For patients presenting with acute upper gastrointestinal bleeding the best outcomes are achieved when endoscopy is done early but not within an urgent, six hour, timeframe, research shows.

The findings confirm previous suggestions that endoscopic intervention is best done within 24 hours of admission, after patients have had appropriate resuscitation and medical optimisation, Singapore researchers said in the journal Gut.

They conducted a retrospective cohort study of data from 6474 patients who presented to public hospitals with AUGIB and received therapeutic endoscopy within 48 hours.

Outcomes were analysed based on timing of endoscopy after admission, with patients classified as either urgent (within six hours), early (endoscopy within six – 24 hours) and late (24-48 hours).

Using propensity score weighting, the study results showed that significantly more favourable outcomes were reported in patients who received early endoscopy compared with patients who received late or urgent endoscopy.

Urgent timing (n=1008) endoscopy had significantly higher 30-day all-cause mortality, repeat endoscopy rates and ICU admission rates compared with early endoscopy. However, after taking into account bleeding aetiology, the results were only consistent with non-variceal bleeding.

Late endoscopy was associated with higher 30-day mortality, in-hospital mortality and 30-day transfusion rates, but also with a lower rate of ICU admission after endoscopy. For variceal bleeding, late endoscopy was associated with worse outcomes, with higher rates of repeated endoscopy and ICU admission.

The researchers said the findings contrasted with better outcomes seen with urgent endoscopy results seen in some smaller studies but could potentially be explained by the longer medical optimisation time that patients in the early group had when compared with the urgent group.

“There is likely time for a primary and secondary survey, fluid resuscitation, blood transfusion, as well as the pharmacological therapies to take effect,” they noted.

“Patients with active bleeding may have large amounts of fresh blood or clots in the stomach, possibly obscuring the site of injury and rendering endoscopic haemostasis difficult. Gastric acid suppression, especially with the potent intravenous PPI infusion, has been demonstrated to improve outcomes in AUGIB patients,” they added.

Conversely, the higher mortality rate of the late endoscopy group might be explained by a longer time before intervention meaning that haemostasis might not be achieved without endoscopic therapy and the patient may deteriorate too significantly.

However they acknowledged that there would need to be more nuanced considerations for individual patients, given that subgroup analysis showed that endoscopy timing had less impact on outcomes in patients with comorbidities and with variceal bleeding.

Nevertheless, they concluded that the results “suggest that most AUGIB patients need not be rushed to endoscopy immediately. Rather, active resuscitation and optimal medical treatment should be initiated as appropriate, then with endoscopy performed within 24 hours of presentation.”