Diagnosis and Management of Acute Lower Gastrointestinal Bleeding: Guidelines From the British Society of Gastroenterology

This is the first UK national guideline to concentrate on acute lower gastrointestinal bleeding (LGIB) and has been commissioned by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG). The Guidelines Development Group consisted of representatives from the BSG Endoscopy Committee, the Association of Coloproctology of Great Britain and Ireland, the British Society of Interventional Radiology, the Royal College of Radiologists, NHS Blood and Transplant and a patient representative. A systematic search of the literature was undertaken and the quality of evidence and grading of recommendations appraised according to the GRADE(Grading of Recommendations Assessment, Development and Evaluation) methodology. These guidelines focus on the diagnosis and management of acute LGIB in adults, including methods of risk assessment and interventions to diagnose and treat bleeding (colonoscopy, computed tomography, mesenteric angiography, endoscopic therapy, embolisation and surgery). Recommendations are included on the management of patients who develop LGIB while receiving anticoagulants (including direct oral anticoagulants) or antiplatelet drugs. The appropriate use of blood transfusion is also discussed, including haemoglobin triggers and targets.

Diagnosis and management of acute lower gastrointestinal bleeding: guidelines from the British Society of Gastroenterology.

This is the first UK national guideline to concentrate on acute lower gastrointestinal bleeding (LGIB) and has been commissioned by the Clinical Services and Standards Committee of the British Society of Gastroenterology (BSG). The Guidelines Development Group consisted of representatives from the BSG Endoscopy Committee, the Association of Coloproctology of Great Britain and Ireland, the British Society of Interventional Radiology, the Royal College of Radiologists, NHS Blood and Transplant and a patient representative. A systematic search of the literature was undertaken and the quality of evidence and grading of recommendations appraised according to the GRADE(Grading of Recommendations Assessment, Development and Evaluation) methodology. These guidelines focus on the diagnosis and management of acute LGIB in adults, including methods of risk assessment and interventions to diagnose and treat bleeding (colonoscopy, computed tomography, mesenteric angiography, endoscopic therapy, embolisation and surgery). Recommendations are included on the management of patients who develop LGIB while receiving anticoagulants (including direct oral anticoagulants) or antiplatelet drugs. The appropriate use of blood transfusion is also discussed, including haemoglobin triggers and targets.

Non-technical skills and gastrointestinal endoscopy: a review of the literature.

BACKGROUND: Non-technical skills (NTS) have gained increasing recognition in recent years for their role in safe, effective team performance in healthcare. Gastrointestinal endoscopy is a procedure-based specialty with rapidly advancing technology, significant operational pressures and rapidly changing 'teams of experts'. However, to date there has been little focus on the effect of NTS in this field. OBJECTIVES: This review aims to examine the existing literature on NTS in gastrointestinal endoscopy and identify areas for further research. METHOD: A systematic search of MEDLINE, Embase, Cochrane Library, PsychINFO, CINAHL Plus and PubMed databases was performed using search terms Non-Technical Skills, Team Performance or Team Skills, and Endoscopy, Colonoscopy, OGD, Gastroscopy, Endoscopic Retrograde Cholangio-Pancreatography or Endoscopic Ultrasound. RESULTS: Eighteen relevant publications were found. NTS are deemed an essential component of practice, but so far there is little evidence of their integration into training or competency assessment. Those studies examining the effects of NTS and team training in endoscopy are small and have variable outcome measures with limited evidence of improvement in skills or clinical outcomes. NTS assessment in endoscopy is in its early phases with a few tools in development. CONCLUSIONS: The current literature on NTS in gastrointestinal endoscopy is limited. NTS, however, are deemed an essential component of practice, with potential positive effects on team performance and clinical outcomes. A validated reliable tool would enable evaluation of training and investigation into the effects of NTS on outcomes. There is a clear need for further research in this field.

Haplotype analysis finds linkage disequilibrium in the IL-12 gene in patients with HCV.

HCV is a major cause of liver disease worldwide. IL-12 plays an essential role in the balance of T helper 1 (Th1) differentiation versus a T helper 2 (Th2) driven response from its naïve precursor. Linkage disequilibrium measures the degree to which alleles at two loci are associated and the non-random associations between alleles at two loci. Haplotypes of the three IL-12B loci studied were determined in the patient cases and the normal healthy control subjects. The frequency of the 12 possible IL-12B haplotypes on the 3 loci was determined in subjects heterozygous at only one of the loci within the studied haplotype. Haplotype frequencies were compared between the patient groups and controls (n = 49) to determine if any preferential combination of markers occurred using chi-squared and applying the Bonferroni correction. 45 HCV RNA negative patients; 88 HCV RNA positive patients; and 15 uninfected cases at high risk of HCV infection (EU) were studied. The haplotype "C" SNP of the 3'UTR with the "E" 4 bp deletion of the intron 4 region was in linkage disequilibrium (χ(2) = 45.15, P < 0.001, 95% CL). The haplotype analysis of the insertion allele of the promoter with the deletion allele of the intron 4("E") IL-12B polymorphism showed linkage disequilibrium (χ(2) = 5.64, P = 0.02). Linkage disequilibrium of polymorphisms is reported in the IL-12 gene in patients with HCV infection and contributes to the understanding of patient genotype and expected production of IL-12, responding to infection.

