Urgent versus Early Endoscopy in High Risk Patients with Acute Upper

Gastrointestinal Bleeding: a Comparative Study in a Tertiary Center

with a Permanent Endoscopy Call
ANA-MARIA BOIANU1,2, DANIELA MATEI1, M. TANU1, MONICA ACALOVSCHI1
1

Iuliu Haieganu University of Medicine, Professor Dr. Octavian Fodor Regional Institute
of Gastroenterology and Hepatology, Cluj Napoca, Romania
2
University of Medicine from Trgu Mure, Internal Medicine Department, Trgu Mure, Romania

Background. Current guidelines clearly indicate the optimal management of patients with
upper gastrointestinal bleeding, but optimal timing of urgent endoscopy within 24 hours is still a
matter of debate.
Aim. To compare urgent versus early endoscopy in a group of high risk patients with acute
upper gastrointestinal bleeding.
Method. Retrospective nonrandomized comparative study in a tertiary center with a
permanent endoscopy call. Six hundred and eighty nine high risk patients (Glasgow-Blatchford score
12 points) with acute upper gastrointestinal bleeding admitted to the emergency department were
enrolled. All endoscopies were performed within 24 hours after admission. Urgent endoscopy was
defined as within 3 hours from presentation and was performed in 389 patients. Data was collected
from hospital charts and Hospital Manager Program. Statistical analysis was performed using Fishers
exact and Mann-Whitney tests, with a two sided p value < 0.05, respectively < 0.0001 considered
significant.
Results. The main etiology was peptic ulcer followed by variceal bleeding. The global
mortality rate was of 14.8% (102/690). For early versus urgent endoscopy in variceal bleedings,
mortality was higher but without reaching statistical significance (22.1% and 15.5% respectively, p =
0.1590). Postendoscopic Rockall score was significantly higher for the urgent endoscopy group (p =
0.0256) but all outcome parameters were similar.
Conclusion. Considering an optimal setting with a permanent endoscopy call, performance of
endoscopy within 3 hours of presentation is not associated with a significant decrease for mortality in
the high risk patients (p = 0.67451).
Key words: upper gastrointestinal bleeding, urgent endoscopy.

While the importance of endoscopy has been

established in acute upper gastrointestinal bleeding,
optimal timing has not yet been clearly defined [1].
Diagnosis, risk stratification and therapeutic hemostasis as well as further management decisions
depend on endoscopy [1, 2]. Current guidelines
clearly indicate the optimal management of upper
gastrointestinal bleeding [311]. Most of them
recommend upper diagnostic and therapeutic endoscopy within 24 hours of presentation. The guideline
of the Romanian Society of Gastroenterology
reduces this time interval to 16 hours [8]. Urgent or
as soon as possible endoscopy is recommended
in high risk cases and patients presenting with
active bleeding or hemodynamic instability. However, there is no clear definition of the term as
soon as possible and optimal timing of urgent
endoscopy within a 24 hours interval is still a
matter of debate. Several studies have shown that
urgent endoscopy did not decrease mortality [12
ROM. J. INTERN. MED., 2013, 51, 1, 3540

17]. However, there are different definitions of

urgent endoscopy, with variations from 4 to
13 hours in different unselected study populations.
Aim
To compare the outcome and patients
characteristics in a mixed (variceal and nonvariceal
etiology) group of high risk (Glasgow-Blatchford
score 12 points) patients with acute upper
gastrointestinal bleeding and to determine the
impact of timing of urgent endoscopy on the
outcome.
MATERIAL AND METHODS

This is a retrospective comparative nonrandommized study performed between January 2011

July 2012 at Professor Dr. Octavian Fodor
Regional Institute of Gastroenterology and Hepato-

36

Ana-Maria Boianu et al.

logy from Cluj-Napoca, Romania. The hospital

represents a tertiary center specialized in digestive
pathology, with both medical and surgical departments. Six hundred and eighty nine high risk
patients according to Glasgow-Blatchford preendoscopic score ( 12 points) were enrolled. Postendoscopic Rockall score was also calculated, high
risk being defined as a score equal or higher to
6 points. Patients were excluded if they had only
evidence of chronic gastrointestinal bleeding.
Time from emergency unit admission to
endoscopy was registered for each patient. Urgent
endoscopy was defined as within 3 hours from
emergency unit admission. Early endoscopy was
defined as within 324 hours from emergency unit
admission. Data was available from hospital
admission charts and Hospital Manager Program.
Both variceal and nonvariceal high risk cases of
acute upper gastrointestinal bleeding were included.
All endoscopies were performed within 24 hours of
admission in the emergency department.
Outcome was analyzed in terms of in-hospital
mortality, rebleeding and length of hospital stay.
Need for surgery was also analyzed for nonvariceal
bleeding. Statistical analysis was performed using
the following tests: Fishers exact test and MannWhitney test, with a two-sided P value < 0.05,
respectively <0.0001 considered significant.
RESULTS

Patients characteristics are shown in Table I.

