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Gastroesophageal reflux disease (GORD) is a common presentation in general practice. It develops when the reflux of stomach contents cause troublesome symptoms and/or complications. (1) Patients with GORD describe a [...]

ObjectivesExisting scores are not accurate at predicting mortality in upper (UGIB) and lower (LGIB) gastrointestinal bleeding. We aimed to develop and validate a new pre-endoscopy score for predicting mortality in both UGIB and LGIB.Design and settingInternational cohort study. Patients presenting to hospital with UGIB at six international centres were used to develop a risk score for predicting mortality using regression analyses. The score’s performance in UGIB and LGIB was externally validated and compared with existing scores using four international datasets. We calculated areas under receiver operating characteristics curves (AUROCs), sensitivities, specificities and outcome among patients classified as low risk and high risk.Participants and resultsWe included 3012 UGIB patients in the development cohort, and 4019 UGIB and 2336 LGIB patients in the validation cohorts. Age, Blood tests and Comorbidities (ABC) score was closer associated with mortality in UGIB and LGIB (AUROCs: 0.81–84) than existing scores (AUROCs: 0.65–0.75; p≤0.02). In UGIB, patients with low ABC score (≤3), medium ABC score (4–7) and high ABC score (≥8) had 30-day mortality rates of 1.0%, 7.0% and 25%, respectively. Patients classified low risk using ABC score had lower mortality than those classified low risk with AIMS65 (threshold ≤1) (1.0 vs 4.5%; p<0.001). In LGIB, patients with low, medium and high ABC scores had in-hospital mortality rates of 0.6%, 6.3% and 18%, respectively.ConclusionsIn contrast to previous scores, ABC score has good performance for predicting mortality in both UGIB and LGIB, allowing early identification and targeted management of patients at high or low risk of death.

Hepatotropic viruses are extremely common worldwide and among frequent causes of acute hepatitis and acute liver failure. Most commonly, these infections present with a viral prodrome and an acute increase in liver enzymes but atypical presentations can occur. Whereas most infections are benign and self-limiting, chronic states do occur; in the case of Epstein–Barr virus and cytomegalovirus, latency occurs after primary infection, with reactivation occurring at later times of illness. Vaccination programmes for hepatitis A, where available, have led to a significant reduction in incidence. Our knowledge of these viruses continues to expand, especially with regard to hepatitis E and its genotypes. Hepatitis E virus has recently been found in donated human blood and is the causative agent in some patients presenting with neurology signs and symptoms; it is now considered a significant health burden in both developing and developed countries.

Objectives:Numerous reviews indicate bloody hematemesis signifies more severe bleeding than coffee-grounds hematemesis. We assessed severity and outcomes related to bleeding symptoms in a prospective study.Methods:Consecutive patients presenting with hematemesis or melena were categorized as bloody emesis (N=1209), coffee-grounds emesis without bloody emesis (N=701), or melena without hematemesis (N=1069). We assessed bleeding severity (pulse, blood pressure) and predictors of outcome (hemoglobin, risk stratification scores) at presentation, and outcomes of bleeding episodes. The primary outcome was a composite of transfusion, intervention, or mortality.Results:Bloody and coffee-grounds emesis were similar in pulse =100 beats/min (35 vs. 37%), systolic blood pressure =100?mm?Hg (12 vs. 12%), and hemoglobin =100?g/l (25 vs. 27%). Risk stratification scores were lower with bloody emesis. The composite end point was 34.7 vs. 38.2% for bloody vs. coffee-grounds emesis; mortality was 6.6 vs. 9.3%. Hemostatic intervention was more common (19.4 vs. 14.4%) with bloody emesis (due to a higher frequency of varices necessitating endoscopic therapy), as was rebleeding (7.8 vs. 4.5%). Outcomes were worse with hematemesis plus melena vs. isolated hematemesis for bloody (composite: 62.4 vs. 25.6%; hemostatic intervention: 36.5 vs. 13.8%) and coffee-grounds emesis (composite: 59.1 vs. 27.1%; hemostatic intervention: 26.4 vs. 8.1%).Conclusions:Bloody emesis is not associated with more severe bleeding episodes at presentation or higher mortality than coffee-grounds emesis, but is associated with modestly higher rates of hemostatic intervention and rebleeding. Outcomes with hematemesis are worsened with concurrent melena. The presence of bloody emesis plus melena potentially could be considered in decisions regarding timing of endoscopy.

