Timing of Endoscopy in Suspected Upper GI Bleeding
Endoscopy should be performed within 24 hours of presentation after initial hemodynamic stabilization in most patients with suspected upper GI bleeding. 1, 2, 3
Standard Timing: Within 24 Hours
Early endoscopy (within 24 hours) is the recommended standard for the majority of patients presenting with acute upper GI bleeding, as this timing allows for safe risk stratification, improves outcomes in high-risk patients, and reduces hospital length of stay. 1
This 24-hour window applies after initial resuscitation with crystalloids and correction of hypovolemia, not from the moment of presentation. 1, 4
Multiple international consensus guidelines consistently support this timeframe, with strong evidence showing that early endoscopy (within 24 hours) reduces mortality, need for surgery, and hospital stay compared to delayed endoscopy. 1, 2, 3
When to Perform Urgent Endoscopy (Within 12 Hours)
Consider urgent endoscopy within 12 hours specifically for:
Patients with hemodynamic instability (shock index >1, systolic BP <90 mmHg despite resuscitation, heart rate >100 bpm). 4, 5
Patients with active bleeding suggested by bright red blood in emesis or nasogastric aspirate. 4
Patients with high-risk features including suspected variceal bleeding in cirrhotic patients. 4
However, urgent endoscopy (<12 hours) does not improve outcomes compared to early endoscopy (within 24 hours) in most patients, so the 24-hour window remains appropriate for stable patients. 2
Critical Exception: Very Low-Risk Patients
Patients with a Glasgow Blatchford score ≤1 can be safely managed as outpatients without urgent hospitalization or immediate endoscopy, as they are at very low risk for rebleeding, mortality, or need for intervention. 2, 6, 3
These patients can undergo outpatient endoscopy at a later time for diagnostic purposes. 2
Important Caveats
Pre-Endoscopy Requirements
Hemodynamic stabilization must occur before endoscopy, including restoration of blood pressure, correction of coagulopathy, and adequate resuscitation with crystalloids (typically 1-2 liters). 1, 4
Endoscopy should be delayed in patients with active acute coronary syndrome or suspected perforation until these conditions are addressed. 1
Airway Protection
- In patients with massive hematemesis or altered mental status, endotracheal intubation should be performed before endoscopy to protect the airway. 4
Pre-Endoscopic Pharmacotherapy
High-dose IV PPI therapy should be initiated immediately upon presentation (e.g., pantoprazole 80 mg IV bolus followed by 8 mg/hour infusion), even before endoscopy, as this downstages endoscopic lesions and reduces the need for endoscopic intervention. 1, 5, 7
Erythromycin 250 mg IV can be given 30-60 minutes before endoscopy to enhance gastric visualization by promoting gastric emptying. 5, 7
Special Populations
For patients taking anticoagulants (warfarin or DOACs), do not delay endoscopy for reversal unless there is massive bleeding; proceed with endoscopy within 24 hours after initial stabilization. 6
For patients with suspected variceal bleeding, initiate vasoactive drug therapy (terlipressin, somatostatin, or octreotide) and antibiotics immediately, then proceed with endoscopy within 12 hours. 4
Common Pitfall to Avoid
Do not perform "urgent" endoscopy (<12 hours) routinely in all patients, as evidence shows no benefit over early endoscopy (within 24 hours) for most presentations, and it may expose patients to unnecessary risks if adequate resuscitation has not been achieved. 2 The key is proper risk stratification and ensuring hemodynamic stability before proceeding.