Urgent vs. Early Endoscopy in High Risk Patients With Upper Gastrointestinal Bleeding (UGIB)

Acute upper gastrointestinal bleeding (UGIB) is one of the commonest medical emergencies. The condition accounts for 150 per 100,000 populations. A National United Kingdom reported a crude overall mortality rate of 10%. While bleeding stops spontaneously in majority of patients at their presentation, there remains a subgroup of patients who continue to bleed or develop recurrent bleeding. In these patients, the mortality increases manifolds. If these high-risk patients can be identified, early interventions may improve their outcomes. Several prognostic indices are in use for the purpose of patient stratification. They include the Rockall, Glasgow-Blatchford (GBS) and the Baylor scores. The Rockall score is a composite score which incorporates clinical parameters as well as findings during endoscopy which was derived to predict mortality. The GBS is a pre-endoscopy or a clinical score for the prediction for the need of further intervention loosely defined as the need for transfusion, endoscopy or surgery. It has been shown to be accurate in identifying low risk patients for early discharge.

The GBS, being a pre-endoscopy score with clinical parameters, is more suitable for patient triage leading to urgent endoscopy and a higher level of care. A GBS of 0 has been shown to identify patients with upper gastrointestinal bleeding who may be managed safely as outpatients. The proportion of patients requiring endoscopic therapy increases with a higher score. A cut-off score that identifies "high-risk" patients who may benefit from urgent intervention however has not been determined. Guidelines from Societies around the world recommend early endoscopy within 24 hours of presentation for acute upper gastrointestinal bleeding (AUGIB). The guidelines also state that a proportion of patients need emergency "out-of-hours" endoscopy, without defining the "high-risk" group. A recent international consensus on the management of NVUGIB recommended early endoscopy within 24 hours for Non-Variceal Upper Gastro Intestinal Bleeding (NVUGIB), and noted no additional benefit associated with urgent endoscopy (<12 hours) vs. early endoscopy (>12 hours) in unselected patients with NVUGIB. However, there are only limited data on the role of urgent endoscopy in the "selected" subgroup of patients with high-risk NVUGIB.

Patients are randomized in a 1:1 ratio. The patient is randomized to receive; Urgent endoscopy (defined by endoscopy within 6 hours from first consultation by GI specialists at PWH) or Early endoscopy (defined by endoscopy next morning and within 24 hours from first consultation by GI specialists at PWH)

Defined by oesophagogastroduodenoscopy within 6 hours of first presentation of Prince of Wales Hospital

Defined by oesophagogastroduodenoscopy within 24 hours of first presentation of Prince of Wales Hospital

To measure the number of days of hospital stay upon randomization, only counted the hospitalization days of index bleeding.

To measure if emergency surgery or interventional radiology is needed at index bleeding or recurrent bleeding to achieve hemostasis

To measure the adverse events in either group, e.g. myocardial event, cerebrovascular event and acute renal failure.

Inclusion Criteria: Overt signs of upper gastrointestinal bleeding (i.e., melena or hematemesis with or without hypotension) GBS of ≥12 In-patients admitted for reasons other than AUGIB who develop bleeding are also considered for trial enrollment. Patients in Hypotensive shock (SBP ≤90 mmHg or pulse ≥110 bpm) are initially resuscitated and then considered for trial entry if their condition can be stabilized. Exclusion Criteria: continued shock despite initial volume resuscitation (refractory shock) undergo urgent endoscopy < 18 years of age Unable to provide written informed consent Pregnant or lactating women Moribund patients from terminal illnesses. (active treatment not considered)

Lau JYW, Yu Y, Tang RSY, Chan HCH, Yip HC, Chan SM, Luk SWY, Wong SH, Lau LHS, Lui RN, Chan TT, Mak JWY, Chan FKL, Sung JJY. Timing of Endoscopy for Acute Upper Gastrointestinal Bleeding. N Engl J Med. 2020 Apr 2;382(14):1299-1308. doi: 10.1056/NEJMoa1912484.