Endoscopy for acute nonvariceal upper gastrointestinal tract hemorrhage: Is sooner better? A systematic review

Background: While the effectiveness of upper endoscopy has been established for acute nonvariceal upper gastrointestinal tract hemorrhage, its optimal timing has not been clearly defined. Early endoscopy has been advocated fo r its ability to achieve prompt diagnosis, risk stratification, and therape utic hemostasis. Objective: To determine whether early vs delayed endoscopy improves patient and economic outcomes for all risk groups with nonvariceal upper gastroint estinal tract hemorrhage. Methods: A systematic review of 3 computerized databases (MEDLINE, HEALTHST AR, and Cochrane Database of Systematic Reviews) was performed along with h and searching of published abs tracts to identify English-language citation s from 1980 to 2000. Results: Twenty-three studies met explicit inclusion criteria. The highest- quality study examining outcomes in low-risk patients found no significant complications at 1-month follow-up for any outpatients managed with early e ndoscopy. The largest randomized trial of high-risk patients showed no mort ality benefit but a significant decrease in transfusion requirements with e arly endoscopy. Seven of the 8 studies examining the effect of early endosc opy on length of stay as a measure of resource utilization demonstrated a s ignificant reduction compared with that of delayed endoscopy. However, most included studies were found to suffer from 1 or more potentially significa nt methodologic shortcomings. Conclusions: The overwhelming majority of existing data suggest that early endoscopy is safe and effective for all risk groups. The clinical and econo mic outcomes of early endoscopy should be confirmed in additional well-desi gned randomized controlled trials. Given the strength of the evidence, effo rts to develop a more standardized and time-sensitive approach to acute non variceal upper gastrointestinal tract hemorrhage should be undertaken.