Hemodynamic Status as a Determinant Factor of Optimal Endoscopy Timing in Upper Gastrointestinal Bleeding: An International Survey of 533 Clinicians

Aims Upper gastrointestinal bleeding (UGIB) poses a significant threat to patients presenting to the emergency department, particularly those with associated hemodynamic instability. Timely endoscopy is crucial for optimal management, yet there remains ongoing debate regarding the most appropriate timing, especially in relation to the patient's hemodynamic status. This study aimed to assess clinical practice patterns and gain a clearer understanding of the pre-endoscopic assessment and timing of endoscopy for patients with acute UGIB.

Methods This study was conducted as an international online survey from April 2023 to November 2023. The target population included practicing physicians actively managing patients with UGIB. Data collection and management were facilitated through Research Electronic Data Capture (REDCap). We assessed clinicians' opinions on the optimal timing of endoscopy for variceal and non-variceal bleeding under three hemodynamic conditions: stable, unstable but responding to resuscitation, and unstable not responding to resuscitation. For each question, respondents selected a single option corresponding to the time frame for endoscopy: within 2, 6, 12, 24, or>24 hours from the patient’s presentation. The primary analysis provided a descriptive summary of responses presented as proportions. Secondary analyses examined variations in responses based on clinical experience, practice setting, and the estimated annual number of UGIB cases encountered. We also asked clinicians how they define hemodynamic instability.

Results A total of 533 clinicians from 50 countries completed the survey. Among the respondents, 54.6% work in university-based hospitals, and 67.7% reported managing more than 100 UGIB cases annually. Regarding clinical experience, 55.7% have less than 10 years of experience, while 44.3% have more than 10 years. For hemodynamically stable variceal bleeding, the majority (29.1%) recommended endoscopy within 12 hours, 37.7% suggested it within 6 hours for unstable responders, and 60% within 2 hours for unstable non-responders. Similarly, for non-variceal bleeding, 43.1% recommended endoscopy within 24 hours for stable patients, 30.2% within 6 hours for unstable responders, and 47.8% within 2 hours for unstable non-responders. The most common definition of hemodynamic instability was systolic blood pressure<100 mmHg and heart rate>100 bpm, or the presence of syncope, orthostatic hypotension, or signs of organ hypoperfusion. Additionally, younger doctors were more likely to adhere to guideline recommendations compared to their counterparts with over 15 years of clinical experience.

Conclusions Our findings reveal a consistent trend: the more hemodynamically unstable the patients are, the earlier gastroenterologists tend to recommend performing endoscopy for both variceal and non-variceal bleeding. However, there is significant variability in assessment approaches among respondents. This study highlights opportunities to improve consistency in clinical practice and identifies potential areas for further research.

Publication History

Article published online:
27 March 2025