Endoscopy 2002; 34(7): 527-530
DOI: 10.1055/s-2002-33219
Original Article
© Georg Thieme Verlag Stuttgart · New York

Overlooked Lesions at Emergency Endoscopy for Acute Nonvariceal Upper Gastrointestinal Bleeding

C.-L.  Cheng1 , C.-S.  Lee1 , N.-J.  Liu1 , P.-C.  Chen1 , C.-T.  Chiu1 , C.-S.  Wu1
  • 1Division of Hepatogastroenterology, Dept. of Internal Medicine, Chang Gung Memorial Hospital, Taipei, Taiwan, Republic of China
Further Information

Publication History

Submitted 26 July 2001

Accepted after Revision 22 January 2002

Publication Date:
12 August 2002 (online)

Background and Study Aims: Excessive blood covering the examination field is a frequent cause of diagnostic failure in emergency endoscopy for acute upper gastrointestinal bleeding. The implications and outcome in these patients have not been well described.
Patients and Methods: The records for 1459 consecutive patients who presented at our medical center with acute nonvariceal upper gastrointestinal bleeding during a 15-month period were reviewed. All of the patients underwent emergency endoscopy within 24 h of initial presentation. Patients in whom an identifiable bleeding source was not found in spite of an overtly bloody lumen were designated as having a failure of diagnosis, and these cases were analyzed further.
Results: Diagnosis failed in 25 patients (1.7 %), 16 of whom underwent repeat endoscopy or surgical intervention. Bleeding vessels were identified in 13 of these patients. Gastric and duodenal ulcers were the most commonly overlooked lesions, with locations in the cardia (n = 3), fundus (n = 2), posterior wall of the antrum (n = 1), duodenal bulb (n = 3), second part of the duodenum (n = 2), and in the stoma of a Billroth II gastrectomy (n = 2). The rates for endoscopic complications, recurrent bleeding, surgery, and mortality were significantly higher in the group with diagnostic failure than in patients with acute upper gastrointestinal bleeding in whom diagnosis did not fail (8 % vs. 0.4 %; 20 % vs. 3.1 %; 16 % vs. 2.9 %; and 20 % vs. 3.6 %, respectively).
Conclusions: In acute nonvariceal upper gastrointestinal bleeding, diagnostic failure is associated with higher morbidity and mortality. The data from this study emphasize the importance of good preparation before the procedure and adequate removal of blood during emergency endoscopy procedures.


  • 1 Laine L, Peterson W L. Bleeding peptic ulcer.  N Engl J Med. 1994;  331 717-727
  • 2 Forrest J AH, Finlayson N DC, Shearman D JC. Endoscopy in gastrointestinal bleeding.  Lancet. 1974;  ii 394-397
  • 3 Gilbert D A, Silverstein F E, Tedesco F J. et al . The national ASGE survey on upper gastrointestinal bleeding, 3: endoscopy in upper gastrointestinal bleeding.  Gastrointest Endosc. 1981;  27 94-102
  • 4 Cooper G S, Chak A, Way L E. et al . Early endoscopy in upper GI hemorrhage: associations with recurrent bleeding, surgery, and length of hospital stay.  Gastrointest Endosc. 1999;  49 145-152
  • 5 Storey D W, Bown S G, Swain C P. Endoscopic prediction of recurrent bleeding in peptic ulcers.  N Engl J Med. 1981;  305 915-916
  • 6 Lau J Y, Chung S C, Leung J W. et al . The evolution of hemorrhage in bleeding peptic ulcers: a sequential endoscopic study.  Endoscopy. 1998;  30 513-518
  • 7 Cotton P B, Rosenberg M T, Waldram R PL. et al . Early endoscopy of oesophagus, stomach, and duodenal bulb in patients with haematemesis and melaena.  Br Med J. 1973;  2 505-509
  • 8 Chung Y FA, Wong W K, Soo K C. Diagnostic failures in endoscopy for acute upper gastrointestinal hemorrhage.  Br J Surg. 2000;  87 614-617
  • 9 Sontheimer J, Salm R, Cegla M. et al . Technical aid for facilitating emergency endoscopy.  Endoscopy. 1989;  21 283-284
  • 10 Hintze R E, Binmoeller K F, Adler A. et al . Improving endoscopic management of severe upper gastrointestinal hemorrhage using a new wide-channel endoscope.  Endoscopy. 1994;  26 613-616
  • 11 Lawrence S, Riemann J F. Intravenous erythromycin to clear the stomach of obstructing clots.  Gastrointest Endosc. 1994;  40 774-775
  • 12 Wu D C, Lu C Y, Lu C H. et al . Endoscopic hydrogen peroxide spray may facilitate localization of the bleeding site in acute upper gastrointestinal bleeding.  Endoscopy. 1999;  31 237-241
  • 13 [Anon] . Consensus conference: therapeutic endoscopy and bleeding ulcers.  JAMA. 1989;  262 1369-1372
  • 14 Dagradi A E, Arguello J F, Weingarten Z G. Failure of endoscopy to establish a source for upper gastrointestinal bleeding.  Am J Gastroenterol. 1979;  72 395-402
  • 15 Stollman N H, Putcha R V, Neustater B R. et al . The uncleared fundal pool in acute upper gastrointestinal bleeding: implications and outcomes.  Gastrointest Endosc. 1997;  46 324-327

C.-S. Lee, M.D.

Division of Hepatogastroenterology · Dept. of Internal Medicine · Chang Gung Memorial Hospital

5 Fu-Shin Street · Kweishan · Taoyuan · Taiwan ·

Fax: + 886-3-3272236

Email: cslee218@hotmail.com.tw