Timing of Upper Endoscopy Influences Outcomes in Patients With Acute Nonvariceal Upper GI Bleeding

Abstract

Purpose: Upper endoscopy performed within 24 hours is a mainstay of treatment in patients with an upper gastrointestinal bleed (UGIB). Despite this, the role for more urgent endoscopy (within 12 hours) is unclear. This study aimed to assess whether patients presenting with high-risk or lower- risk UGIB, as defined by established risk scores, have different outcomes with urgent vs. non-urgent endoscopy. Methods: A retrospective study of 361 patients admitted to an academic hospital from 2004 to 2014 with nonvarcieal UGIB. Primary outcomes included a composite of inpatient death, inpatient rebleeding, need for surgical or interventional radiologic intervention, or endoscopic reintervention. For each patient, the Glasgow-Blatchford score (GBS) was calculated, with lower- risk defined as a GBS < 12, and high-risk defined as a GBS > 12. Time to endoscopy was defined as the time from arrival in the emergency department to the procedure start time for the initial endoscopy. Results: Of the 361 patients, the mean age was 64 years and the mean GBS was 9.5. The median time to endoscopy was 20.8 hours with 223 patients (62%) undergoing endoscopy within 24 hours and 89 patients (25%) within 12 hours. 37 patients (10%) experienced the primary outcome. Patients who underwent urgent endoscopy within 12 hours had an increased risk of reaching the composite outcome compared to patients who underwent non-urgent endoscopy (OR 5.6; 95% CI 2.8-11.4; p<0.001). In the lower-risk group (GBS <12), patients who underwent urgent endoscopy were more likely to reach the composite outcome (OR 0.71 per 6 hours; 95% CI 0.55-0.91; p=0.008). In high-risk patients (GBS >12), time to endoscopy did not predict the composite outcome (adjusted OR 0.93 per 6 hours; 95% CI 0.77-1.13; p=0.47). Conclusions: In a cohort of patients presenting with non-variceal UGIB, urgent endoscopy significantly predicts worse outcomes in lower-risk patients when compared with non-urgent endoscopy. In high-risk patients, time to endoscopy is not a significant predictor of worse outcomes.