Does early endoscopy in acute upper GI bleeding results in improved outcome
Date First Published:
January 22, 2010
Last Updated:
April 22, 2010
Report by:
Aleksandr Valkov, SpR (SRFT)
Search checked by:
A Valkov, SRFT
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?
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$.af]) AND( [bleeding.af] OR[H?morrhage.af]) AND ([endoscopy.af] OR [gastroscopy.af] OR [oesophagogastroduodenoscopy.af] OR [OGD])AND ([timing.af] OR [early.af] OR [delayed.af]); Limit to Humans and English Language
World wide web using Google- 1st 5 pages of search[Endoscopy early Gastrointestinal bleeding]
Medline and Embase(1980-present) using NHS Libraries interface ([gastrointestinal.af]OR [GI.af] OR[UGIB.af] OR[PUD.af] OR[DU.af] OR[ ulcer.af] OR[ Vari$.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]
Outcome:
569 articles were found, including 2 relevant cochrane review, one good quality metaanalysis and six other relevant articles.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Terlipressin for acute esophageal variceal hemorrhage (Review) Ioannou GN, Doust J, Rockey DC 20-Jan-03 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 | ||||
| Emergency sclerotherapy versus medical interventions for bleeding oesophageal varices in cirrhotic patients (Review) 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 | ||||
| Endoscopy for Acute Nonvariceal Upper Gastrointestinal Tract Hemorrhage: Is Sooner Better? 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 | early | ||||
| need for surgery | |||||
| desaturations | |||||
| Consensus Recommendations for Managing Patients with Nonvariceal Upper Gastrointestinal Bleeding 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) | ||||
| Urgent vs. elective endoscopy for acute non-variceal upper-GI bleeding: an effectiveness study David J. Bjorkman, MD, MSPH, SM, Atif Zaman, MD, M. Brian Fennerty, MD, David Lieberman, MD, James A. DiSario, MD, Ginger Guest-Warnick, BA 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 |
Author Commentary:
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
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.
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:
- Ioannou GN, Doust J, Rockey DC. Terlipressin for acute esophageal variceal hemorrhage (Review)
- D’Amico G, Pagliaro L, Pietrosi G, Tarantino I. Emergency sclerotherapy versus medical interventions for bleeding oesophageal varices in cirrhotic patients (Review)
- 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?
- Alan Barkun, MD, MSc; Marc Bardou, MD, PhD; and John K. Marshall, MD, MSc. Consensus Recommendations for Managing Patients with Nonvariceal Upper Gastrointestinal Bleeding
- 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