This week we’re covering endoscopy for Upper GI Bleed. Specifically, the optimal timing of endoscopy by our colleagues in GI.
A Review Of: Lau JYW et al. Timing of Endoscopy for Acute Upper Gastrointestinal Bleeding. NEJM 2020. PMID: 32242355
What: A randomized clinical trial in Hong Kong where stable patients with an upper GI bleed (UGIB) with “high risk features” (Glasgow-Blatchford score >12) were assigned to “urgent” endoscopy (within 6 hrs of GI consultation) or “early" endoscopy (the next morning or within 24 hrs after GI consultation). Patients otherwise received standard medical management of UGIB including PPI drip, vasoactive drugs and antibiotics as indicated. Emergent endoscopy was offered if the patient demonstrated evidence of further bleeding and/or hypotensive shock. The main outcome was death from any cause within 30 days, with a slew of secondary outcomes.
RebelEM has a nice write-up and episode on it here: https://rebelem.com/rebel-cast-ep82-timing-of-endoscopy-for-ugib/
The Bottom Line also has a nice review on the topic: https://www.thebottomline.org.uk/summaries/em/timing-of-endoscopy-for-acute-upper-gastrointestinal-bleeding/
Why: For many causes of upper GI bleed, endoscopy is the definitive treatment to stop bleeding and localize high-risk lesions. But there have not been many randomized studies that specifically looked at the timing for "high-risk" patients with upper GI bleed. In this study, there was no significant difference in all-cause mortality within 30 days, no difference in further bleeding within 30 days, pRBC transfusion, nor mean duration of hospitalization. It suggests that some "high-risk" patients with UGIB could potentially wait overnight for their endoscopy. But keep in mind that the sickest patients still went for emergent endoscopy, so these results don’t apply to patients with ongoing bleeding or hypotensive shock. The authors themselves comment on this. The patients studied also had a low incidence of variceal bleeding (<10%). Keep this in mind when applying this study to your local population.
If you have an unstable patient with suspected UGIB, we should be proactive in pushing for endoscopy as soon as possible. But for the hemodynamically stable patient with high-risk features, this evidence suggests that endoscopy within 24 hrs could be a valid approach as well, as long as the patient is monitored for signs of further bleeding.
As always, read through it and talk with your attendings.
*Note* High-risk in this context was defined using the Glasgow-Blatchford criteria, which can be found on MDCalc and the QxCalculate phone app.
Written By:
Dr. Jorge Aceves
The Weekly Cheese was a FOAMed initiative created by Former Cook County EM Chief Resident, Dr. Jorge Aceves. Why’s it called the Weekly Cheese? You’ll have to tweet him and ask.
Twitter : @joaceve91
Peer Reviewed by:
Neeraj Chhabra MD, MSCR
Division of Medical Toxicology, Department of Emergency Medicine
Cook County Health
Assistant Professor, Rush Medical College
Twitter: @NeerajBC