Out of hours admissions have higher mortality for many conditions but upper gastrointestinal haemorrhage studies have produced variable outcomes. Prospective study of 12 months consecutive admissions of upper gastrointestinal haemorrhage from four international high volume centres. Admission period (weekdays, weeknights or weekends), demographics, haemodynamic parameters, laboratory results, endoscopy findings, further procedures and 30-day mortality were recorded. Five upper gastrointestinal haemorrhage risk scores were calculated. 2118 patients, 60% male, median age 66 years were studied. Compared with patients presenting on weekdays, patients presenting at weekends had no significant differences in comorbidity, pulse, systolic BP, risk scores, frequency of peptic ulcers or varices. Those presenting on weekdays had lower haemoglobin (p?=?0.007) and were more likely to have a normal endoscopy (p?

Hepatitis E is hyperendemic in many developing countries in Asia and Africa, and is caused by hepatitis E virus (HEV) genotypes 1 and 2, which are spread via the faecal–oral route by contaminated water. Recent data show that HEV infection is also endemic in developed countries. In such geographical settings, hepatitis E is caused by HEV genotypes 3 and 4, and is mainly a porcine zoonosis. In a minority of cases, HEV causes acute and chronic hepatitis, but infection is commonly asymptomatic or unrecognized. HEV infection is associated with a number of extrahepatic manifestations, including a range of neurological injuries. To date, 91 cases of HEV-associated neurological injury — most commonly, Guillain–Barré syndrome, neuralgic amyotrophy, and encephalitis/myelitis — have been reported. Here, we review the reported cases, discuss possible pathogenic mechanisms, and present our perspectives on future directions and research questions.

Hepatotropic viruses are extremely common worldwide and among the most common causes of acute hepatitis and acute liver failure. Seroprevalence rates are high and higher rates are increasingly being found as assays become more sensitive. Most commonly, they present with a viral prodrome and an acute increase in liver enzymes but atypical presentations can occur. Whereas the majority of infections are benign and self-limiting, chronic states do occur, and in the case of Epstein–Barr virus and cytomegalovirus latency occurs after primary infection, with reactivation occurring at later times of illness. Vaccination programmes for hepatitis A, where available, have led to a significant reduction in incidence. Our knowledge of these viruses continues to expand, especially with regard to hepatitis E and its genotypes. Hepatitis E virus has recently been found in donated human blood and the causative agent in some cases of patients presenting with neurology signs and symptoms; it is now considered a significant health burden in both developing and developed countries.

To determine whether there is an association between an acute preceding hepatitis E virus (HEV) infection and neuralgic amyotrophy (NA), and if so, whether patients with HEV-related NA differ from patients without an associated HEV infection.

The aim of the study was to determine whether Guillain-Barré syndrome (GBS) is associated with preceding hepatitis E virus infection.

SUMMARYHepatitis E virus (HEV) infection is a worldwide disease. An improved understanding of the natural history of HEV infection has been achieved within the last decade. Several reservoirs and transmission modes have been identified. Hepatitis E is an underdiagnosed disease, in part due to the use of serological assays with low sensitivity. However, diagnostic tools, including nucleic acid-based tests, have been improved. The epidemiology and clinical features of hepatitis E differ between developing and developed countries. HEV infection is usually an acute self-limiting disease, but in developed countries it causes chronic infection with rapidly progressive cirrhosis in organ transplant recipients, patients with hematological malignancy requiring chemotherapy, and individuals with HIV. HEV also causes extrahepatic manifestations, including a number of neurological syndromes and renal injury. Acute infection usually requires no treatment, but chronic infection should be treated by reducing immunosuppression in transplant patients and/or the use of antiviral therapy. In this comprehensive review, we summarize the current knowledge about the virus itself, as well as the epidemiology, diagnostics, natural history, and management of HEV infection in developing and developed countries.

