Subscribe to RSS
Is Early Endoscopy in the Emergency Room Beneficial in Patients with Bleeding Peptic Ulcer? A ”Fortuitously Controlled” Study
Submitted 26 October 2004
Accepted after Revision 3 November 2004
12 April 2005 (online)
Background and Study Aims: In previous randomized trials, early endoscopy improved the outcome in patients with bleeding peptic ulcer, though most of these studies defined ”early” as endoscopy performed within 24 hours after admission. Using the length of hospital stay as the primary criterion for the clinical outcome, we compared the results of endoscopy done immediately after admission (early endoscopy in the emergency room, EEE) with endoscopy postponed to a time within the first 24 hours after hospitalization, but still during normal working hours (”delayed” endoscopy in the endoscopy unit, DEU).
Patients and Methods: We conducted a retrospective analysis of data from 81 consecutive patients with bleeding peptic ulcer admitted in 1997 and 1998 (age range 16 - 90 years). Of these 81 patients, 38 underwent DEU (the standard therapy at the hospital) and 43 underwent EEE. Patients in the two groups were comparable with regard to admission criteria, were equally distributed with respect to their risk of adverse outcome (assessed using the Baylor bleeding score and the Rockall score), and differed only in the treatment they received. Endoscopic hemostasis was performed whenever possible in all patients with Forrest types I, IIa, and IIb ulcer bleeding.
Results: We found similar rates in the two groups for recurrent bleeding (16 % in DEU patients vs. 14 % in EEE patients), persistent bleeding (8 % in DEU patients vs. none in EEE patients), medical complications (21 % in DEU patients vs. 26 % in EEE patients), the need for surgery (8 % in DEU patients vs. 9 % in EEE patients), and the length of hospital stay (5.1 days for DEU patients vs. 5.9 days for EEE patients). None of the differences between the two groups in these parameters were statistically significant. None of the patients died.
Conclusions: Early endoscopy in an emergency room did not improve the clinical outcome in our 81 consecutive patients with bleeding peptic ulcer.
- 1 Cook D J, Guyatt G H, Salena B J, Laine L A. Endoscopic therapy for acute nonvariceal upper gastrointestinal hemorrhage: a meta-analysis. Gastroenterology. 1992; 102 139-148
- 2 Sacks H S, Chalmers T C, Blum A L. et al . Endoscopic hemostasis: an effective therapy for bleeding peptic ulcers. JAMA. 1990; 264 494-499
- 3 Panes J, Viver J, Forne M. et al . Controlled trial of endoscopic sclerosis in bleeding peptic ulcers. Lancet. 1987; 2 1292-1294
- 4 Laine L. Multipolar electrocoagulation in the treatment of active upper gastrointestinal tract hemorrhage: a prospective controlled trial. N Engl J Med. 1987; 316 1613-1617
- 5 Lin H J, Wang K, Perng C L. et al . Early or delayed endoscopy for patients with peptic ulcer bleeding: a prospective randomized study. J Clin Gastroenterol. 1996; 22 267-271
- 6 Lee J G, Turnipseed S, Romano P S. et al . Endoscopy-based triage significantly reduces hospitalization rates and costs of treating upper gastrointestinal bleeding: a randomized controlled trial. Gastrointest Endosc. 1999; 50 755-761
- 7 Rockall T A, Logan R F, Devlin H B, Northfield T C. Selection of patients for early discharge or outpatient care after acute upper gastrointestinal haemorrhage. National Audit of Acute Upper Gastrointestinal Haemorrhage. Lancet. 1996; 347 1138-1140
- 8 Cooper G S, Chak A, Way L E. et al . Early endoscopy in upper gastrointestinal hemorrhage: associations with recurrent bleeding, surgery, and length of hospital stay. Gastrointest Endosc. 1999; 49 145-152
- 9 Cooper G S, Chak A, Connors A F, Jr. et al . The effectiveness of early endoscopy for upper gastrointestinal hemorrhage: a community-based analysis. Med Care. 1998; 36 462-474
- 10 Spiegel B M, Vakil N B, Ofman J J. Endoscopy for acute nonvariceal upper gastrointestinal tract hemorrhage: is sooner better? A systematic review. Arch Intern Med. 2001; 161 1393-1404
- 11 Blum A L, Stutz R, Haemmerli U P. et al . A fortuitously controlled study of steroid therapy in acute viral hepatitis. I: Acute disease. Am J Med. 1969; 47 82-92
- 12 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
- 13 Saeed Z A, Ramirez F C, Hepps K S. et al . Prospective validation of the Baylor bleeding score for predicting the likelihood of rebleeding after endoscopic hemostasis of peptic ulcers. Gastrointest Endosc. 1995; 41 561-565
- 14 Rockall T A, Logan R F, Devlin H B, Northfield T C. Risk assessment after acute upper gastrointestinal haemorrhage. Gut. 1996; 38 316-321
- 15 Rockall T A, Logan R F, Devlin H B, Northfield T C. Variation in outcome after acute upper gastrointestinal haemorrhage. The National Audit of Acute Upper Gastrointestinal Haemorrhage. Lancet. 1995; 346 346-350
- 16 Gardner M J, Altman D G (eds). Statistics with Confidence. 1st edn. London; British Medical Journal 1989
- 17 D'Amico G, Pietrosi G, Tarantino I, Pagliaro L. Emergency sclerotherapy vs. medical interventions for bleeding oesophageal varices in cirrhotic patients. Cochrane Database Syst Rev. 2002; 1 CD002233
- 18 Sung J J, Chung S C, Yung M Y. et al . Prospective randomised study of the effect of octreotide on rebleeding from oesophageal varices after endoscopic ligation. Lancet. 1995; 346 1666-1669
- 19 Besson I, Ingrand P, Person B. et al . Sclerotherapy with or without octreotide for acute variceal bleeding. N Engl J Med. 1995; 333 555-560
G. Dorta, M. D.
Gastroentérologie, CHUV BH 10/535
Rue du Bugnon 47 · CH-1011 Lausanne · Switzerland ·
Fax: + 41-21-314-0707