Optimal timing of endoscopy for acute upper gastrointestinal bleeding: a systematic review and meta-analysis

The interaction of patients' physical status and time to endoscopy on mortality risk in patients with upper gastrointestinal bleeding: A national prospective cohort study

BACKGROUND AND AIM

The correct time to perform an upper endoscopy is decisive in acutely GI bleeding patients. However, patients' physical status may affect mortality. We speculated that the physical status and procedural time could be the principal factors accountable for death-risk. The primary aim was to verify the interaction between physical status and time to endoscopy on mortality; the secondary aim was to verify the interaction of the physical status and time to endoscopy on the length of stay (LOS).

METHODS

Consecutive patients admitted to 50 Italian hospitals were included. Clinical and endoscopic data were recorded. A multiple logistic regression analysis was performed and the interaction of adjusted clinical physical status and time to endoscopy on mortality was calculated.

RESULTS

Complete data were available for 3.190 patients. The time frames did not interfere with outcomes but influenced LOS. Conversely, the ASA score correlated with mortality, LOS, need for transfusions and rebleeding risk.

CONCLUSION

Endoscopy time should be tailored to the patient's physical. In our experience, ASA 1-2-3 patients can be safely submitted to endoscopy to reduce the LOS; on the contrary, keen attention should be paid to ASA4 patients, following the 'not too early-not too late' rule (12-24 h from admission).

Endoscopy for acute upper gastrointestinal bleeding: a protocol for systematic review and network meta-analysis of randomized controlled trials

Background

Previous studies have reached mixed conclusions regarding the timing of endoscopic approaches for managing individuals with acute upper gastrointestinal bleeding (AUGIB). Therefore, the authors performed a protocol for systematic review and meta-analysis to assess the efficacy of various timing endoscopic approaches in managing individuals with AUGIB.

Methods

The authors will search multiple databases, including PubMed, Embase, Web of Science, China National Knowledge Infrastructure, VIP Database, Wanfang Database, WHO International Clinical Trials Registry Platform, and Chinese Clinical Trial Register. The search will cover the entire duration, starting from the establishment of these databases until July 2023. The selection criteria will focus on randomized controlled trials that assess the efficacy of endoscopy with varying timing in managing patients with AUGIB. The primary outcomes will include primary hemostasis and inpatient death. The secondary outcomes will include recurrent bleeding, need for surgical intervention, admission to the ICU, blood transfusion needs, and duration of hospitalization. Two reviewers will select the studies, extract data, and assess the risk of bias. A Bayesian approach will be used to conduct a network meta-analysis.

Results

The results of this systematic review and meta-analysis will be published in peer-reviewed journals.

Conclusion

This network meta-analysis provides comprehensive evidence of different timing endoscopic approaches for managing individuals with AUGIB.

Superiority of urgent vs early endoscopic hemostasis in patients with upper gastrointestinal bleeding with high-risk stigmata

Background

Guidelines recommend that all patients with upper gastrointestinal bleeding (UGIB) undergo endoscopy within 24 h. It is unclear whether a subgroup may benefit from an urgent intervention. We aimed to evaluate the influence of endoscopic hemostasis and urgent endoscopy on mortality in UGIB patients with high-risk stigmata (HRS).

Methods

Consecutive patients with suspected UGIB were enrolled in three Japanese hospitals with a policy to perform endoscopy within 24 h. The primary outcome was 30-day mortality. Endoscopic hemostasis and endoscopy timing (urgent, ≤6 h; early, >6 h) were evaluated in a regression model adjusting for age, systolic pressure, heart rate, hemoglobin, creatinine, and variceal bleeding in multivariate analysis. A propensity score of 1:1 matched sensitivity analysis was also performed.

Results

HRS were present in 886 of 1966 patients, and 35 of 886 (3.95%) patients perished. Median urgent-endoscopy time (n = 769) was 3.0 h (interquartile range [IQR], 2.0–4.0 h) and early endoscopy (n = 117) was 12.0 h (IQR, 8.5–19.0 h). Successful endoscopic hemostasis and urgent endoscopy were significantly associated with reduced mortality in multivariable analysis (odds ratio [OR], 0.22; 95% confidence interval [CI], 0.09–0.52; P = 0.0006, and OR, 0.37; 95% CI, 0.16–0.87; P = 0.023, respectively). In a propensity-score-matched analysis of 115 pairs, adjusted comparisons showed significantly lower mortality of urgent vs early endoscopy (2.61% vs 7.83%, P < 0.001).

Conclusions

A subgroup of UGIB patients, namely those harboring HRS, may benefit from endoscopic hemostasis and urgent endoscopy rather than early endoscopy in reducing mortality. Implementing triage scores that predict the presence of such lesions is important.