Endoscopy within six hours did not improve outcomes in non-variceal upper GI bleeding

Design

Systematic review and meta-analysis of 9 studies

Population

10,785 adults with non-variceal upper GI bleeding (2,638 within 6 h, 8,147 later)

Primary outcome

Mortality and rebleeding

Effect

Mortality OR 0.88 (0.58-1.34); rebleeding OR 1.23 (0.90-1.67); ICU OR 1.41 (1.20-1.66)

Guidelines recommend endoscopy within 24 hours for non-variceal upper gastrointestinal bleeding, but many units push for the first few hours. This meta-analysis pooled nine studies of 10,785 adults: 2,638 had endoscopy within six hours and 8,147 later.

Ultra-early endoscopy did not reduce mortality (OR 0.88, 95% CI 0.58 to 1.34) or rebleeding (OR 1.23, 0.90 to 1.67), nor transfusion, surgery, repeat endoscopy or length of stay. Intensive care admission was more frequent with ultra-early endoscopy (OR 1.41, 1.20 to 1.66). Results were consistent in high-risk patients, most often defined by a Glasgow-Blatchford score above 12.

Where timing was not randomised, sicker patients may have been scoped sooner. But the findings fit earlier randomised evidence in high-risk patients. The priority in the first hours is resuscitation, then endoscopy within 24 hours.

• Resuscitate first: fluids, restrictive transfusion and correction of coagulopathy, before rushing to endoscopy.
• Aim for endoscopy within 24 hours in non-variceal bleeding, including high-risk patients who are stabilised.
• Reserve emergency endoscopy for patients who remain unstable despite resuscitation.
• Start intravenous proton pump inhibitor therapy while awaiting endoscopy in suspected ulcer bleeding.

Why it matters

It removes pressure to scope unstable-but-resuscitable patients at night without improving outcomes.

Don't overread it

Where timing was not randomised, those scoped earliest may have been sicker.

The statistics, in plain English

An odds ratio of 0.88 with an interval from 0.58 to 1.34 is compatible with anything from a benefit to harm, so no mortality advantage is shown. The higher intensive care admission may reflect sicker patients being scoped early rather than harm from timing.

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