Original Articles
Urgent vs. elective endoscopy for acute non-variceal upper-GI bleeding: an effectiveness study

https://doi.org/10.1016/S0016-5107(04)01287-8Get rights and content

Abstract

Background

Urgent endoscopy in patients with acute upper-GI bleeding identifies many patients who may be safely treated without hospitalization. The aim of this multicenter trial was to determine whether urgent endoscopy effectively decreases health care resource utilization in a real-life setting where primary care providers determine the course of care.

Methods

Ninety-three outpatients with acute upper-GI bleeding were randomized to either urgent endoscopy (before hospitalization) or elective endoscopy after admission. The results of urgent endoscopy and a recommendation regarding patient disposition were provided to the attending physician. Medical outcomes and resource utilization were measured.

Results

The timing of endoscopy did not affect resource utilization or patient outcomes. Length of stay was similar (urgent endoscopy, OR 3.98 days: 95% CI[2.84, 5.11] vs. elective endoscopy, OR 3.26 days: 95% CI[2.32, 4.21], p = 0.45). The mean number of days in an intensive care unit was the same (1.2 days). The urgent endoscopy group had more high-risk endoscopic lesions (15 vs. 9; p = 0.031). Outpatient care was recommended for 19 patients (40%). Only 4 patients were discharged.

Conclusions

Urgent endoscopy did not reduce hospitalization or resource utilization because the results of early endoscopy did not impact the decision by attending physicians regarding admission. For early (triage) endoscopy to impact resource utilization, the results of endoscopy must change subsequent patient care.

Section snippets

Patients and methods

The study design was prospective, randomized, blinded, and multicenter, with concealed allocation, comparing urgent endoscopy (UE) with elective endoscopy (EE). Every effort was made to study the intervention without impacting the otherwise normal process of patient care. The main outcomes of the study were specifically resource utilization (hospitalization, length of stay, ICU days, units of blood transfused, repeat endoscopy) and clinical outcomes (morbidity, mortality, need for

Results

The demographics of the two treatment groups were similar (Table 3); no significant difference was detected in any variable. The timing of endoscopy did not affect either health care resource utilization or patient outcomes (Table 4). The total length of stay was similar (OR 3.98 days: 95% CI[2.84, 5.11], median, 3 days; and OR 3.26 days: 95% CI[2.32, 4.21], median, 3 days, for UE and EE, respectively; p = 0.45). Central tendency summary statistics for the number of ICU days was the same (mean

Discussion

The timing of endoscopy in patients with acute UGI bleeding remains a subject of debate, particularly for the patient who responds rapidly to volume resuscitation and has no further evidence of bleeding. Although it may seem intuitive that early endoscopy would improve care, randomized trials have indicated that “diagnostic” early endoscopy does not improve mortality, the frequency of recurrent bleeding, the need for surgery, or the length of hospital stay.18., 19., 20. The overwhelming

References (32)

  • L Laine

    Multipolar electrocoagulation versus injection therapy in the treatment of bleeding peptic ulcers. A prospective, randomized trial

    Gastroenterology

    (1990)
  • N.S Nishioka et al.

    Endoscopic therapy of bleeding peptic ulcers: a cost-benefit analysis

    Gastrointest Endosc

    (1987)
  • G.S Dulai et al.

    Utilization of health care resources for low-risk patients with acute, nonvariceal upper GI hemorrhage: an historical cohort study

    Gastrointest Endosc

    (2002)
  • J.A Hay et al.

    Upper gastrointestinal hemorrhage clinical guideline: determining the optimal hospital length of stay

    Am J Med

    (1996)
  • L Laine et al.

    Bleeding peptic ulcer

    N Engl J Med

    (1994)
  • G.F Longstreth

    Epidemiology of hospitalization for acute upper gastrointestinal hemorrhage: a population-based study

    Am J Gastroenterol

    (1995)
  • Cited by (0)

    The preliminary results of this work were presented at Digestive Diseases Week, May 21-24, 2000, San Diego, California (Gastrointest Endosc 2000;51:AB129).

    This study was supported by grants from the American Society for Gastrointestinal Endoscopy, the American College of Gastroenterology, and the American Digestive Health Foundation.

    View full text