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122 EARLY IS GOOD; IS EARLIER BETTER? DOES ENDOSCOPY WITHIN SIX HOURS OF PRESENTATION IMPROVE OUTCOMES IN HIGH-RISK PATIENTS PRESENTING WITH ACUTE NONVARICEAL UPPER GASTROINTESTINAL BLEEDING (ANVUGIB)? L Keyvani, LE Targownik, SK Murthy, S Leeson
BACKGROUND: ANVUGIB is a serious cause of morbidity and mortality and is associated with 5% to 10% case-fatality rate. The evidence to date suggests that performance of endoscopy within 24 h of presentation reduces the risk of rebleeding and mortality in patients presenting with ANVUGIB. However, it is unclear whether performing endoscopy earlier within this 24 h window provides any additional benefit. The benefits of performing even earlier endoscopy would likely be most pronounced in high-risk patients, including the elderly, those with evidence of shock on presentation and patients with history of severe comorbid illness. Therefore, we sought to determine if there were significant differences in outcomes between high-risk ANVUGIB patients who undergo endoscopies within 6 h of presentation ('earlier') vs between 6 h to 24 h from presentation ('early').
METHODS: We performed a retrospective review of all patients with ANVUGIB who presented to one of our two tertiary care medical centres in Winnipeg, Manitoba between 1999 and 2004.We selected the patients who were high-risk based on their having a clinical Rockall score of
RESULTS: We analyzed 311 patients with ANVUGIB who received their endoscopy within first 24 h of presentation of whom 181 were high-risk based on their clinical Rockall scores. Of these high-risk patients, 63 had endoscopy 'earlier' whereas 118 had 'early' endoscopy. There were no significant differences in the base line characteristics between the comparator groups. Patients receiving 'earlier' endoscopy were more likely to have undergone endoscopic hemostasis (44% vs 37%)though the difference was not statistically significant (P>0.2).There were no differences in the incidence of adverse outcomes (22% 'earlier' vs 21% 'early', P>0.2). Patients in 'earlier' endoscopy group were significantly more likely to have a hospital stay exceeding five days (68% vs 50%; P=0.024).
CONCLUSION: There is no difference in the rate of adverse outcomes in high-risk ANVUGIB patients who undergo endoscopy within the first 6 h of arrival vs those undergoing endoscopy between 6 h and 24 h of presentation to the hospital. The optimal timing of endoscopy within first 24 h should be confirmed in well designed randomized controlled trial setting.