We noticed a male predominance (461 out of 689)
and a median age of 62.5 years. The predominant
etiology was peptic ulcer followed by variceal
bleeding. Despite the fact that the study population
was a high risk one according to GlasgowBlatchford score, most bleedings were not active at
the time of endoscopy but presented high risk
stigmata of recent hemorrhage.
Time analysis revealed that most cases
presented during day-time and working days, but
the number of cases presenting off hours and
during weekdays was also significant and not to be
neglected. Three hundred and eighty nine out of
689 endoscopies were performed within 3 hours of
presentation to the emergency department. Median
time to endoscopy was 149 minutes, with a maximum of 1433 minutes and a medium value of 309
minutes. Treatment was oriented by the etiology
and endoscopic stigmata of recent hemorrhage. For
bleedings of variceal etiology, endoscopic band
ligation was the treatment of choice in most cases
(156/218 patients), whenever technically possible.

Oozing and collapsed varices were associated with

the impossibility or failure of endoscopic haemostasis and placement of Sengstaken-Blackmore
tube. For nonvariceal bleeding, all patients received
acid suppression medication.
Table I
Characteristics of high risk patients with upper digestive tract
bleeding
Patients characteristics, n = 689
Median age (years )
Gender (male / female)
Use of drugs
NSAIDs
Acetylsalicylic acid
Acenocumarolum
Clopidogrel
Alcohol cosumption
Endoscopic findings
Active bleeding
Etiology
Angiodysplasia
Erosive disease
Esophagitis
Mallory-Weiss tear
Dieulafoy lesion
Upper digestive tract malignancy
Peptic ulcer
Variceal bleeding
Other
Stigmata of recent hemorrhage according
to Forrest classification for nonvariceal
bleeding (n = 471)
IA
IB
IIA
IIB
IIC
III
Endoscopic appearance for variceal
bleeding (n = 218)
Collapsed varices
Cloth
Red spots
Hematocystic dilatations
Spurting vessel
Oozing
Efraction point

n (%)
62.8
2.02
116 (16.8%)
51 (7.4%)
47 (7%)
19 (2.8%)
243 (35.3%)
182 (26.4%)
25 (3.6%)
51 (7.4%)
14 (2%)
20 (2.9%)
14 (2%)
52 (7.5%)
282 (40.9%)
218 (31.8%)
13 (1.9%)

24 (5.1%)
90 (19.1%)
84 (17.8%)
77 (16.3%)
50 (10.6%)
146 (31.0%)
14 (6.4%)
24 (11.0%)
87 (39.9%)
19 (8.7%)
45 (20.6%)
17 (7.8%)
12 (5.5%)

Endoscopic treatment consisted of injection

therapy with adrenaline 1:10.000 and/or alcohol in
142 patients (59 cases with adrenaline, 13 cases with
alcohol, 70 cases with adrenaline and alcohol),
combined haemostasis injection therapy plus
hemoclip placement or argon plasma coagulationin 60 patients (21 adrenaline injection plus hemoclip
placement, 8 alcohol injection plus hemoclip placement, 24 cases of both adrenaline and alcohol
injection plus hemoclip placement, 7 adrenaline
injection and argon plasma coagulation), argon
plasma coagulation (26 patients), hemoclip placement

Urgent versus early endoscopy in acute upper gastrointestinal bleeding

(7 patients). Surgery was performed in 46 patients

(6.67%).
A comparison of patients characteristics is
given in Table II.
Table II
Comparison of the two groups of patients with upper
digestive tract bleeding. U.E. urgent endoscopy;
E.E. early endoscopy
Characteristics
Demographics
Age (years)
Females/Males
Risk scoring
Preendoscopic
Rockall score
Postendoscopic
Rockall score
Glasgow-Blatchford
score

U.E.
(n = 389)

E.E.
(n = 300)

p value

62.4 13.4 63.3 14.4 0.4383

123/266
105/195
0.3497
3.6 1.5

3.5 1.4

0.6311

6.2 1.9

5.9 1.9

0.0256

15.2 2.3

14.9 2

0.0700

15 (5.8%)
56 (21.6%)
52 (20.0%)
41 (15.8%)
24 (9.2%)
71 (27.4%)

9 (4.2%)
34 (16.0%)
32 (15.0%)
36 (16.9%)
26 (12.2%)
75 (35.4%)

