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Three Part Question

In [adult patient with acute upper gastrointestinal bleeding] does [early endoscopy] results in [improved outcome]

Clinical Scenario

a patient presents in A/E with Severe Acute Upper Gastrointestinal bleeding. After conservative management, how urgent should endoscopy be performed?
Is there is benefit from very early endoscopy?

Search Strategy

Cochrane Library as: [Bleeding] AND [endoscopy]; [endoscopy!] AND [ time] AND [gastrointestinal]
Medline and Embase(1980-present) using NHS Libraries interface ([gastrointestinal.af]OR [GI.af] OR[UGIB.af] OR[PUD.af] OR[DU.af] OR[ ulcer.af] OR[ Vari$.af]) AND( [bleeding.af] OR[H?morrhage.af]) AND ([endoscopy.af] OR [gastroscopy.af] OR [oesophagogastroduodenoscopy.af] OR [OGD])AND ([timing.af] OR [early.af] OR [delayed.af]); Limit to Humans and English Language

World wide web using Google- 1st 5 pages of search[Endoscopy early Gastrointestinal bleeding]

Search Outcome

569 articles were found, including 2 relevant cochrane review, one good quality metaanalysis and six other relevant articles.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Ioannou GN, Doust J, Rockey DC 20 jan 2003 USA	patients with oesophageal variceal bleeding and receiving treatment with terlipressin;including one high quality RCT comparing in 219 patients terlipressin versus Emergency Sclerotherapy	Cochrane review comparing terlipressin treatment to various other treatments including Emergency Sclerotherapy	Mortality	Terlipressin (26/105); Sclerotherapy(19/114) OR 1.64 [ 0.85, 3.15 ] CI 95%; p-0.14	only one study out of review relates to the topic, though that particular trial was of a high quality; comparing only to one out of possible endoscopic intervention- laser, banding etc.
			Failure of initial haemostasis	20/105( Terlipressin); 20/114( Sclerotherapy) OR 1.11 [ 0.56, 2.19 ] CI 95%, p- 0.77
			Rebleedings	26/105(Terlipressin); 29/114(Sclerotherapy); OR 0.96 [ 0.52, 1.78 ], CI95%, p-0.91
			number of other procedures required to control Bleeding ( TIPS, Thamponade, Sclerotherapy, Surgery)	17/105(Terlipressin); 21/114( Sclerotherapy) OR 0.86 [ 0.43, 1.72 ] CI95%, p-0.66
			Number of blood transfusions	mean(SD)4.7(4.8)(Terlipressin);mean(SD) 4.5(4.3)(Sclerotherapy)- Mean Difference 0.20 [ -1.01, 1.41 ], CI95%, p-0.75
			Length of Hospitalization	Mean(SD)17 (10) (Terlipressin); Mean(SD)18 (10)(Sclerotherapy), Mean Difference- -1.00 [ -3.65, 1.65 ] CI95%, p-0.46
D’Amico G, Pagliaro L, Pietrosi G, Tarantino I 2001 Italy	1146 cirrhotic patients with acute variceal bleeding	Cochrane review of 12 RCT comparing sclerotherapy versus various vasoactive treatments (vasopressin (± nitroglycerin), terlipressin, somatostatin, or octreotide)	failure to control bleeding (11 RCTs, 977 pts)	Risk Differrence( Combined)CI95% -0.03 (-0.07 to 0.01)p=0.14	only sclerotherapy is chosen as endoscopic treatment selection includes patients only with variceal UGIB
			Five-day failure rate(7 RCTs, 759 pts)	Risk Differrence( Combined)CI95% -0.05 (-0.12 to 0.01)p=0.087
			rebleeding (11 RCTs, 1082 pts)	Risk Differrence( Combined)CI95% -0.01(-0.06 to 0.04)p=0.68
			rebleeding before other elective treatments (9 RCTs, 975 pts)	Risk Differrence( Combined)CI95% -0.02 (-0.06 to 0.03) p=0.46
			mortality(12 RCTs, 1146 pts)	Risk Differrence( Combined)CI95% -0.04 (-0.08 to 0.00) p= 0.079
			mortality before other elective treatments (5 RCTs, 474 pts)	Risk Differrence( Combined)CI95% -0.02 (-0.07 to 0.04) p= 0.54
			transfused blood units (7 RCTs, 793 pts)	(weighted mean difference CI95%) -0.17 (-0.52 to 0.19) p= 0.36
			Adverse events (11 RCTs, 1082pts)	Risk Differrence( Combined)CI95% 0.08 (0.02 to 0.14) p= 0.0066
			serious adverse events (5 RCTs, 602 pts)	Risk Differrence( Combined)CI95% 0.05 (0.02 to 0.08) p= 0.0032
Brennan M. R. Spiegel, MD; Nimish B. Vakil, MD; Joshua J. Ofman, MD, MSHS june 11, 2001 USA	Patients presenting with nonvariceal bleeding	Systematic Review of 23 articles, though only 4 randomised	early discharge in stable NVUGIB	46% immediate discharge afterimmediate endoscopy(110 pts, Lee); no significant differences in the rest of the studies
			mortality	no difference in all studies
			rebleeding
			need for surgery
			desaturations	early
Alan Barkun, MD, MSc; Marc Bardou, MD, PhD; and John K. Marshall, MD, MSc 2003	Patients with Nonvariceal Upper Gastrointestinal Bleeding	Clinical Guideline	< 24 h endoscopy in low risk patients	allows for safe and prompt discharge of patients classified as low risk (Recommendation: A [vote: a, 92%; b, 8%]; Evidence: I)	applies only to non variceal bleedings
			< 24 h endoscopy in high risk patients	improves patient outcomes for patients classified as high risk (Recommendation: C [vote: a, 64%; b, 36%]; Evidence: II-2)
			< 24 h endoscopy	reduces resource utilization for patients classified as either low or high risk (Recommendation: A [vote: a, 88%; b, 12%]; Evidence: I)
David J. Bjorkman, MD, MSPH, SM, Atif Zaman, MD, M. Brian Fennerty, MD, David Lieberman, MD, James A 2000 USA	93 patients with acute nonvariceal upper gastrointestinal bleeding	randomised controlled trial comparing < than 6 h endoscopy versus 6-48h	total length of stay	OR 3.98 days: 95% CI[2.84, 5.11], median, 3 days; and OR 3.26 days: 95% CI[2.32-4.21], median, 3 days, for <6h Endoscopy and 6-48h Endoscopy, respectively; p = 0.45.	Unstable patients were excluded from the study, thus possibly removing the group that would have benefit the most from emergent endoscopy
			transfusions requirement	19 patients in early vs 15patients in 6-24h endoscopy(p=0.43); The mean number of transfusions was 1.54 for the Emergent Endoscopy group and 2.14 for the 6-48h Endoscopy group (p = 0.34)
			mortality	0 in both groups
			surgery requirements	1 in each group

