Endoscopy 2011; 43(4): 300-306
DOI: 10.1055/s-0030-1256110
Original article

© Georg Thieme Verlag KG Stuttgart · New York

Urgent endoscopy is associated with lower mortality in high-risk but not low-risk nonvariceal upper gastrointestinal bleeding

L.  G.  Lim1 , K.  Y.  Ho1 , Y.  H.  Chan2 , P.  L.  Teoh3 , C.  J.  L.  Khor1 , L.  L.  Lim1 , A.  Rajnakova1 , T.  Z.  Ong4 , K.  G.  Yeoh1
  • 1Department of Gastroenterology and Hepatology, National University Health System, Singapore
  • 2Biostatistics Unit, National University Health System, Singapore
  • 3Health Research Services, National University Health System, Singapore
  • 4KPJ Kajang Specialist Hospital, Kajang, Selangor, Malaysia
Further Information

Publication History

submitted 31 March 2010

accepted after revision 5 September 2010

Publication Date:
28 February 2011 (online)

Background and study aims: The role of urgent endoscopy in high-risk nonvariceal upper gastrointestinal bleeding (NVUGIB) is unclear. The aim of this study was to determine whether esophagogastroduodenoscopy (EGD) performed sooner than the currently recommended 24 h in high-risk patients presenting with NVUGIB is associated with lower all-cause in-hospital mortality.

Methods: All adult patients undergoing EGD for the indications of coffee-grounds vomitus, hematemesis or melena at a university hospital over an 18-month period were enrolled. Patients with variceal and lower gastrointestinal bleeding were excluded. Data were prospectively collected.

Results: A total of 934 patients were included. The area under the receiver operating characteristic curve (AUROC) for the Glasgow-Blatchford score (GBS) was 0.813 for predicting all-cause in-hospital mortality, with a cut-off score of ≥ 12 resulting in 90 % specificity. In low-risk patients with GBS < 12, presentation-to-endoscopy time in those who died and in those who survived was similar. In high-risk patients with GBS of ≥ 12, presentation-to-endoscopy time was significantly longer in those who died than in those who survived. Multivariate analysis of the high-risk cohort showed presentation-to-endoscopy time to be the only factor associated with all-cause in-hospital mortality. For high-risk patients, the AUROC for presentation-to-endoscopy time in predicting all-cause in-hospital mortality was 0.803, with a sensitivity of 100 % at the cut-off time of 13 h. All-cause in-hospital mortality in high-risk patients was significantly higher in those with presentation-to-endoscopy time of > 13 h compared with those undergoing endoscopy in < 13 h from presentation (44 % vs. 0 %; P < 0.001).

Conclusions: Endoscopy within 13 h of presentation was associated with lower mortality in high-risk but not low-risk NVUGIB.