Polymorphic differences in SOD-2 may influence HCV viral clearance.

Hepatitis C virus (HCV) is a pathogen causing chronic hepatitis, cirrhosis, and liver cancer occurring in about 3% of the world's population. Most individuals infected with HCV develop persistent viremia. Oxidative stress may play an important role in the pathogenesis of a number of diseases including HCV infection and diabetes mellitus. Polymorphisms in the antioxidant genes may determine cellular oxidative stress levels as a primary pathogenic role in HCV and/or in its complications. Patients with HCV and normal, healthy controls were investigated for a superoxide dismutase (SOD-2) polymorphism in the mitochondrial targeting sequence with Ala/Val (C-9T) substitution. Polymorphisms in antioxidant gene SOD-2 were carried out by PCR, restriction fragment length polymorphism assays and by polyacrylamide gel electrophoresis. For the SOD-2 polymorphism, the RNA positive group showed a higher percentage of "CT" genotype than the RNA negative group (89.3% vs. 66.1%, P = 0.001, χ(2) = 11.9). The RNA negative group had more TT genotypes than the RNA positive group (27.4% vs. 6.80%, P = 0.01, χ(2) = 11.6). The exposed uninfected group had an increased frequency of the "CT" genotype (86.2% vs. 66.1%, P = 0.02, χ(2) = 5.5). The RNA positives had a higher frequency of the "CT" from the normal controls (72.1% vs. 89.2%, P = 0.005, χ(2) = 7.8).

CD81 sequence and susceptibility to hepatitis C infection.

Several cell surface molecules have hepatitis C virus (HCV) binding properties and may serve as receptors facilitating viral entry into cells. The large extracellular loop (LEL) of CD81 has been shown to bind the HCV envelope protein E2 with several critical residues for the CD81-HCV-E2 interaction. It was hypothesised that variation in the CD81 LEL sequence may modify susceptibility to HCV infection. HCV RNA negative patients with spontaneous viral clearance (RNA -ve); HCV RNA positive cases, who are affected chronically (RNA +ve); and patients at high risk of HCV infection, exposed but uninfected patients (EU) were studied. Genomic DNA was extracted from whole blood samples and four exons of the CD81 LEL gene were amplified by PCR and sequenced. The cDNA derived from CD81 (≈700 bp) was sequenced following RNA extraction from peripheral blood mononuclear cells. Patients, who are RNA positive, RNA negative, and exposed uninfected were sequenced for four DNA sections (A, B, C, and D). Sixty-two (43M:19F) patients, from all the patient cohorts, were sequenced and compared for the C section alone (which encompasses the important binding region of the molecule for envelope protein) including 21 (14M:7F) HCV RNA negative, 15 (10M:5F) HCV RNA positive and 26 (20M:6F) exposed uninfected and no sequence differences were observed. The entire CD81 sequence from cDNA was obtained in 23 cases-11 RNA -ve, 5 RNA +ve and 7 EU. In 7 of the 23 cases, the nucleotides were confirmed with the genomic sequence (4 RNA -ve and 3 EU cases). No sequence variation was found in any of the patients studied by either method, including gene sections encoding the residues most important for CD81-HCV E2 binding. The LEL of CD81 is a molecule that is highly conserved. No differences in nucleotide sequence influencing susceptibility to, or outcome of HCV infection or evidence of methylation of the gene were found.

Polymorphisms in the IL-12B gene and outcome of HCV infection.

Most people with hepatitis C virus (HCV) develop chronic infection with persistent viremia. Resolution of infection is associated with antiviral cellular immune responses of T helper 1 (Th1) type. Interleukin-12 (IL-12) is a key cytokine in the generation of Th1 responses, and functionally relevant polymorphisms of the IL12B gene and its promoter have been described recently. We sought an association between three IL12B polymorphisms and outcome of HCV infection in 195 HCV antibody-positive patients; 123 were chronically infected with detectable HCV RNA, and 72 had spontaneously resolved infection testing repeatedly negative for HCV RNA. Genotyping was performed for a single nucleotide polymorphism (SNP) in the 3'-UTR (1188A/C) of the IL12B gene and for 4-bp insertion/deletion polymorphisms in the IL12B promoter region and in the intron 4 region of the IL12B gene. We found chronically infected patients were significantly more likely than those with resolved HCV infection to be homozygous for the 3'-UTR A allele (66% vs. 50%; chi-square = 4.12, p = 0.04 with Yates correction), which has been associated with lower IL-12 production. No other significant association was found. Our findings support the concept that an individual's genetically determined ability to produce IL-12 is another factor that can influence the outcome of HCV infection.