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OPTIMAL TIMING OF ENDOSCOPY IN ACUTE UPPER GASTROINTESTINAL BLEEDING: IMPACT ON REBLEEDING, MORTALITY AND RESOURCE UTILISATION

Gaurav Nigam 1, Stig Borbjerg Laursen 2, Joanna Leithead 3, Sarah Hearnshaw 4, Kathryn Oakland 5, Vipul Jairath 6, John Grant-Casye 7, John Morris 8, Simon Travis 9, Andrew Douds 10, Adrian Stanley 8

Affiliations

1 Oxford University NHS Hospitals, Oxford, United Kingdom

2 Odense University Hospital, Odense, Denmark

3 Forth Valley Royal Hospital, Larbert, United Kingdom

4 Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, United Kingdom

5 HCA Healthcare UK, Oxford, United Kingdom

6 Alimentiv Inc., London, Canada

7 NHS Blood and Transplant, Oxford, United Kingdom

8 Glasgow Royal Infirmary, Glasgow, United Kingdom

9 John Radcliffe Hospital, Oxford, United Kingdom

10 Queen Elizabeth Hospital, Fakenham, United Kingdom

Summary

AI Generated

Analysis of 3,001 UK patients with acute upper gastrointestinal bleeding found that endoscopy within 0-12 hours was associated with higher adjusted odds of rebleeding and mortality compared to endoscopy at 12-24 hours, despite higher baseline severity in the early group.

After adjusting for confounding variables including baseline severity, the 0-12 hour endoscopy group had 91% higher odds of rebleeding (OR 1.91, 95% CI 1.38-2.69) and 59% higher odds of mortality (OR 1.59, 95% CI 1.09-2.34) compared to the 12-24 hour group.
Patients undergoing endoscopy within 0-12 hours were younger, more haemodynamically unstable, had higher median Glasgow Blatchford Scores (10.0 vs 9.0 vs 8.0), and higher lactate levels than those in the 12-24 and 24-48 hour groups.
The 24-48 hour endoscopy group showed comparable adjusted odds of rebleeding (OR 0.93) and mortality (OR 0.74) to the 12-24 hour group, but had longer median hospital stay (5 vs 4 days).
Endotherapy was performed more frequently in the 0-12 hour group (41%) compared to 12-24 hour (28%) and 24-48 hour (17%) groups.
This observational audit analysis is relevant to clinicians managing acute upper gastrointestinal bleeding and developing endoscopy timing protocols.

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This summary was generated by an AI large language model based on the content transcript. It is for informational purposes only and should not be considered a substitute for clinical judgment. Always rely on your professional expertise and the full clinical context when making clinical decisions.

Abstract

Introduction

The optimal timing of endoscopy in acute upper gastrointestinal bleeding (AUGIB) management remains debated. We assessed time to endoscopy's impact on rebleeding and mortality based on patient characteristics and pre-endoscopic factors.

Aims & Methods

Data from 3,001 patients with AUGIB undergoing endoscopy within 48 hrs of referral from the prospective multicentre UK 2022 audit were analysed. Patients were categorised into 0-12 hrs, 12-24 hrs, and 24-48 hrs groups based on the time to endoscopy from referral. Regression analyses, adjusting for age, admission status (inpatient vs new admission), vital signs, symptoms, comorbidities, laboratory parameters, red blood cell transfusion, and pre-endoscopic management, assessed the association between endoscopy timing and rebleeding and mortality.

Results

Patients undergoing endoscopy within 0-12 hrs were younger, more likely to be haemodynamically unstable, and had a higher median Glasgow Blatchford Score (GBS) compared to those undergoing endoscopy in the 12-24 and 24-48 hrs groups. Despite a higher proportion receiving endotherapy (41% for the 0-12 hrs group, 28% for the 12-24 hrs group, and 17% for the 24-48 hrs group; p<0.001), the 0-12 hrs group had the highest rates of rebleeding (16%) and mortality (10%), compared to 9% rebleeding and 6% mortality in the 12-24 hrs group, and 7% rebleeding and 5% mortality in the 24-48 hrs group (p<0.001). The median length of stay was longer for the 0-12 hrs and the 24-48 hrs groups at 5 days, compared to 4 days in the 12-24 hrs group (p < 0.001). (see table)

Regression analysis indicated that, compared to the 12–24-hrs group, the 0–12 hrs group had higher odds of rebleeding (OR 1.91, 95% CI 1.38-2.69, p < 0.001), after adjusting for confounding variables. However, the 24–48 hrs group exhibited comparable odds of rebleeding (OR 0.93, 95% CI 0.60-1.45, p < 0.001) compared to the 12–24-hrs group. Regression analysis for mortality showed the 0-12 hrs group had higher odds of mortality compared to the 12-24 hrs group (OR 1.59, 95% CI 1.09-2.34, p = 0.001), while the 24-48 hrs group had similar odds of death (OR 0.74, 95% CI 0.43-1.23, p = 0.001).

Table: Patient characteristics in relation to time of endoscopy (n=3001)

Characteristic	0-12 hrs, N = 1,366	12-24 hrs, N = 944	24-48 hrs, N = 691	p-value*
Age	67 (52, 79)	69 (55, 80)	71 (56, 81)	0.001
Hemodynamically unstable	653 (50%)	377 (42%)	270 (41%)	<0.001
GBS	10.0 (7.0, 13.0)	9.0 (6.0, 12.0)	8.0 (5.0, 11.0)	<0.001
Pre-endoscopy peak blood lactate	2.20 (1.40, 3.90)	1.80 (1.20, 2.80)	1.80 (1.30, 2.90)	<0.001
Stigmata of recent bleed	642 (47%)	259 (28%)	121 (18%)	<0.001
Endo therapy	563 (41%)	224 (24%)	114 (17%)	<0.001
Death	136 (10%)	60 (6.4%)	35 (5.1%)	<0.001
Rebleeding	196 (16%)	74 (8.9%)	41 (6.7%)	<0.001
Length of stay	5 (3, 10)	4 (2, 8)	5 (3, 10)	<0.001

*Between the group comparison

Conclusion

The findings suggest a complex relationship between the timing of endoscopy and clinical outcomes in patients with AUGIB. Earlier endoscopy (0-12 hrs) may be associated with a higher risk of rebleeding, mortality and resource utilisation, while later endoscopy (24-48 hrs) may not be associated with increased adverse outcomes, but may lead to a longer hospital stay. Despite the initial severity of illness, early endoscopy may not translate to improved patient outcomes in AUGIB management. These results highlight the need for individualised management when determining the optimal timing of endoscopy in AUGIB.