnaires were developed and a data-entry graphical user interface was designed by using EpiData software.ResultsTotal of 2977 hospitalized patients from 8 medical centers were included. A total of 95.47% (2842/2977) of patients were admitted to a general ward, 3.53% (105/2977) were admitted to an emergency ward, and 1.00% (31/2977) were admitted to an intensive care unit. Peptic ulcer remained the most common cause of NVUGIB (73.26%), but there was a declining trend in its constituent ratio, from 2008 to 2012. A total of 14.41% (429/2977) of patients had co-morbid conditions, 92.85% (2764/2977) used proton-pump inhibitors (PPIs) prior to endoscopic treatment, 19.65% (585/2977) underwent emergency endoscopy, and 23.45% (698/2977) received a transfusion of red blood cell suspensions. A total of 5.34% (159/2977) underwent endoscopic therapy, with a treatment rate of 16.9% in high-risk peptic ulcer patients (96/568). A total of 7.69% (237/2977) were administered aspirin, of whom 32.50% (77/237) resumed aspirin intake after gastrointestinal bleeding was controlled. The median length of hospitalization was 8 days (IQR, 5–11) and the mortality rate was 1.71% (51/2977).ConclusionsPeptic ulcer was still the most common cause of NVUGIB in China. The proportion of patients with high-risk peptic ulcer bleeding who received endoscopic therapy was 16.9%. Only 19.65% of NVUGIB patients underwent emergency endoscopy.

EFFICACY OF INITIAL AND PERMANENT HEMOSTASIS OF THE ENDOSCOPIC HEMOCLIP METHOD COMBINED WITH HIGH-DOSE INFUSION OF PROTON PUMP INHIBITOR IN PATIENTS WITH PEPTIC ULER BLEEDING

Background: Peptic ulcer bleeding is one of the common medical emergencies. The hemostatic efficacy of endoscopic therapeutic modalities has been reported in many studies and frequently has been found to exceed 90%. Four groups of modalities are used in the endoscopic management of bleeding peptic ulcers: thermal probe methods, injection sclerotherapy, local spray methods, and mechanical hemostatic therapy. The endoscopic hemoclip method is a safe and effective hemostatic therapy for managing bleeding peptic ulcers. Objective: To determine the success rate of hemoclip in endoscopic hemostasis. Patients and methods: Clinical intervention study on 36 patients with peptic ulcer bleeding admitted in Can Tho Central General Hospital from May 2012 to November 2014. All the patients underwent emergency endoscopy for hemostasis by hemoclip and high-dose PPI use. Results: The success rate of initial hemostasis was 97.2%, and permanent hemostasis was 91.7%. The rates of rebleeding, surgery, mortality were 11.1%, 5.6%, 2.8%, respectively. Conclusion: Endoscopic hemostasis therapy by clipping combined with high- dose PPI is an effective, relatively safe treatment for peptic ulcer bleeding. Key words: Peptic ulcer bleeding, hemoclip, endoscopic hemostasis therapy

The Manchester Triage System (MTS): a score for emergency management of patients with acute gastrointestinal bleeding.

Suspected gastrointestinal (GI) bleeding is a common initial diagnosis in emergency departments. Despite existing endoscopic scores to estimate the risk of GI bleeding, the primary clinical assessment of urgency can remain challenging. The 5-step Manchester Triage System (MTS) is a validated score that is often applied for the initial assessment of patients presenting in emergency departments. All computer-based records of patients who were admitted between January 2014 and December 2014 to our emergency department in a tertiary referral hospital were analyzed retrospectively. The aim of our retrospective analysis was to determine if patient triage using the MTS is associated with rates of endoscopy and with presence of active GI bleeding. In summary, 5689 patients with a GI condition were treated at our emergency department. Two hundred eighty-four patients (4.9 %) presented with suspected GI bleeding, and 165 patients (58 %) received endoscopic diagnostic. Endoscopic intervention for hemostasis was needed in 34 patients (21 %). In patients who underwent emergency endoscopy, triage into MTS categories with higher urgency was associated with higher rates of endoscopic confirmation ofsuspected GI bleeding (79 % of patients with MTS priority levels 1 or 2, 53 % in level 3 patients, and 40 % in levels 4 or 5 patients; p = 0.024). The MTS is an established tool for triage in emergency departments and could have a potential to guide early clinical decision-making with regards to urgency of endoscopic evaluation in patients with suspected GI bleeding.

