Summary Background The association between ulcerative colitis and cytomegalovirus (CMV) has been recognised for over 50 years; and the role of CMV in ulcerative colitis in general, and steroid resistance in particular, remains a topic of ongoing controversy. The outcome for patients with CMV reactivation appears worse than that for patients without reactivation, but it is not entirely clear whether CMV is a contributor or a bystander and if treatment with anti‐virals alters the course of inflammatory bowel disease (IBD). Aim To review the role of CMV associated with IBD, including epidemiology, clinical features, diagnosis and management strategies. Methods By reviewing literature available on CMV associated with IBD in adult patients. A PubMed literature search was performed using the following terms individually or in combination: CMV colitis, cytomegalovirus colitis, IBD and CMV, CMV treatment. Results Cytomegalovirus reactivation is common in patients with severe colitis, with a reported prevalence of 4.5–16.6%, and as high as 25% in patients requiring colectomy for severe colitis. The outcome for this group of patients appears worse than that for patients without reactivation; however, reported remission rates following treatment with anti‐viral therapy are as high as 71–86%. Conclusions Evidence, although not conclusive, supports testing for CMV colonic disease in cases of moderate to severe colitis, by processing biopsies for haematoxylin and eosin staining with immunohistochemistry and/or, CMV DNA real‐time polymerase chain reaction; and if present treating with ganciclovir.

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The development of portal hypertension has serious implications in the natural history of liver cirrhosis, leading to complications such as ascites, hepatic encephalopathy and variceal bleeding. The management of acute variceal bleeding has improved in the last two decades, but despite the advances in endoscopic methods the overall prognosis remains poor, particularly within a subgroup of patients with more advanced disease. The role of Transjugular Intrahepatic Portosystemic Shunt (TIPSS) is a well-established method of achieving haemostasis by immediate portal decompression; however, its use in an emergency setting as a rescue strategy is still associated with high mortality. It has been shown that ‘early’ use of TIPSS as a pre-emptive strategy in a patient with acute variceal bleed in addition to the standard of care confers superior survival outcomes in a subgroup of patients at high risk of treatment failure and death. The purpose of this review is to appraise the literature around the indications, patient selection, utility, complications and economic considerations of pre-emptive TIPSS.

ConclusionThe complication rate does not significantly increase with increasingly deranged coagulation. This is despite very low usage of FFP in this study. There is a trend towards an increased risk of bloodstaining and hypotension in the high INR group, which does not achieve statistical significance. Disclosure of Interest None Declared. Introduction Patients with chronic liver disease have several unplanned admissions during their disease trajectory. 1 We undertook a service improvement initiative to develop a new care pathway for patients with ASLD. Methods Six month pilot of 20 ASLD patients, (≥ 2admissions in last 12 months/'would you be surprised question' with 6-12 mths prognosis/Childs C). Team of hepatologist, community matron, hepatology nurse specialist and service improvement facilitator developed 'Durham Metrics': quantitative and qualitative metrics ( Figure) to evaluate ASLD pathway, on best practice, 2 further refined with focussed discussion with stakehoders. Results The metrics demonstrated that patient expereince prepilot was poor with multiple unplanned admissions and/or long waits, preferred place of death was not discussed; care was not co-ordinated, and quality of life was often poor as a result. All post-pilot metrics reported significant improvements. Use of alternative community services, and shared care plans led to improved efficiency. 83% achieved their preferred place of care and death contrast to nil pre pilot. PWE-156 DURHAM METRICS TO EVALUATE EFFECTIVENESS OFConclusion Key metrics of performance are essential to evaluate service improvement project. The project metrics designed for this project were able to capture changes initiated by pathway however more data and time is needed to draw statistically valid conclusions. Introduction The ideal management of variceal bleeding in the setting of acute alcoholic hepatitis is unclear. We present the outcome of this subgroup of patients in a cohort of patients treated with primary TIPS for variceal bleeding. Methods A retrospective analysis on patients who had TIPS procedure performed as a primary treatment modality within 72 h of acute variceal bleeding from December 2010 to April 2013 with a minimum of 6 months follow up was performed. Results 56 patients were included into the final analysis. In AH patients (n = 18) mean age was 48 years (30-65), mean discriminant function (DF) was 51 (24-87) and mean MELD score was 22. The 6 month mortality was 50%(9/18) with (7/9) dying within 30 days. The median HVPG (mmHg) pre-TIPS and post-TIPS were 16.5 and 6.5 respectively. In non-AH patient (n = 38) average age was 51y (25-70) mean MELD score was 14 (22-7). The mortality was 13% (5/38) at 6 months, (3/5) died by day 30. The median HVPG (mmHg) pre-TIPS and post-TIPS was 23 and 10 respectively. Conclusion In patients with variceal bleeding complicating AH there is a higher 30 day and 6 month mortality in patients managed with a primary TIPS in comparison to patients with cirrhosis. The ideal management of this complex group remains unclear...

BACKGROUND: Nutrition is a modifiable risk factor for patients undergoing multimodal oncologic interventions and plays a major supportive role in the setting of bladder cancer. For patients undergoing radical cystectomy (RC), malnutrition is associated with increased postoperative complications and mortality. OBJECTIVES: The purpose of this scoping review is to characterize the role of nutritional interventions for patients undergoing RC for bladder cancer. METHODS: A multi-database systematic scoping review based on the Preferred Reporting Items for Systematic Reviews extension for Scoping Reviews (PRISMA-ScR) guidelines was performed. Search terms were developed a priori to identify clinical trials that focused on nutritional interventions for patients with bladder cancer undergoing RC. Eligible articles were original research articles or abstracts from clinical trials evaluating nutritional interventions in adult patients undergoing RC. Articles were excluded if they did not focus on a nutritional intervention, if patients did not carry a diagnosis of bladder cancer, or if RC was not performed. Articles were reviewed independently by the authors, and inclusion/exclusion were based on consensus agreement. RESULTS: A total of 83 articles were identified, of which 17 were included in the final analysis. A total of 49 articles were excluded during abstract screening. An additional 17 articles were excluded based on the review of full-text articles. Results of the scoping review suggest that data on the use of nutritional screening, assessment, and intervention for patients undergoing RC are scarce. Although parenteral nutrition (PN) appears to be associated with greater complications after RC, early introduction of food postoperatively or feeding enterally offers benefit and immunonutrition supplements with a focus on a high protein diet has the potential to better optimize surgical outcomes. CONCLUSIONS: Although the prevalence and consequences of malnutrition among patients undergoing RC are well-established, there are limited data evaluating the use of nutritional screening, assessment, and interventions for this population. The pursuit of future clinical trials in this space is critical.

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The present letter to editor is related to Bohra A et al Prognostic significance of hepatic encephalopathy in patients with cirrhosis treated with current standards of care. World J Gastroenterol 2020; 26(18): 2221-2231. Hepatic encephalopathy (HE) is a significant and frequent major decompensating event in cirrhosis. However clinical studies examining the clinical outcome of HE are lacking despite its high prevalence.