Introduction
In patients with upper gastrointestinal bleeding (UGIB), the European Society of Gastrointestinal Endoscopy (ESGE) recommends adopting the following definitions regarding the timing of upper GI endoscopy: urgent (6-12h), early (≤24h), and delayed (>24h) (1). There is no consensus definition of emergent endoscopy, but previous publications use the timeline of <6h (2).
Early endoscopy is associated with better outcomes, and guidelines suggest that it should be performed within this time frame (1).
Last ESGE guideline about variceal bleeding (VB) suggests performing urgent endoscopy in this context (3). This is based on a meta-analysis showing lower overall mortality when endoscopy was performed <12h compared to >12h (4). Surprisingly, ESGE concludes that the optimal timing in this setting is controversial due to a lack of high-level evidence. In fact, except for this study, all the others examining this aspect show that performing endoscopy before 12h does not provide benefits (5,6).
Aims & Methods
We aim to compare whether urgent endoscopy (6-12h) provides benefits to VB and explore predictors for mortality.
Methods: Retrospective analysis of a prospective registry of UGIB patients admitted to 'Virgen de las Nieves University Hospital' (2013-2020). VB was defined as that coming from gastric or esophageal varices. Endoscopy timings were defined according to ESGE: emergent (<6h), urgent (6-12h), early (≤24h) and delayed (>24h) (1).
Main outcomes were in-hospital (endoscopy therapy, transfusion, rebleeding, misbalance of chronic condition, hospital stay, and mortality) and delayed-6 months (bleeding, cardiovascular events, mortality). Statistical analysis was performed using SPSS.
Results
1459 UGIB patients were collected, 216 with VB.
Statistical differences in main outcomes are shown in Table 1 (each letter in the subscript denotes column proportions that do not differ significantly from each other). No differences were found for the other outcomes.
Timing
(% patients) | <6h (39.7%) | 6-12h (28.8%) | 12-24h (17.4%) | 24h (2.7%)
| p |
| Endoscopy therapy | 85.1% a | 63.5% b | 65.8% b | 66.7% b | 0.014 |
| Misbalance of chronic condition | 48.3% a | 30.2% b | 23.7% b | 50% a | 0.026 |
| Rebleeding | 22.1% a | 7.9% b | 7.9% b | 16.7% a | 0.037 |
| In-hospital mortality | 27.4% a | 13.6% b | 11.1% b | 50% a | 0.025 |
We also compared basal characteristics and found differences in MAP(ASH) score≥2 (92.3% vs. 66.7% vs. 77.4% vs. 75%; p=0.003) and GBS≥12 (69% vs. 44.4% vs. 52.6% vs. 83.3%; p= 0.011).
Independent risk factors for in-hospital mortality were MAP(ASH)≥2 (1.26, 95% CI 1.03-1.54), misbalance of chronic condition (OR 9.92, 95% CI 3.56-27.61, p=0.000), and rebleeding (OR 3.95, 95% CI 1.45-10.79, p=0.007). The timing of endoscopy performing was not an independent prognostic factor for mortality.
We also conducted subgroup analysis to assess whether performing endoscopy before 12h provides benefits in other UGIB patients, without finding differences for patients with non-variceal bleeding or in those at higher risk of poor outcomes (GBS≥12, MAP(ASH)≥2, ASA≥3).
Conclusion
Our study highlights, in line with the majority of available ones (5,6), that endoscopy before 12h does not provide a benefit in patients with VB. This necessitates a reconsideration of the ESGE recommendation. Patients with endoscopy performed before 6 or after 24h have poor outcomes. However, multivariate analysis shows that the timing of endoscopy is not an independent prognostic factor for mortality. On the other hand, the decompensation of basal chronic disease and the severity of bleeding (determined by MAP(ASH) and rebleeding) are the determinants of patient outcomes.
References
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- Gralnek IM, Camus Duboc M, Garcia-Pagan JC, Fuccio L, Karstensen JG, Hucl T, et al.. Endoscopic diagnosis and management of esophagogastric variceal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2022 Nov;54(11):1094-1120.
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- Zhang W, Huang Y, Xiang H, Zhang L, Yuan L, Wang X, et al. Timing of endoscopy for acute variceal bleeding in patients with cirrhosis (CHESS1905): A nationwide cohort study. Hepatol Commun. 2023 May 4;7(5):e0152.