Efficacy of Endoscopic Hemostasis with Soft Coagulation Using Hemostatic Forceps for Upper Gastrointestinal Bleeding over a 12-year Period: 2016 ACG Presidential Poster Award

Introduction: The endoscopic submucosal dissection (ESD) technique was introduced to obtain en bloc specimens of early gastric cancer. Endoscopic high-frequency soft coagulation is used to manage visible bleeding and/or nonbleeding vessels during ESD. Upper gastrointestinal bleeding (UGIB) is the most common gastroenterological emergency, and has a considerable morbidity and mortality. This study aimed to compare the etiology and clinical outcome of nonvariceal UGIB between two periods during the last 12 years. Methods: The present retrospectively study evaluated the medical records of patients who underwent emergency endoscopic hemostasis for nonvariceal UGIB from 2003 to 2014. The patients were divided into two periods: the first period was from 2003 to 2008 and the second period was from 2009 to 2014. The study revealed the characteristics of these patients and compared the treatment outcome of endoscopic hemostasis between soft coagulation and other modalities. In addition, endoscopic hemostasis rate was compared between specialists and trainees. The specialists already had the fundamental skills and knowledge needed for ESD, and each specialist assisted more than 40 gastric ESD procedures. Results: 566 patients underwent emergency endoscopy with nonvariceal UGIB. Among the 502 out of 566 patients who underwent endoscopic hemostasis, 197 were in the first period and 305 patients were in the second period. Whereas peptic ulcer lesions were the main cause of bleeding (89.4%) during the whole study period, small and multiple ulcers in addition to duodenal ulcers significantly increased in the second period. Endoscopic hemostasis was successfully performed in 97.0% in the first period and in 95.4% in the second period with no significant difference between the periods. In the modality of hemostasis, the rate of endoscopic hemostasis with soft coagulation using the ESD technique significantly increased in the second period compared to the first period (71.1% vs.11.7%, p < 0.001). The rate of endoscopic hemostasis performed by trainees was significantly higher in the second period than in the first period (76.1% vs.56.3%, p < 0.001). Rebleeding after endoscopic hemostasis decreased in the second period (9.8%) compared to the first period (15.7%). Conclusion: This retrospective study suggested that endoscopic hemostasis with soft coagulation using the ESD technique was safe even performed by trainees and might lead to a lower rebleeding rate after endoscopic hemostasis for UGIB.

PWE-150 Anaesthetic Support and Theatre Access for Emergency Endoscopy in Major Upper Gastrointestinal Bleeding (UGIB); Where Can We Improve?

