Performing endoscopy for acute upper GI bleeding within six hours did not improve outcomes compared to completing the procedure within 24 hours, a trial found.
The trial included 516 patients with overt signs of acute upper GI bleeding and a Glasgow-Blatchford score of 12 or higher (scores range from 0 to 23, with higher scores indicating a higher risk of further bleeding or death). They were randomized to endoscopy either within six hours (urgent) or between six and 24 hours (early) after gastroenterologic consultation. Results were published by the New England Journal of Medicine on April 2.
The primary outcome of mortality within 30 days occurred in 8.9% of the urgent-endoscopy group and 6.6% of the early-endoscopy group (difference, 2.3 percentage points; 95% CI, −2.3 to 6.9 percentage points). Rates of further bleeding within 30 days were also not significantly different between groups: 10.9% in the urgent group and 7.8% in the early group (difference, 3.1 percentage points; 95% CI, −1.9 to 8.1 percentage points). Initial endoscopy found ulcers with active bleeding or visible vessels in 105 of the 158 patients (66.4%) with peptic ulcers in the urgent group and in 76 of the 159 patients (47.8%) with peptic ulcers in the early group. Rates of hemostatic treatment were 60.1% with urgent endoscopy and 48.4% with early endoscopy.
“The observed higher incidences of further bleeding and death with urgent endoscopy than with early endoscopy contrast sharply with our hypothesis that urgent endoscopy would be associated with improved outcomes,” the authors said. They noted that a small benefit to urgent endoscopy could not be ruled out by the findings but that the numerically higher number of deaths in the urgent group “raises the possibility that patients may benefit from treatment for coexisting medical illnesses and a period of acid suppression.”
The study had several limitations that restrict its generalizability, the authors noted. The results do not apply to patients with ongoing bleeding and hypotensive shock or to hospitals without 24-hour endoscopy. There were also relatively few patients with variceal bleeding in the trial.
An accompanying editorial reviewed the previous observational research on the timing of endoscopy and noted that a trial such as this one had been long awaited. “The available evidence suggests that most patients hospitalized with upper gastrointestinal bleeding need not be rushed to immediate endoscopy. Rather, resuscitation and treatment for coexisting active medical conditions should be initiated as appropriate and endoscopy then performed within 24 hours after presentation,” the editorial concluded.