  • 1 Enestvedt B K, Gralnek I M, Mattek N et al. An evaluation of endoscopic indications and findings related to nonvariceal upper-GI hemorrhage in a large multicenter consortium.  Gastrointest Endosc. 2008;  67 422-429
  • 2 Rockall T A, Logan R F, Devlin H B et al. Variation in outcome after acute upper gastrointestinal haemorrhage. The National Audit of Acute Upper Gastrointestinal Haemorrhage.  Lancet. 1995;  346 346-350
  • 3 Rockall T A, Logan R F, Devlin H B et al. Risk assessment after acute upper gastrointestinal haemorrhage.  Gut. 1996;  38 316-321
  • 4 Saeed Z A, Winchester C B, Michaletz P A et al. A scoring system to predict rebleeding after endoscopic therapy of nonvariceal upper gastrointestinal hemorrhage, with a comparison of heat probe and ethanol injection.  Am J Gastroenterol. 1993;  88 1842-1849
  • 5 Blatchford O, Murray W R, Blatchford M. A risk score to predict need for treatment for uppergastrointestinal haemorrhage.  Lancet. 2000;  356 1318-1321
  • 6 Stanley A J, Ashley D, Dalton H R et al. Outpatient management of patients with low-risk upper-gastrointestinal haemorrhage: multicentre validation and prospective evaluation.  Lancet. 2009;  373 42-47
  • 7 Chen I C, Hung M S, Chiu T F et al. Risk scoring systems to predict need for clinical intervention for patients with nonvariceal upper gastrointestinal tract bleeding.  Am J Emerg Med. 2007;  25 774-779
  • 8 Adler D G, Leighton J A, Davila R E et al. ASGE guideline: The role of endoscopy in acute non-variceal upper-GI hemorrhage.  Gastrointest Endosc. 2004;  60 497-504
  • 9 British Society of Gastroenterology Endoscopy Committee. Non-variceal upper gastrointestinal haemorrhage: guidelines.  Gut. 2002;  51 (Suppl. 4) iv1-6
  • 10 Schacher G M, Lesbros-Pantoflickova D, Ortner M A et al. Is early endoscopy in the emergency room beneficial in patients with bleeding peptic ulcer? A “fortuitously controlled” study.  Endoscopy. 2005;  37 324-328
  • 11 Tai C M, Huang S P, Wang H P et al. High-risk ED patients with nonvariceal upper gastrointestinal hemorrhage undergoing emergency or urgent endoscopy: a retrospective analysis.  Am J Emerg Med. 2007;  25 273-278
  • 12 Lee J G, Turnipseed S, Romano P S et al. Endoscopy-based triage significantly reduces hospitalization rates and costs of treating upper GI bleeding: a randomized controlled trial.  Gastrointest Endosc. 1999;  50 755-761
  • 13 Bjorkman D J, Zaman A, Fennerty M B et al. Urgent vs. elective endoscopy for acute non-variceal upper-GI bleeding: an effectiveness study.  Gastrointest Endosc. 2004;  60 1-8
  • 14 Barkun A N, Bardou M, Kuipers E J. International Consensus Upper Gastrointestinal Bleeding Conference Group. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding.  Ann Intern Med. 2010;  152 101-113
  • 15 Blatchford O, Davidson L A, Murray W R et al. Acute upper gastrointestinal haemorrhage in west of Scotland: case ascertainment study.  BMJ. 1997;  315 510-514
  • 16 Ananthakrishnan A N, McGinley E L, Saeian K. Outcomes of weekend admissions for upper gastrointestinal hemorrhage: a nationwide analysis.  Clin Gastroenterol Hepatol. 2009;  7 296-302e1
  • 17 Bell C M, Redelmeier D A. Mortality among patients admitted to hospitals on weekends as compared with weekdays.  N Engl J Med. 2001;  345 663-668
  • 18 Kostis W J, Demissie K, Marcella S W et al. Weekend versus weekday admission and mortality from myocardial infarction.  N Engl J Med. 2007;  356 1099-1109
  • 19 Saposnik G, Baibergenova A, Bayer N et al. Weekends: a dangerous time for having a stroke?.  Stroke. 2007;  38 1211-1215
  • 20 Adamopoulos A B, Baibas N M, Efstathiou S P et al. Differentiation between patients with acute upper gastrointestinal bleeding who need early urgent upper gastrointestinal endoscopy and those who do not. A prospective study.  Eur J Gastroenterol Hepatol. 2003;  15 381-387
  • 21 Shaheen A A, Kaplan G G, Myers R P. Weekend versus weekday admission and mortality from gastrointestinal hemorrhage caused by peptic ulcer disease.  Clin Gastroenterol Hepatol. 2009;  7 303-310
  • 22 Targownik L E, Murthy S, Keyvani L et al. The role of rapid endoscopy for high-risk patients with acute nonvariceal upper gastrointestinal bleeding.  Can J Gastroenterol. 2007;  21 425-429
  • 23 Müller T, Barkun A N, Martel M. Non-variceal upper GI bleeding in patients already hospitalized for another condition.  Am J Gastroenterol. 2009;  104 330-339
  • 24 Garcia-Tsao G, Bosch J. Management of varices and variceal hemorrhage in cirrhosis.  N Engl J Med. 2010;  362 823-832
  • 25 Garcia-Tsao G, Sanyal A J, Grace N D et al. Practice Guidelines Committee of the American Association for the Study of Liver Diseases; Practice Parameters Committee of the American College of Gastroenterology. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis.  Am J Gastroenterol. 2007;  102 2086-2102
  • 26 Spiegel B M. Endoscopy for acute upper GI tract hemorrhage: sooner is better.  Gastrointest Endosc. 2009;  70 236-239

K. G. YeohMD 

Department of Gastroenterology and Hepatology
University Medicine Cluster
National University Health System

5 Lower Kent Ridge Road
Main Building 1, Level 6
Singapore 119074

Fax: +65-67751518

Email: khay_guan_yeoh@nuhs.edu.sg