Introduction The 2015 NCEPOD “Time to get control” report recommends that hospitals admitting patients with severe UGIB have access to critical care and anaesthetic support for urgent endoscopy. We examined our emergency pathway including theatre urgency codes, time to therapy and clinical outcomes. Methods We analysed all patients who had emergency endoscopy in theatre for suspected severe UGIB at Queen’s Medical Centre, Nottingham, UK, between 1st March 2014 and 28th February 2015. We examined patient demographics, ASA and UGIB risk scores, shock index (SI; heart rate/systolic BP), referral times to endoscopy and breach rates, anaesthetic and operator details, endoscopic findings and therapy (blood product use, interventional radiology and surgery), procedural documentation, re-bleed plans, discharge location, complications and inpatient mortality. Results 95 patients (60 male mean [±SD] age 59.2 [±19.1]; 35 female, 55.2 [±28.4]) with suspected severe UGIB were treated in emergency theatres over the 12 month period. 93/95 (98%) had significant UGIB; 82% ASA grade ≥3 and Glasgow Blatchford Scores (GBS) were recorded in 18% of cases; median (range) score 12 (1–19). 64% were classified as theatre urgency 1 (U1; within 60 mins) and 25% U3 (within 180 mins). 64% of those in U1 had a high shock index (SI > 0.9). However, median time from referral to endoscopy was 215 (range 37–1370) minutes. 47% breached the theatre urgency code times; including 59% of those assigned to U1. A consultant gastroenterologist was present in theatre in 86/95 (91%) of cases and 96% of patients received a general anaesthetic with rapid-sequence induction. The UGIB was non-variceal in 55/95 (58%; endoscopic intervention in 63%), variceal in 32/95 (34%), no cause found 8/95 (8%). 70% received a blood transfusion within 24 hrs of admission, mean 2.7(±2.5) units packed cells. 9/95 (10%) had CT angiography and 6/95 (6%) underwent coil embolization. No patients underwent surgery. An endoscopy report was generated for all cases, but re-bleed plans were only documented in 51%. Following endoscopy, 63/95 (67%) required a high-dependency bed and inpatient mortality was 21%. Conclusion Patients undergoing emergency endoscopy in theatre for acute UGIB had high risk scores and inpatient mortality, but 47% breached theatre urgency timings. These delays may impact on patient outcomes and are likely multifactorial. Potential reasons include time for resuscitation, transfer from admitting areas and co-ordination of emergency endoscopy teams and equipment. These logistics need to be understood more and improved to achieve improvements in patient care. Disclosure of Interest None Declared

PTH-033 How Good is Emergency Endoscopy? An Observational Study of Technical and Non-Technical Performance and Procedure Quality

Introduction Patients undergoing emergency endoscopy are acutely unwell, often comorbid with higher mortality compared to routine cases. Therapeutic intervention is likely and procedures may be conducted out of hours in less familiar environments. There is a longer learning curve, posing challenges for skill acquisition and retention. NCEPOD identified good decision-making and teamwork as areas for improvement for patient safety in urgent cases. The Upper GI Bleed Toolkit sets quality standards for 24/7 service provision. However, variation exists on when urgent procedures are performed, equipment availability, endoscopy teams, procedure setting and access to senior supervision. This study investigated whether the endoscopist’s performance in technical and non-technical skill is also implicated. Methods Aims: To compare performance in urgent/emergency (E) and routine (R) GI endoscopy in a tertiary unit. A prospective observational comparative study was conducted with live ratings of technical skill (DOPS 1–4*) non-technical skill (ENTS 1–4*), degree of completion of a 13 item endoscopy safety checklist (SC) and Patient Safety Incidents (PSI). Over 2 months, consecutive E cases were live rated by an independent trained observer using validated tools. R cases matched for endoscopist experience and procedure were rated within the following 24 h. Wilcoxon and t tests were used to compare paired E and R data and Spearman’s rank was used to examine correlation between the different variables. (*1 = poor 4 = excellent) Results 41 E & 41 R cases performed by independent endoscopists on the on-call GIB rota were assessed. All variables were poorer for E compared to R cases (Table). ENTS, DOPS and SC completion were positively correlated. PSI were inversely correlated with ENTS, DOPS and SC completion (Image) Conclusion Performance in urgent/emergency endoscopy was significantly poorer than for routine procedures and resulted in more PSI. Different technical and non-technical skills may be required for emergency endoscopy. In these complex higher-risk cases, poorer non-technical skills and suboptimal checklist completion may be negatively impacting technical performance in endoscopists who perform well in the routine setting. These offer targeted training opportunities and performance assessments to enhance safety and quality. Disclosure of Interest None Declared