Active bleeding (I) for

71 (27.4%)
nonvariceal etiology

33 (15.6%)

Stigmata of recent
haemorrhage for
nonvariceal bleeding
IA
IB
IIA
IIB
IIC
III

0.1835

0.1002

Stigmata of recent
haemorrhage for
variceal bleeding
Spurting
Oozing
Red spots
Collapsed
Cloth
Hematocystic
dilatations
Efraction point

29 (23.0%)
11 (8.7%)
45 (35.7%)
10 (7.9%)
13 (10.3%)

16 (17.4%)
7 (7.6%)
42 (45.6%)
5 (5.4%)
11 (11.9%)

13 (10.3%)
9 (7.1%)

7 (7.6%)
4 (4.3%)

Active bleeding for

variceal etiology
Spurting/Oozing

40 (31.7%)

27 (29.3%)

0.9133

Use of drugs
NSAIDs
Acetylsalicylic acid
Acenocumarolum
Clopidogrel
Alcohol consumption

59 (15.1%)
32 (8.2%)
25 (6.4%)
9 (2.3%)
139 (35.7%)

57 (19%)
19 (6.3%)
22 (7.3%)
10 (3.3%)
104 (34.6%)

0.1828
0.3470
0.6400
0.4180
0.7717

67 (17.2%)
59 (15.1%)

41 (13.6%)
43 (14.3%)

0.1981
0.7495

25/259

21/212

1.000

9 5.6
0.84 2.5

10 7.7
0.9 2.7

0.0412
0.8161

Rebleeding
Mortality
Surgery for
nonvariceal bleeding
Length of hospital
stay (days)
Intensive care (days)

0.3531

37

No statistically significant difference is to be

noticed except for a significantly higher complete
Rockall score for the urgent endoscopy group. For
the nonvariceal bleedings, there was no statistical
difference between the two groups (urgent versus
early endoscopy), if we consider stigmata of recent
hemorrhage (spurting bleeding, oozing, visible
vessel or adherent cloth). Also, there was no
statistical difference from the therapeutic point of
view: urgent versus early endoscopy was not
associated with a statistically significant difference
in terms of endoscopic and/or surgical hemostasis
requirement.
The outcome was analyzed in terms of inhospital mortality, in-hospital rebleeding and length
of hospital stay. Global mortality for the entire high
risk group was of 14.8%, with a 15.2% mortality
rate for the urgent endoscopy group and a 14.3%
mortality rate for the early endoscopy group.
Regarding variceal bleeding, there was no statistical
significant difference in terms of mortality for
urgent versus early endoscopy, 15.5% and 22.1%,
respectively (p = 0.2248, Fishers exact test).
Global rebleeding rate was 15.6%, with no
difference between the urgent versus early endoscopy groups (p = 0.1981).
The median length of hospital stay for the entire
study population was of 8 days, and the mean value
of 9.5 days, ranging 1 to 64 days. There was no
statistical difference in terms of length of hospital
stay between the 2 groups (p = 0.4542, MannWhitney test).
DISCUSSION

Our study was performed in an optimal

setting of permanent endoscopy with performance
of diagnosis and therapeutic intervention during the
first 24 hours after presentation in the emergency
department.
These results suggest that there is no
significant difference in the rate of main outcome
indicators (mortality, rebleeding rate, surgical
requirement, length of hospital stay), when high
risk patients with acute upper gastrointestinal
bleeding are managed with either urgent or early
endoscopy. Endoscopy might be safely delayed up
to 3 hours in most of the high risk patients, but
probably case to case selection based on simple
clinical judgement is necessary. Higher postendoscopic scores were noticed in the urgent endoscopy
group, suggesting a correlation between clinical
and endoscopic data. Our findings have important

38

Ana-Maria Boianu et al.

implications for those situations in which endoscopic facilities are not permanently or immediately
available. There may still be unmeasurable and
intangible factors or associations of factors
determining adverse events.
Numerous studies have indicated multiple
benefits of early endoscopy, performed within 24
hours from presentation to hospital [12, 14, 15, 17].
However, there is a limited number of studies to
support the use of urgent endoscopy within this 24
hours interval, especially in high risk patients. Our
results are concordant with several recent studies
that have also shown no significant difference in
terms of outcome comparing endoscopy performed
in variable time intervals within 24 hours [1216].
Thai et al. defined urgent endoscopy within 8
hours from presentation and found no significant
difference, but his study included only 106 high
risk patients with nonvariceal bleeding [16]. Two
other studies defined urgent endoscopy within 6
hours from presentation but also found no difference
between the 2 groups of high risk patients [13, 15].
One of the studies [15] included a mixed population,
with both variceal and nonvariceal bleedings, and
the other [13] included only nonvariceal bleedings.
The only study that showed a significant increase
in mortality belonged to Lim et al., but the study
population included only patients with nonvariceal
bleeding and the cut-off value was of 13 hours,
beyond which an increase in mortality was noticed
[17]. A recent larger study , which included only
nonvariceal bleedings, performed in the United
Kingdom, showed no reduction in mortality if
endoscopies were performed sooner than 12 hours,
but suggested a decrease in risk adjusted length of
hospital stay for patients that had an endoscopy
below 12 hours from presentation [18].
Though it is expected for urgent endoscopy to
be be associated with improved outcomes, several
factors could explain the lack of obvious superiorrity of urgent versus early endoscopy. These
include poor visualization with ongoing bleeding,
difficult haemostasis because bleeding site is
obscured, the commencement of healing with
downstaging of endoscopic lesions.

