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Our data support the stepwise approach to management of BCS, with very good outcomes from venoplasty combined with stenting when required. TIPSS should only be offered where HV interventions are not feasible or unsuccessful.

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with primary biliary cirrhosis based on serum albumin levels, platelet count and serum alkaline phosphatase level. A easy accessible online tool is available where values can be entered and score greater than 50% is considered to predict the presence of varices, thereby warranting oesophago-gastro-duodenoscopy (OGD). The aim of this study was to validate this score in an external validation cohort from Liverpool. Methods Retrospective study involving 80 PBC patients under follow up at a university hospital. Of them, patients who had undergone a OGD for any clinical reason were identified and findings of the OGD noted. Results of blood tests to allow calculation of the NVP score were recorded. An NVP probability of 0.5 was used as the cut-off to analyse the performance of the score. Results Patients involved in the study had mean albumin levels of 36, platelets of 260 with an ALP ranging between 58 and 811. 97% were female and median age of patients was 67 years. 30 PBC patients who had an OGD were identified. 10 of the 30 patients had varices on endoscopy. The NVP Score performed well in identifying those in whom varices were absent in this cohort (sensitivity of 100%, specificity 69%, Negative Predictive Value 100% and Positive Predictive Value 10%; overall accuracy 84.5%) and had a good discriminating power with AUROC 0.89. Conclusion The NVP Score proved to be a highly sensitive tool to discriminate patients with PBC who do not have varices and in whom OGD is unnecessary in our cohort. The study therefore strongly supports the view that prospectively applying the score in patients with PBC will help to direct endoscopic evaluation in the right category of patients thereby ensuring effective use of resources. REFERENCE1 Patanwala I, et al.

were retrospectively reviewed. Only patients who were in the intensive care unit requiring ventilatory and/or inotropic support and general anaesthesia for stabilisation at the time of ERCP were included. Data collected included indications, co-morbidities, technical success and 30-day mortality. Results A total of 2237 ERCPs were performed during this period, out of which 36 (2%) emergency ERCP's were performed in 32 patients. There were 15 males and 17 females. 27/32 patients (84%) had not had previous ERCP. The median age of patients was 79 years (range 42e89). ASA grade prior to the presenting illness was 1 in 6 (17%); 2 in 15 (42%); 3 in 15 (42%). All cases were performed under general anaesthesia in emergency theatre. 27/36 cases (75%) required inotropic support. Indications included cholangitis 28/36 (78%); acute pancreatitis with cholangitis 5/36 (14%); post-operative bile leak 3/36 (8%). Biliary cannulation was achieved in all cases (100%). Endoscopic findings included: common bile duct (CBD) stones in 26/36 (72%); bile leak in 3/36 (8%); CBD stricture in 2/36 (6%); Mirizzi's in 1/36 (3%); blocked plastic stent in 1/36 (3%) and post-sphincterotomy bleed with clot obstruction in 1/36 (3%). Sphincterotomy was performed in 25/36 (69%) cases. 23/36 (64%) patients had stent insertion and in 11/36 (30%) patients balloon trawl was sufficient to clear the ducts. A rapid reduction in bilirubin was observed within 24e48 h following ERCP (Pre ERCP bilirubin: median 104, range 9e553 mmol/l; post ERCP bilirubin: median 29.5 range 12e217 mmol/l p<0.001 (Wilcoxon Signed rank test). 30-day mortality was 25% (8/32 patients) and the majority of these patients (6/8, 75%) died within 24 h of ERCP due to overwhelming sepsis. There was a single case of post sphincterotomy bleed that required a repeat procedure due to clot obstruction. There were no other procedure related complications. The median length of hospital stay was 21 days (range 2e49). Conclusion Although the 30-day mortality remains high due to multi-organ dysfunction, ERCP is successful in majority of these patients and translates to a good outcome for this cohort of critically ill patients, in whom the prognosis is inevitably poor without an emergency ERCP.

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