Introduction
The timing of performing upper gastrointestinal endoscopy(EGD) in patients with acute upper GI bleeding remains controversial. Different recommendations exist regarding the ideal time interval between the first clinical presentation of acute upper GI bleeding and EGD, assuming no postponement before patient arrival at the hospital. While it is generally agreed that upper gastrointestinal endoscopy should be performed within 24 hours of the first clinical presentation of acute upper GI bleeding, this recommendation poses a significant challenge for medical staff during weekends and healthcare centres with fewer resources than major hospitals.
Aims & Methods
This study was conducted at the Department of Internal Medicine, Gastroenterology Division, at Aleppo University Hospital between July 2018 and June 2020. The study included patients who were admitted due to acute upper gastrointestinal bleeding. The clinical manifestation of upper gastrointestinal bleeding, its duration, and the interval between the first upper gastrointestinal bleeding and the GI endoscopy were determined. Patients were divided into three groups: Group I underwent urgent endoscopy within less than 24 hours of the first bleeding; Group II underwent endoscopy between 24 and 72 hours from the first bleeding; and Group III underwent endoscopy after 72 hours or more of bleeding.
Results
234 patients were included in the study who were admitted to the hospital and underwent upper gastrointestinal endoscopy. Among them, 58.55% were male and 41.45% were female. The average age of the patients was 57.15.
The most common manifestation of acute upper gastrointestinal bleeding was melena, which was observed in 67.59% of cases, followed by hematemesis (52.99%) and epigastric pain (30.34%). The rate of normal esophageal endoscopy findings was 40% in the first group, 54.84% in the second group, and 64.4% in the third group. Hiatal hernia was observed in 30.77% of patients in the first group, 29.03% in the second group, and 28.89% in the third group. Reflux esophagitis was diagnosed in 10.77% of patients in the first group, 10.48% in the second group, and 20% in the third group. Esophageal varices were diagnosed in 10.77% of patients in the first group, 9.68% in the second group, and 13.33% in the third group.
There was no statistically significant difference in the rates of esophageal endoscopy findings among the study groups, except for the presence of blood-filled esophagus, which was significantly more common in the first group (P < 0.05). The highest rate of normal findings in upper gastrointestinal endoscopy was observed in the third group, which was statistically significant (P < 0.05). Blood in the stomach and erosive gastritis were most frequently observed in the first group, with a statistically significant difference in their favor.
The rates of observing gastric ulcers, gastric erosions, hypertensive gastropathy, gastric varices, gastric tumors, portal hypertensive gastropathy, and diffuse mucosal bleeding were similar among the three study groups without a significant statistical difference . The upper gastrointestinal endoscopy was normal in the duodenum in the highest percentage among patients in group three, with a statistically significant difference (P < 0.05). Blood in the duodenum and duodenal edema were observed with the highest rate in patients of the first group with a statistically significant difference compared to the other two groups (P < 0.05). The evaluation of the duodenum among patients of the first group could not be achieved with a higher rate compared to the other two groups, and the statistical difference was significant.
The percentage of observing esophageal ulcers, esophageal biopsies, adherent thrombus, and vascular distortion were similar among the three groups without a significant statistical difference (P > 0.05). The cause of bleeding was identified with certainty by visualizing the bleeding lesion in 32.31% of patients in the first group, 9.68% of patients in the second group, and 4.44% of patients in the third group. There was a statistically significant difference between the groups in favor of the first group.
Conclusion
Our research revealed no significant variance in endoscopic results in patients who underwent endoscopy at distinct time intervals. However, performing early endoscopy, within 24 hours of the first clinical presentation of acute upper GI bleeding, had a higher incidence of detecting the bleeding lesion and identifying the cause of bleeding in comparison to delayed endoscopy. Our study emphasizes the significance of early endoscopy in patients with acute upper GI bleeding to enhance the possibility of identifying the cause of bleeding and administering timely interventions to minimize complications and mortality.
References
1. Acute upper gastrointestinal bleeding: management. London: National Institute for Health and Clinical Excellence: Guidance; 2012.
2. Barkun AN, Bardou M, Kuipers EJ, Sung J, Hunt RH, Martel M, et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med 2010;152(2): 101e13.
3. Gralnek IM, Dumonceau JM, Kuipers EJ, Lanas A, Sanders DS, Kurien M, et al. Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European society of gastrointestinal endoscopy (ESGE) guideline. Endoscopy 2015;47(10):a1e46.
4. Hwang JH, Fisher DA, Ben-Menachem T, Chandrasekhara V, Chathadi K, Decker GA, et al. The role of endoscopy in the management of acute nonvariceal upper GI bleeding. Gastrointest Endosc 2012;75(6):1132e8
5. Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol 2012;107(3):345e60. quiz 61. 6 Stanley AJ, Ashley D, Dalton HR, Mowat C, Gaya DR, Thompson E, et al. Outpatient management of patients with low-risk upper-gastrointestinal hemorrhage: multicenter validation and prospective evaluation. Lancet 2009;373(9657):42e7