Background: Prior studies have failed to show a benefit to earlier endoscopic intervention in acute GI bleeding. However, those studies were performed in all-comers without attention to the varying risk within the patient population.
Study design: Randomized controlled trial.
Setting: Single center in Hong Kong.
Synopsis: Patients at high risk for further bleeding or death by clinical score were randomized to endoscopy within 6 hours (“urgent endoscopy”), vs. the following day (“early endoscopy”), of GI consultation. Those who required immediate endoscopic intervention because of hemodynamic instability were excluded. All were prescribed proton-pump inhibitor drip, with the addition of vasoactive drugs and antibiotics if there was a suspected variceal bleed. There was no difference in 30-day mortality between the two groups – 8.9% with urgent endoscopy and 6.6% with early endoscopy (HR, 1.35; 95% CI, 0.72-2.54). There was no difference in length of hospital stay or the number of transfusions. Earlier endoscopy within 6 hours was associated with a higher number of actively bleeding lesions requiring intervention and a nonstatistical increase in recurrent bleeding within 30 days. It is believed that more time on proton-pump inhibitor infusion prior to endoscopy allows for stabilization of bleeds, thus requiring less intervention when endoscopy does occur.
Bottom line: Early endoscopy within 6 hours was not beneficial for those at high risk for rebleeding and death from upper GI bleed.
Citation: Lau JYW et al. Timing of endoscopy for acute upper gastrointestinal bleeding. N Engl J Med. 2020;382:1299-308. doi:10.1056/NEJMoa1912484.
Dr. Lee is a hospitalist at Northwestern Memorial Hospital and Lurie Children’s Hospital and assistant professor of medicine, Feinberg School of Medicine, all in Chicago.