What are the indications for urgent endoscopy?

Indications for Urgent Endoscopy

Urgent endoscopy (within 6-24 hours) is indicated for patients with hemodynamic instability (shock, persistent hypotension, or ongoing bleeding requiring repeated transfusions), active hematemesis, or high-risk clinical features including age >65 years, comorbidities, and evidence of significant blood loss. 1

Hemodynamic Criteria Requiring Urgent Intervention

Immediate resuscitation must precede endoscopy, but the procedure should not be delayed once stabilization is achieved. 1

• Persistent hemorrhage causing hemodynamic instability (shock, hypotension requiring vasopressors, or repeated transfusions) mandates emergency endoscopy 1
• Active hematemesis with shock requires urgent intervention, defined by tachycardia >100 bpm, systolic BP <100 mmHg, or orthostatic changes 1
• Patients requiring >2 units of packed red blood cells to maintain hemoglobin >7-9 g/dL should undergo urgent endoscopy 2

High-Risk Clinical Predictors

Risk stratification using clinical criteria identifies patients who benefit most from urgent intervention:

• Age >65 years is an independent predictor of rebleeding and mortality 1
• Bright red blood in nasogastric aspirate predicts poor outcomes and need for emergency endoscopy, though 3-16% of confirmed upper GI bleeds may have negative aspirate 1, 3
• Hemoglobin <100 g/L (10 g/dL) at presentation in acute bleeding warrants urgent evaluation, as cardiac output changes occur at this threshold 1, 2
• Comorbid conditions including cardiac disease, liver disease, or renal failure increase risk 1

Timing Framework: Urgent vs Early Endoscopy

The evidence distinguishes between urgent (<6 hours), early (6-24 hours), and delayed (>24 hours) endoscopy:

For high-risk patients, endoscopy within 24 hours is the standard of care 1. Recent high-quality evidence shows that urgent endoscopy (<6 hours) does not reduce 30-day mortality compared to early endoscopy (6-24 hours) in most patients 4, 5, 6. However, urgent endoscopy may reduce transfusion requirements (57.5% vs 68.4%, p<0.001) 5.

• Emergency endoscopy (<6 hours) is reserved for patients with persistent active bleeding despite resuscitation 1
• Early endoscopy (within 24 hours) is appropriate for most patients once hemodynamically stable 1, 7
• Endoscopy should not be performed until adequate resuscitation is achieved, with stable blood pressure and central venous pressure when possible 1

Specific Clinical Scenarios

Variceal Bleeding

• Suspected variceal bleeding requires immediate endoscopy after patient stabilization, as this significantly impacts prognosis 1, 8

Coagulopathy

• Coagulopathy should be corrected with prothrombin complex concentrate (PCC) rather than fresh frozen plasma when available, but endoscopy should not be delayed for correction 1
• The degree of coagulopathy must be assessed objectively before therapeutic decisions 1

Low-Risk Patients

• Patients with Glasgow-Blatchford Score ≤8 can be safely discharged for outpatient investigation 1
• For low-risk patients, early endoscopy reduces length of stay and costs but does not affect mortality or rebleeding 1

Critical Pitfalls to Avoid

• Do not delay endoscopy beyond 24 hours in patients with significant bleeding once stabilized 2
• Do not perform endoscopy before adequate resuscitation—stabilization of blood pressure and intravascular volume must precede diagnostic measures 1
• Do not administer excessive crystalloid volumes, as over-expansion can exacerbate portal pressure, impair clot formation, and increase rebleeding risk 2
• In severely bleeding patients, consider endotracheal intubation before endoscopy to prevent pulmonary aspiration 1

Institutional Requirements

Hospitals must have protocols ensuring:

• Access to trained endoscopists capable of therapeutic hemostasis available for urgent procedures 1
• Trained support staff and appropriate equipment available for urgent endoscopy 1
• Multidisciplinary team with prespecified notification chain including gastroenterology and surgery 1

Endoscopic Therapy Indications

Once endoscopy is performed, therapeutic intervention is indicated for:

• Active bleeding (spurting or oozing) 1
• Non-bleeding visible vessel 1
• Adherent blood clot (after removal to expose underlying lesion) 1
• Patients with clean ulcer base or flat pigmented spots have low rebleeding risk and do not require endoscopic therapy 1