The majority of patients who are hospitalized with upper gastrointestinal (GI) bleeding do not require immediate endoscopy, but available evidence suggests that these patients should still undergo the procedure within 24 hours of presentation, according to an editorial written by Loren Laine, MD, of the Yale School of Medicine, which was published in the New England Journal of Medicine.1
Endoscopy findings can help predict risk and guide treatment of patients who are hospitalized with upper GI bleeding. Regarding timing, guidance from the European Society of Gastrointestinal Endoscopy and the International Consensus Group supports commencing endoscopy within 24 hours of bleeding presentation. In contrast, several randomized trials have found no reduction in mortality or recurrent bleeding when endoscopy commences within 12 hours of presentation vs more than 12 hours afterwards.
Pre-endoscopic risk stratification with the Glasgow-Blatchford score, among other prognostic tools, may be helpful in deciding the timing of endoscopy, according to Dr Laine. In patients with a hemodynamically stable condition and no serious comorbidities, evidence suggests that endoscopy could be performed as soon as possible but within routine hours. In patients who are hemodynamically unstable and who present with other high-risk features, guidelines suggest performing endoscopy within 12 hours. In these patients, hemodynamic resuscitation and screening for comorbidities may be necessary prior to early endoscopy.
Observational studies on the timing of endoscopy for high-risk patients have shown inconsistent findings, however, and Dr Laine wrote that a large randomized trial with a high-risk patient population may be needed.
In a recent trial by Lau et al, patients with high risk of mortality or recurrent bleeding underwent endoscopy within either 6 hours following gastroenterologic consultation or within 6 to 24 hours following consultation.2 Mortality from any cause at 30 days was lower than expected in the participants who received endoscopy within 6 to 24 hours vs within 6 hours. Endoscopy within 6 hours of consultation was also associated with a slightly higher bleeding incidence rate.
While this trial suggests waiting 24 hours to perform endoscopy in high-risk patients, Dr. Laine wrote that she favors “endoscopy within 24 hours for patients hospitalized with upper GI bleeding to avoid potentially prolonging hospitalization unnecessarily.”
1. Laine L. Timing of endoscopy in patients hospitalized with upper gastrointestinal bleeding. N Engl J Med. 2020;382(14):1361-1363
2. Lau JYW, Yu Y, Tang RSY, et al. Timing of endoscopy for acute upper gastrointestinal bleeding. N Engl J Med. 2020;382(14):1299-1308