Clinical Pearls & Morning Reports
A randomized trial by Lau et al. assessed whether endoscopy performed within 6 hours after gastroenterologic consultation, as compared with endoscopy performed between 6 and 24 hours after consultation, improved outcomes among patients in stable condition who were hospitalized with acute upper gastrointestinal bleeding and who were assessed as having a high risk of further bleeding and death. Read the NEJM Original Article here.
Q: What is the Glasgow–Blatchford score?
A: Patients with a Glasgow–Blatchford score of 12 or higher were eligible for enrollment in the trial by Lau et al. The Glasgow–Blatchford score is a validated risk-assessment score for the prediction of clinical outcomes in patients with acute upper gastrointestinal bleeding, including the need for interventions and the risk of death (scores range from 0 to 23, with higher scores indicating a higher risk of further bleeding or death). The Glasgow–Blatchford score is based on the systolic blood pressure, pulse rate, hemoglobin and serum urea levels at admission, whether the patient presented with melena or syncope, and the presence or absence of hepatic disease or cardiac failure.
Q: Have prior studies addressed whether urgent endoscopy decreases mortality in stable patients with acute upper gastrointestinal bleeding?
A: Many observational studies, three randomized, controlled trials, and two systematic reviews have shown that urgent endoscopy (the definitions of which have varied among studies, ranging from within 2 hours to within 12 hours after presentation) in unselected patients with acute upper gastrointestinal bleeding did not decrease mortality. The three randomized trials were not designed to focus on patients at high risk for further bleeding or death and did not report an assessment of patients’ risk.
A: Lau et al. found that, as compared with endoscopy performed within 24 hours after gastroenterologic consultation, endoscopy performed within 6 hours after consultation did not lead to lower mortality or a lower incidence of further bleeding. A total of 23 patients (8.9%) in the urgent-endoscopy group and 17 (6.6%) in the early-endoscopy group died (hazard ratio, 1.35; 95% CI, 0.72 to 2.54, P=0.34). Further bleeding within 30 days occurred in 28 patients (10.9%) in the urgent-endoscopy group and 20 patients (7.8%) in the early-endoscopy group (hazard ratio, 1.46; 95% CI, 0.83 to 2.58). The duration of hospitalization did not differ between the urgent-endoscopy group and the early-endoscopy group, and the two groups were similar in the number of patients who were admitted to the intensive care unit, the percentage of patients who received a transfusion, and the mean number of units of packed red cells received by transfusion.
A: Although the trial enrolled patients who were predicted to be at high risk for further bleeding and death, the authors excluded patients who had persistent hypotensive shock despite undergoing resuscitation. Thus, the results are not generalizable to patients with ongoing bleeding and hypotensive shock, who require urgent intervention. In addition, trial hospitals offered around-the-clock endoscopy service with a fellow and a senior endoscopist. The results are not generalizable to hospitals that do not have such support. Finally, the proportion of patients with variceal bleeding in the trial cohort was small. Trial findings may not be applicable in localities with a high prevalence of esophagogastric varices.