Comment(s)

All Existing evidence that I found about the role of endoscopy in Upper GI Bleeding, separate this topic into Variceal and Nonvariceal Bleeding. Two High quality Cochrane reviews suggest that first choice treatment Emergency Endoscopy is not more effective than conservative treatment ( ex. Vasoactive agents)and does not improve any of the outcomes( mortality, rebleedings, hospital stay, need for other procedures, transfusion requirements). One of the reviews revealed statistically higher incidence of adverse effects in the Emergency Endoscopy group. Evidence about Non Variceal bleeding is of less quality. Only Systematic Review on the topic had significant flaws in methodology, and included randomised and non randomised titles, most of which had serious flaws. Most of the trials excluded the most unstable patients. Clinical Consensus guidelines recommend endoscopy in the first 24 hours, as it improves outcome, and results of my search support this recommendation. Though most of the evidence I found about Emergent Endoscopy(less than 6 h) suggest that it is not beneficial, compared to Endoscopy in first 24 hours, evidence is quite limited. There was no good RCT including unstable patients with NVUGIB. More evidence is needed to support or deny usefulness of Emergent Endoscopy

Clinical Bottom Line

Very Good Evidence that in Variceal UGIB endoscopic treatment is not improving outcome, compared to conservative treatment, and results in increased amount of adverse effects. Good Evidence exists to support that Endoscopy in first 24 hours improves outcome in patients presenting with nonvariceal UGIB. Not enough evidence exists to suggest that Endoscopy in first 6 hours improves outcome.

References

1. Ioannou GN, Doust J, Rockey DC Terlipressin for acute esophageal variceal hemorrhage (Review) Copyright © 2009 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd. Reviews 2003, Issue 1. Art. No.: CD002147. DOI: 10.1002/14651858.CD002147
2. D’Amico G, Pagliaro L, Pietrosi G, Tarantino I Emergency sclerotherapy versus medical interventions for bleeding oesophageal varices in cirrhotic patients (Review) © 2009 The Cochrane Collaboration. Published by JohnWiley & Sons, Ltd. Cochrane Database of Systematic Reviews 2002, Issue 1. Art. No.: CD002233. DOI: 10.1002/14651858.CD0
3. Brennan M. R. Spiegel, MD; Nimish B. Vakil, MD; Joshua J. Ofman, MD, MSHS Endoscopy for Acute Nonvariceal Upper Gastrointestinal Tract Hemorrhage: Is Sooner Better? ARCH INTERN MED Arch Intern Med. 2001;161:1393-1404/ VOL 161, JUNE 11, 2001
4. Alan Barkun, MD, MSc; Marc Bardou, MD, PhD; and John K. Marshall, MD, MSc Consensus Recommendations for Managing Patients with Nonvariceal Upper Gastrointestinal Bleeding Annals of Internal Medicine Ann Intern Med. 2003;139:843-857,18 November 2003 Annals of Internal Medicine Volume 139 • Number 10
5. David J. Bjorkman, MD, MSPH, SM, Atif Zaman, MD, M. Brian Fennerty, MD, David Lieberman, MD, James A. DiSario, MD, Ginger Guest-Warnick, BA Urgent vs. elective endoscopy for acute non-variceal upper-GI bleeding: an effectiveness study Gastrointestinal Endoscopy (Gastrointest Endosc 2000;51:AB129); VOLUME 60, NO. 1, 2004