Timing of endoscopy for acute upper GI bleeding

Trial question
What is the role of urgent endoscopy in patients with acute upper gastrointestinal bleeding who are at high risk for further bleeding or death?
Study design
Single center
Open label
RCT
Population
Characteristics of study participants
37.0% female
63.0% male
N = 516
516 patients (191 female, 325 male).
Inclusion criteria: patients with overt signs of acute upper gastrointestinal bleeding and a Glasgow-Blatchford score ≥ 12.
Key exclusion criteria: continued shock despite initial volume resuscitation, age < 18 years, unable to provide written informed consent, pregnant or lactating women, moribund from terminal illnesses.
Interventions
N=258 urgent-endoscopy (endoscopy within 6 hours of gastroenterology consultation).
N=258 early-endoscopy (endoscopy between 6 and 24 hours after gastroenterology consultation).
Primary outcome
Death from any cause at 30 days
8.9%
6.6%
8.9 %
6.7 %
4.5 %
2.2 %
0.0 %
Urgent-endoscopy
Early-endoscopy
No significant difference ↔
No significant difference in death from any cause at 30 days (8.9% vs. 6.6%; HR 1.35, 95% CI 0.72 to 2.54).
Secondary outcomes
No significant difference in the rate of further bleeding within 30 days (10.9% vs. 7.8%; HR 1.46, 95% CI 0.83 to 2.58).
No significant difference in ICU admission (1.6% vs. 1.2%; HR 1.33, 95% CI 0.3 to 5.9).
Significant increase in endoscopic hemostatic treatment during initial endoscopy (60.1% vs. 48.4%; HR 1.24, 95% CI 1.06 to 1.46).
Safety outcomes
No significant differences in persistent bleeding, recurrent bleeding, fatal and nonfatal adverse events.
Significant difference in ulcers with active bleeding or visible vessels (66.4% vs. 47.8%).
Conclusion
In patients with overt signs of acute upper gastrointestinal bleeding and a Glasgow-Blatchford score ≥ 12, urgent-endoscopy was not superior to early-endoscopy with respect to death from any cause at 30 days.
Reference
James Y W Lau, Yuanyuan Yu, Raymond S Y Tang et al. Timing of Endoscopy for Acute Upper Gastrointestinal Bleeding. Reply. N Engl J Med. 2020 Apr 2;382(14):1299-1308.
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