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.
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.
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