Timing of upper endoscopy influences outcomes in patients with acute nonvariceal upper GI bleeding

Post written by Navin L. Kumar, MD, and John R. Saltzman, MD, from the Brigham and Women’s Hospital, Division of Gastroenterology, Hepatology and Endoscopy and Harvard Medical School, Boston, Massachusetts.

Kumar_headshotJohn Saltzman, MD
The focus of our study was to assess whether patients admitted with acute nonvariceal upper gastrointestinal bleeding (UGIB) with lower-risk vs high-risk bleeding have different outcomes with urgent compared with non-urgent endoscopy.

Current guidelines advise that upper endoscopy be performed within 24 hours of presentation in patients with acute nonvariceal upper GI bleeding (UGIB). The role of more urgent endoscopy (ie,

We conducted a retrospective cohort study at a single academic center of patients admitted with nonvariceal UGIB. Our primary outcome was a composite of inpatient death from any cause, inpatient rebleeding, need for surgical or interventional radiologic intervention, or endoscopic re-intervention. We calculated the Glasgow-Blatchford score (GBS) for each patient and stratified the study sample by lower-risk (GBS < 12) and high-risk (GBS ≥ 12) bleeding severity.

In our study of 361 patients, we found that lower-risk patients who were taken urgently to endoscopy (ie, < 12 hours) were more likely to reach the composite outcome (adjusted OR .71 per 6 hours, P=0.008) compared with non-urgent endoscopy. Of note, these lower-risk patients had a mean GBS of 7.2, and thus should not be considered “lowest-risk” (ie, GBS < 2). In contrast, time to endoscopy was not a significant predictor of the primary outcome (adjusted OR .93 per 6 hours, P=0.47) in high-risk patients. Thus, in contrast to prior literature, our study found that timing of endoscopy was associated with clinical outcomes in acute nonvariceal UGIB – specifically noting worse outcomes with urgent endoscopy in lower-risk patients.

We hypothesize that lower-risk patients, as opposed to high-risk patients, who are taken earlier to endoscopy may receive inadequate fluid resuscitation given that they appear more stable on presentation. Our study underscores the importance of adequate resuscitation prior to undergoing endoscopy, and highlights the need for additional prospective studies to assess the role of prognostic bleeding scores in determining the optimal timing of endoscopy for patients with acute nonvariceal UGIB.

In summary, we found that urgent endoscopy does predict worse outcomes in acute nonvariceal UGIB, particularly in lower-risk patients. Clinicians should ensure optimal medical management, including adequate resuscitation, prior to having patients with UGIB undergo upper endoscopy.

Find the article abstract here.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.

3 thoughts on “Timing of upper endoscopy influences outcomes in patients with acute nonvariceal upper GI bleeding

  1. John Cronin

    Well done on the study. Not sure I’m on board with the inadequate resuscitation conclusion though. Are there not other confounding factors that caused these “low risk” patients to be scoped earlier?
    Can fluid resuscitation not continue at/during endoscopy? If these patients are having an acute bleed, and are tachycardic and hypotensive they need blood specifically. I’m not sure giving other “fluid” such as crytalloid is of any benefit.
    In your summary: “…we found that urgent endoscopy does predict worse outcomes in acute nonvariceal UGIB, particularly in lower-risk patients”. This should say “only” rather than “particularly”?
    Well done again – further work needed to test the hypothesis you came up with.

    1. Navin Kumar

      Hi John,

      Thanks so much for reading our post and your posted comments. We agree that there may be other confounding factors at play that we were unable to account for – certainly a limitation of our retrospective study. We should clarify that these patients were “lower,” but not “low” risk, as this cohort included patients with GBS scores < 12. In terms of the resuscitation theory, we hypothesize that lower-risk patients may appear more stable on presentation and thus not receive the careful attention to hemodynamics as more high-risk patients. During endoscopy, IV hydration does continue but the patient should be adequately resuscitated prior to the procedure, given the risks of hypotension due to sedating medications as well as potential bleeding from endoscopic therapy. We do agree that further investigation with prospective studies in this field of research is needed both to confirm these findings as well as provide additional explanations for why more urgent endoscopy is potentially harmful.

      Thanks again,
      Navin

Leave a Comment

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s