Hepatitis E has been regarded as a disease of the developing world, where it causes large waterborne outbreaks and sporadic cases of hepatitis. Recent research has shown this received wisdom to be mistaken.

Hepatitis E virus (HEV) was discovered during the Soviet occupation of Afghanistan in the 1980s, after an outbreak of unexplained hepatitis at a military camp. A pooled faecal extract from affected soldiers was ingested by a member of the research team. He became sick, and the new virus (named HEV), was detected in his stool by electron microscopy. Subsequently, endemic HEV has been identified in many resource-poor countries. Globally, HEV is the most common cause of acute viral hepatitis. The virus was not initially thought to occur in developed countries, but recent reports have shown this notion to be mistaken. The aim of this Seminar is to describe recent discoveries regarding HEV, and how they have changed our understanding of its effect on human health worldwide.

The CT findings in a 24-year-old woman with acute chest symptoms revealed excess mediastinal soft tissue and a fat-containing cavity. A fat-fluid level in a pleural effusion suggested preoperatively the diagnosis of mediastinal teratoma, which had leaked into the pleural space.

BackgroundHepatitis E virus (HEV) is a common zoonotic infection associated with pigs which is endemic in many developed countries. Most infections are asymptomatic, with only a minority causing clinically evident hepatitis. Numerous extra-hepatic manifestations are associated with HEV, most commonly neurological injury. The aim of the study was to explore the relationship between HEV and acute neurological illness.Methods464 consecutive patients presenting to 4 centres in the UK, France and the Netherlands with acute non-traumatic neurological illnesses were prospectively tested for HEV by serology and PCR.Findings11/464 patients (2.4%) had evidence of current/recent HEV infection. Neurological cases in which HEV infection was found included neuralgic amyotrophy (n=3, all PCR positive); cerebrovascular event (n=4); seizure (n=2); encephalitis (n=1); and an acute combined facial and vestibular neuropathy (n=1). Symptoms of hepatitis were mild and no patients were clinically jaundiced.InterpretationThe 3 cases of HEV associated neuralgic amyotrophy had similarities with other previously described HEV-associated cases; all were middle-aged males with bilateral involvement of the brachial plexus. This observation supports a causal relationship between HEV and neuralgic amyotrophy. To further understand the relevance of HEV infection in patients with acute neurological illnesses, case control studies are warranted.

BackgroundHEV-NA may have a distinct clinical phenotype and outcome compared to cases of NA without HEV infection.MethodsCases of NA were identified in 11 centres from 7 countries, with retrospective analysis of demographics, clinical/laboratory findings, treatment and outcome. HEV-NA cases were compared to NA cases without evidence of HEV infection.Findings57 HEV-NA and 61 NA without HEV cases were studied. 56/57 of HEV-NA cases were IgM positive (53 IgG positive). In 36 HEV RNA was recovered from the serum and in one from the CSF (all genotype 3). 51/57 HEV-NA cases were anicteric (median ALT was 259 IU/L: range 12–2961). In 6 the liver function tests (LFT) were normal. HEV-NA cases were more likely to have bilateral involvement (p<0.001), damage outside the brachial plexus (p<0.01), reduced reflexes (p=0.03), sensory symptoms (p=0.04) with more extensive damage to the brachial plexus. There was no difference in outcome between both groups at 12 months.InterpretationPatients with HEV-NA are usually anicteric with modest rises in ALT and have a distinct clinical phenotype. Involvement outside the brachial plexus is more common. Patients presenting with NA should be tested for HEV, irrespective of LFT. Prospective treatment/outcome studies of HEV-NA are now warranted.

