Timing of Endoscopy for Acute Upper GastroIntestinal Bleeding
Acute upper gastrointestinal bleeding (AUGIB) is a common medical emergency. In Western countries, its incidence was estimated to be over 100 cases per 100 000 adults per year. Fortunately, the mortality rates of AUGIB have decreased over the past few decades, largely attributable to improvements in endoscopic and pharmacological therapies.
However, there is limited clinical data regarding the optimal timing of endoscopy within the 24-hour period. Authors have recently conducted a randomised controlled trial (RCT) to investigate the clinical outcomes of AUGIB patients receiving urgent (<6 hours) vs early (<24 hours) endoscopy.
Key messages
Question
Does the timing of endoscopy affect clinical outcomes in patients presenting with acute upper gastrointestinal bleeding?
Findings
In this retrospective, territory-wide, cohort study with 6474 patients, authors observed significant more favorable outcomes among patients who received endoscopy between 6 and 24 hours after admission, compared with patients who received endoscopy within 6 hours and between 24 and 48 hours.
Study findings demonstrate that urgent endoscopy (≤6 hours) has worse outcomes compared with early endoscopy (6-≤24 hours). In contrast, the outcomes for late timing (24-≤48 hours) were more variable.
Among AUGIB patients receiving therapeutic endoscopies, urgent endoscopy timing was associated with higher 30-day all-cause mortality, in-hospital mortality and increased ICU admission rates.
Late endoscopy timing was also associated with increased 30-day all-cause mortality, in-hospital mortality rates and 30-day transfusion rate, compared with the early endoscopy group but was also associated with a lower rate of ICU admission after endoscopy.
For variceal bleeding, only late endoscopy was associated with worse outcomes, with higher rates of repeated endoscopy and ICU admission.
Meaning
Appropriate timing of endoscopy within 24 hours, after resuscitation and medical optimization, is associated with better clinical outcomes in patients presenting with acute upper gastrointestinal bleeding.
Endoscopy within 24 hours for acute nonvariceal upper gastrointestinal bleeding is associated with superior outcomes compared with urgent or late endoscopy. This may highlight the importance of adequate resuscitation and pharmacotherapy.
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What is already known on this subject?
It is commonly recommended that acute upper gastrointestinal bleeding (AUGIB) patient should receive endoscopic intervention within 24 hours on presentation to hospital, to identify the source of bleeding, risk-stratify patients and provide potential endoscopic treatments.
What are the new findings?
This study results suggest that performing therapeutic endoscopy within 6–24 hours is associated with significantly better clinical outcomes, when compared with those performed ≤6 hours or 24–48 hours.
How might it impact on clinical practice in the foreseeable future?
This study emphasizes the importance of adequate resuscitation and medical optimization before endoscopy in patients presenting with AUGIB. Given that AUGIB is one of the most common inpatient diseases, authors believe that this result has the potential to impact the management of patients around the world.
OBJECTIVE
While it is recommended that patients presenting with acute upper gastrointestinal bleeding (AUGIB) should receive endoscopic intervention within 24 hours, the optimal timing is still uncertain. We aimed to assess whether endoscopy timing postadmission would affect outcomes.
DESIGN
We conducted a retrospective,
territory-wide, cohort study with healthcare data from all public hospitals in
Hong Kong. Adult patients (age ≥18) that presented with AUGIB between 2013 and
2019 and received therapeutic endoscopy within 48 hours were recruited.
Patients were classified based on endoscopic timing postadmission: urgent
(t≤6), early (6
RESULTS
Results showed that urgent timing had worse outcomes compared with early endoscopy, with higher 30-day all-cause mortality, repeat endoscopy rates (p<0.001) and ICU admission rates. Late endoscopy was associated with worse outcomes, with higher 30-day mortality, in-hospital mortality and 30-day transfusion rates.
CONCLUSION
Compared with urgent and late endoscopy among patients who have received therapeutic endoscopies, early endoscopy was associated with superior outcomes especially among patients with non-variceal bleeding. This supports the notion that non-variceal AUGIB patients should receive endoscopy within 24 hours, but also emphasises the importance of prior resuscitation and pharmacotherapy.
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