Why should you wait before performing endoscopy (scopy) in an upper gastrointestinal (UGI) bleed instead of doing it immediately?

Timing of Endoscopy in Upper Gastrointestinal Bleeding

For patients with acute upper gastrointestinal bleeding (UGIB), early endoscopy (within 24 hours of presentation) is recommended rather than urgent endoscopy (≤12 hours), as early endoscopy provides optimal outcomes while allowing for proper resuscitation and stabilization. 1

Initial Risk Assessment and Stabilization

• Use the Glasgow Blatchford Score (GBS) to stratify patients:

  • GBS ≤1: Very low risk - can be managed as outpatients 1, 2
  • GBS >1: Higher risk - requires inpatient management and endoscopy within 24 hours 1

• Before endoscopy, prioritize:

  • Hemodynamic resuscitation (fluid resuscitation is essential before endoscopy) 1
  • Blood transfusion for hemoglobin <80 g/L in patients without cardiovascular disease 1
  • Higher transfusion thresholds for patients with cardiovascular disease 1

Optimal Timing for Endoscopy

Why Not Immediate Endoscopy?

1. Patient Stabilization: Adequate resuscitation before endoscopy reduces procedure-related complications 1

2. Downstaging of Lesions: Pre-endoscopic PPI therapy may downstage high-risk lesions, potentially decreasing the need for endoscopic intervention 1

3. Resource Optimization: Ensures availability of:

   • Trained endoscopist in endoscopic hemostasis
   • Proper support staff 1

4. Evidence of Outcomes: Urgent endoscopy (≤12 hours) has not been shown to improve patient outcomes compared to early endoscopy (≤24 hours) 2, 3

5. Potential Harm of Urgent Timing: A territory-wide cohort study demonstrated that urgent endoscopy (≤6 hours) was associated with higher 30-day mortality, repeat endoscopy rates, and ICU admission rates compared to early endoscopy (6-24 hours) 3

Evidence-Based Timing Recommendations

• Early Endoscopy (≤24 hours): Recommended for most patients with acute UGIB 1, 2

• Avoid Urgent Endoscopy (≤12 hours): Not recommended as standard practice as it does not improve outcomes 2

• Late Endoscopy (>24 hours): Associated with worse outcomes including higher 30-day mortality and in-hospital mortality 3

Special Considerations

• Anticoagulated Patients: Do not delay endoscopy in patients receiving anticoagulants (vitamin K antagonists, DOACs) 1

• Suspected Non-Bleeding Causes: In hemodynamically stable patients with coffee grounds emesis but no significant drop in hemoglobin, consider non-GI bleeding causes (e.g., myocardial infarction, pulmonary embolism) 4

• Post-Endoscopy Monitoring: Patients with high-risk stigmata should be hospitalized for at least 72 hours after endoscopic hemostasis, as 60-76% of rebleeding episodes occur within this timeframe 5

Common Pitfalls to Avoid

• Rushing to endoscopy before adequate resuscitation, which can increase procedure-related complications

• Delaying endoscopy beyond 24 hours, which is associated with worse outcomes including higher mortality 3

• Focusing solely on the GI bleed in stable patients with coffee grounds emesis, potentially missing other serious conditions 4

• Premature discharge of patients with high-risk lesions before the 72-hour observation period, risking missed rebleeding episodes 5

By following these evidence-based recommendations, clinicians can optimize the timing of endoscopy in UGIB to improve patient outcomes while ensuring appropriate resource utilization.