Hepatitis E virus (HEV) is the most common cause of viral hepatitis in the world. It is estimated that millions of people are infected every year, resulting in tens of thousands of deaths. However, these estimates do not include industrialized regions and are based on studies which employ assays now known to have inferior sensitivity. As such, this is likely to represent a massive underestimate of the true global burden of disease. In the developing world, HEV causes large outbreaks and presents a significant public-health problem. Until recently HEV was thought to be uncommon in industrialized countries, and of little relevance to clinicians in these settings. We now know that this is incorrect, and that HEV is actually very common in developed regions. HEV has proved difficult to study in vitro, with reliable models only recently becoming available. Our understanding of the lifecycle of HEV is therefore incomplete. Routes of transmission vary by genotype and location: endemic regions experience large waterborne epidemics, while sporadic cases in industrialized regions are zoonotic infections likely spread viathe food chain. Both acute and chronic infection has been observed, and a wide range of extrahepatic manifestations have been reported. This includes neurological, haematological and renal conditions. As the complete clinical phenotype of HEV infection is yet to be characterized, a large proportion of cases go unrecognized or misdiagnosed. In many cases HEV infection does not feature in the differential diagnosis due to a lack of knowledge and awareness of the disease amongst clinicians. In combination, these factors have contributed to an underestimation of the threat posed by HEV. Improvements are required in terms of recognition and diagnosis of HEV infection if we are to understand the natural history of the disease, improve management and reduce the burden of disease around the world.

Objective To compare the predictive accuracy and clinical utility of five risk scoring systems in the assessment of patients with upper gastrointestinal bleeding.Design International multicentre prospective study.Setting Six large hospitals in Europe, North America, Asia, and Oceania.Participants 3012 consecutive patients presenting over 12 months with upper gastrointestinal bleeding.Main outcome measures Comparison of pre-endoscopy scores (admission Rockall, AIMS65, and Glasgow Blatchford) and post-endoscopy scores (full Rockall and PNED) for their ability to predict predefined clinical endpoints: a composite endpoint (transfusion, endoscopic treatment, interventional radiology, surgery, or 30 day mortality), endoscopic treatment, 30 day mortality, rebleeding, and length of hospital stay. Optimum score thresholds to identify low risk and high risk patients were determined.Results The Glasgow Blatchford score was best (area under the receiver operating characteristic curve (AUROC) 0.86) at predicting intervention or death compared with the full Rockall score (0.70), PNED score (0.69), admission Rockall score (0.66, and AIMS65 score (0.68) (all P<0.001). A Glasgow Blatchford score of ≤1 was the optimum threshold to predict survival without intervention (sensitivity 98.6%, specificity 34.6%). The Glasgow Blatchford score was better at predicting endoscopic treatment (AUROC 0.75) than the AIMS65 (0.62) and admission Rockall scores (0.61) (both P<0.001). A Glasgow Blatchford score of ≥7 was the optimum threshold to predict endoscopic treatment (sensitivity 80%, specificity 57%). The PNED (AUROC 0.77) and AIMS65 scores (0.77) were best at predicting mortality, with both superior to admission Rockall score (0.72) and Glasgow Blatchford score (0.64; P<0.001). Score thresholds of ≥4 for PNED, ≥2 for AIMS65, ≥4 for admission Rockall, and ≥5 for full Rockall were optimal at predicting death, with sensitivities of 65.8-78.6% and specificities of 65.0-65.3%. No score was helpful at predicting rebleeding or length of stay.Conclusions The Glasgow Blatchford score has high accuracy at predicting need for hospital based intervention or death. Scores of ≤1 appear the optimum threshold for directing patients to outpatient management. AUROCs of scores for the other endpoints are less than 0.80, therefore their clinical utility for these outcomes seems to be limited.Trial registration Current Controlled Trials ISRCTN16235737.