The edition · Internal Medicine
Endoscopy within six hours did not improve outcomes in non-variceal upper GI bleeding
A meta-analysis of 10,785 patients found ultra-early endoscopy no better than endoscopy within 24 hours, even in high-risk bleeders; a potassium-competitive acid blocker lifted H. pylori eradication where clarithromycin resistance is documented; and a referral trial in prostate cancer improved cholesterol, not cardiac events.
The edition in brief
Nine studies of 10,785 adults with non-variceal upper gastrointestinal bleeding compared endoscopy within six hours against later endoscopy within the usual window. Ultra-early endoscopy did not reduce mortality (OR 0.88, 95% CI 0.58–1.34) or rebleeding (OR 1.23, 0.90–1.67), including in high-risk patients, and was associated with more ICU admission; resuscitation first, then endoscopy within 24 hours, remains the target. In an international trial of 2,487 men starting androgen deprivation therapy for prostate cancer, routine referral to an internist or cardiologist improved a hierarchical composite (win ratio 1.60), almost entirely by lowering cholesterol with protocol statins; cardiovascular death, MI, stroke and heart failure did not differ. A retrospective cohort from a 714-bed US academic centre found that encounters needing post-acute care referral accounted for 85.5% of excess hospital days. And a meta-analysis of patients with documented clarithromycin-resistant H. pylori found eradication in 74.7% with potassium-competitive acid blocker regimens versus 52.7% with proton pump inhibitor regimens (RR 1.42), strongest with vonoprazan.
Ultra-early endoscopy did not reduce death or rebleeding in non-variceal upper GI bleeding
In non-variceal upper GI bleeding, resuscitate well and scope within 24 hours; endoscopy within six hours does not improve outcomes, even in high-risk patients.
Routine cardiovascular referral at the start of androgen deprivation lowered cholesterol but not events
Treat cardiovascular risk factors in men on androgen deprivation therapy, but routine specialist referral did not reduce heart attacks, strokes or heart failure.
Patients needing post-acute care referral accounted for 85% of excess hospital days
Start discharge planning on admission for patients likely to need post-acute care — they carry most of the avoidable hospital days.
Glasgow-Blatchford 0–1: the upper GI bleed who can go home
Patients with a Glasgow-Blatchford score of 0–1 can usually have outpatient endoscopy rather than admission.
Vonoprazan-based regimens eradicated clarithromycin-resistant H. pylori far more often than PPI regimens
When treating H. pylori where clarithromycin resistance is likely, swap the PPI for a P-CAB such as vonoprazan if available — and prefer a regimen without clarithromycin.
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