From the Guidelines
Endoscopy is not preferred in acute upper GI bleed patients when they have active acute coronary syndrome, suspected perforation, or when endoscopic expertise may be suboptimal, as stated in the international consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding 1. When considering the management of acute upper GI bleed, it's crucial to weigh the benefits of early endoscopy against potential risks in specific patient populations.
- Patients with active acute coronary syndrome may require stabilization of their cardiac condition before undergoing endoscopy to minimize the risk of cardiac complications.
- Suspected perforation is another scenario where immediate surgical intervention may be necessary, potentially delaying or avoiding the need for endoscopy.
- The availability of skilled endoscopists is also a critical factor; if expertise is suboptimal, it may be prudent to delay the procedure until more experienced personnel are available, as the quality of the endoscopy can significantly impact patient outcomes. Additionally, patients with a very low Blatchford score, indicating a low risk of adverse outcomes, might not require immediate endoscopy and could potentially be managed as outpatients, although this approach remains controversial 1. The decision to postpone endoscopy should be made on a case-by-case basis, considering the individual patient's risk factors, clinical presentation, and the availability of appropriate medical and endoscopic expertise.
From the Research
Conditions where Endoscopy may not be Preferred
- In patients with acute upper GI bleed who are hemodynamically unstable, endoscopy may not be preferred until the patient is stabilized 2.
- Patients with severe coagulopathy or those taking anticoagulant medications may not be suitable for endoscopy until their coagulation status is corrected 2.
- In cases where the risk of rebleeding is low, early endoscopy may not be necessary, and a more conservative approach can be taken 3.
Specific Clinical Scenarios
- If a patient has a high Glasgow-Blatchford bleeding score, indicating a high risk of further bleeding, urgent endoscopy may not be necessary if the patient is stable, and early endoscopy within 24 hours can be performed instead 3.
- In patients with peptic ulcers, active bleeding or visible vessels may be found on initial endoscopy, but this does not necessarily mean that urgent endoscopy is required 3.
Timing of Endoscopy
- The timing of endoscopy in acute upper GI bleed patients depends on various factors, including the patient's hemodynamic stability, risk of rebleeding, and the presence of comorbidities 4, 3.
- While urgent endoscopy (within 6 hours) may be beneficial in some cases, early endoscopy (within 24 hours) can be sufficient for many patients, especially those with low-risk bleeding scores 3.