title: Acute variceal haemorrhage in the United Kingdom: patient characteristics, management and outcomes in a nationwide audit.
abstract: BACKGROUND
  Despite advances in treatment, acute variceal haemorrhage remains life-threatening.
  
  
  OBJECTIVE
  To describe contemporary characteristics, management and outcomes of patients with cirrhosis and acute variceal haemorrhage and risk factors for rebleeding and mortality.
  
  
  METHODS
  Multi-centre clinical audit conducted in 212 UK hospitals.
  
  
  RESULTS
  In 526 cases of acute variceal haemorrhage, 66% underwent endoscopy within 24h with 64% (n=339) receiving endoscopic therapy. Prior to endoscopy, 57% (n=299) received proton pump inhibitors, 44% (n=232) vasopressors and 27% (n=144) antibiotics. 73% (n=386) received red cell transfusion, 35% (n=184) fresh frozen plasma and 14% (n=76) platelets, with widely varying transfusion thresholds. 26% (n=135) experienced further bleeding and 15% (n=80) died by day 30. The Model for End Stage Liver Disease score was the best predictor of mortality (area under the receiver operating curve=0.74, P<0.001). Neither the clinical nor full Rockall scores were useful predictors of outcome. Coagulopathy was strongly associated with rebleeding (odds ratio 2.23, 95% CI 1.22-4.07, P=0.01, up to day 30) and mortality (odds ratio 3.06, 95% CI 1.29-7.26, P=0.01).
  
  
  CONCLUSIONS
  Although mortality has improved following acute variceal haemorrhage, rebleeding rates remain appreciably high. There are notable deficiencies in the use of vasopressors and endoscopic therapy. More work is needed to understand the optimum transfusion strategies. Better risk stratification tools are required to identify patients needing more intensive support.
authors.affiliation: NHS Blood & Transplant, John Radcliffe Hospital, Oxford, UK; Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK. Electronic address: vipul.jairath@nhsbt.nhs.uk.
authors.forename: Vipul
authors.initials: V
authors.lastname: Jairath
authors.affiliation: MRC Clinical Trials Unit, London, UK.
authors.forename: Sunita
authors.initials: S
authors.lastname: Rehal
authors.affiliation: Division of Epidemiology and Public Health & Nottingham Digestive Disease Centre, University of Nottingham, UK.
authors.forename: Richard
authors.initials: R
authors.lastname: Logan
authors.affiliation: MRC Clinical Trials Unit, London, UK.
authors.forename: Brennan
authors.initials: B
authors.lastname: Kahan
authors.affiliation: Royal Victoria Infirmary, Newcastle, UK.
authors.forename: Sarah
authors.initials: S
authors.lastname: Hearnshaw
authors.affiliation: NHS Blood & Transplant, John Radcliffe Hospital, Oxford, UK.
authors.forename: Simon
authors.initials: S
authors.lastname: Stanworth
authors.affiliation: Translational Gastroenterology Unit, John Radcliffe Hospital, Oxford, UK.
authors.forename: Simon
authors.initials: S
authors.lastname: Travis
authors.affiliation: NHS Blood & Transplant, John Radcliffe Hospital, Oxford, UK.
authors.forename: Michael
authors.initials: M
authors.lastname: Murphy
authors.affiliation: Western General Hospital, Edinburgh, UK.
authors.forename: Kelvin
authors.initials: K
authors.lastname: Palmer
authors.affiliation: The Royal Free Hospital, London, UK.
authors.forename: Andrew
authors.initials: A
authors.lastname: Burroughs
mesh_terms: D000328:Adult; D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D019540:Area Under Curve; D058625:End Stage Liver Disease / Q000150:complications; D017707:Erythrocyte Transfusion; D004932:Esophageal and Gastric Varices / Q000209:etiology*; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000209:etiology / Q000401:mortality* / Q000628:therapy*; D016558:Hemostasis, Endoscopic / Q000706:statistics & numerical data; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications*; D008297:Male; D008485:Medical Audit; D008875:Middle Aged; D017713:Platelet Transfusion; D054328:Proton Pump Inhibitors / Q000627:therapeutic use; D012372:ROC Curve; D012008:Recurrence; D018570:Risk Assessment; D012720:Severity of Illness Index; D061665:Time-to-Treatment; D016896:Treatment Outcome; D006113:United Kingdom / Q000453:epidemiology; D014662:Vasoconstrictor Agents / Q000627:therapeutic use
chemical_list: D000900:Anti-Bacterial Agents; D054328:Proton Pump Inhibitors; D014662:Vasoconstrictor Agents
keywords: Cirrhosis; Transfusion; Variceal bleeding