Another question to be answered is the safety

of early and urgent endoscopy in high risk patients.
So far, only few older studies have suggested some
adverse effects of rapid endoscopy, such as drop in
oxygen saturation and aspiration pneumonia [19
22]. Early endoscopy is considered a safe procedure
with multiple benefits, especially in terms of
therapy as well as transfusion requirements and
length of hospital stay reduction [2]. Economic
benefits are more obvious for non high risk
patients, in whom early discharge is encouraged
due to the economic burden represented by acute
upper gastrointestinal bleeding for the most common
gastroenterology emergency units [23, 24].
The present study has a few limitations which
could probably account for the higher mortality
rates than the other studies: pharmacological
vasoactive therapy (terlipressin, octreotid) for variceal
bleeding was not always available. Transjugular
porto-systemic shunt has only recently become
available in this center. The important proportion
of patients with variceal bleeding in our group
should also be noticed, as compared with most of
the other studies that have analysed only nonvariceal bleeding.
CONCLUSIONS

Performance of endoscopy within 3 hours

from admission in the emergency unit does not
appear to be associated with a significant decrease
in mortality, rebleeding or length of hospital stay in
a mixed group of high risk patients with
gastrointestinal bleeding. Urgent endoscopy should
be considered on a case by case basis. The defining
parameters for the situations in which the performance of urgent endoscopy should be strongly
considered are probably based on simple clinical
judgement. A higher mortality rate for variceal
bleeding can be noticed for delayed endoscopy, so
probably the presence of hepatic disease, in
particular cirrhosis, may be one of those clinical
factors for considering urgent endoscopy.

Ghidurile indic managementul pacienilor cu hemoragie digestiv

superioar, dar momentul optim al endoscopiei urgente n primele 24 de ore de la
prezentare nu este stabilit.
Scop. Compararea endoscopiei urgente versus precoce pe un grup de
pacieni cu risc nalt cu hemoragie digestiv superioar.
Metod. Studiu comparativ nerandomizat desfurat ntr-un centru teriar cu
gard permanent de endoscopie. Au fost inclui n studiu ase sute opt zeci i

Urgent versus early endoscopy in acute upper gastrointestinal bleeding

39

nou de pacieni cu risc nalt (scor Glasgow-Blatchford 12 puncte). Toate

endoscopiile au fost efectuate n primele 24 de ore de la prezentarea n urgen.
Endoscopia urgent a fost definit ca fiind efectuat n primele 3 ore de la
prezentare i a fost efectuat la 389 de pacieni. Datele au fost culese din foile de
observaie i programul Hospital Manager. Analiza statistic a fost efectuat
folosind testele Fisher i Mann-Whitney, cu valori semnificative statistic pentru p <
0,05, respectiv p < 0,0001.
Rezultate. Etiologia principal a fost cea ulceroas urmat de cea variceal.
Mortalitatea global a fost de 14,8% (102/690). Pentru endoscopia precoce versus
urgent n hemoragiile variceale, mortalitatea a fost mai ridicat dar fr a atinge
limita semnificaiei statistice (22,1% i respectiv 15,5%, p = 0,1590). Scorul
Rockall postendoscopic a fost semnificativ statistic mai mare pentru cei la care s-a
efectuat endoscopie urgent (p = 0,0256), dar toi parametrii de outcome au fost
similari.
Concluzie. Considernd organizarea optim a unei grzi permanente de
endoscopie, efectuarea urgent a acesteia n primele 3 ore de la prezentare nu se
asociaz cu o reducere semnificativ a mortalitii pentru pacienii cu risc crescut
(p = 0,67451).
Corresponding author: Ana-Maria Boianu, no. 66/1 Gh. Marinescu Street, Tg. Mure;
Tel. no.: 0741016626;
E-mail: anamariabotianu@yahoo.com
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Received January 21, 2013