Earlier endoscopic intervention has been expected to improve the outcome and has been recommended in patients with nonvariceal upper gastrointestinal bleeding (NVUGIB). For instance, the American [1] and the European [2] guidelines for NVUGIB before 2020 recommended that endoscopy within 12 hours be considered especially in high risk patients. However, multiple studies pointing out that early endoscopy within 24 hours is enough and urgent endoscopy is not effective in improving outcomes have been published between 2016 and 2020, including a randomized controlled study [3-5]. Furthermore, some studies have reported that the urgent endoscopy group has a rather worse prognosis than the others [6,7]. From this point of view, foreign guidelines revised after 2021 [8,9] consistently suggest that early endoscopy within 24 hours is sufficient as urgent endoscopy does not improve the outcome. Meanwhile, the 2020 Korean guideline took a reserved position recommending that the timing of the endoscopic intervention be followed by the clinician’s judgment [10], referring a study reported that urgent endoscopy was an independent predictor of lower mortality rate in 2018 [11]. Since then, few large-scale studies have been reported in Korea.
In this issue of the Korean Journal of Helicobacter and Upper Gastrointestinal Research, Jeon et al. [12] compared and analyzed the outcomes according to the timing of endoscopy and the patient risk in NVUGIB. This study included 1554 patients from eight institutions and classified them according to the Glasgow–Blatchford score (GBS) and the timing of endoscopy. As results, the need for transfusion was higher, but the rebleeding rate was lower in the delayed endoscopy group (≥24 hours) compared to the early endoscopy group (<24 hours) in univariate analyses. Multivariate analyses revealed that delayed endoscopy was a significant factor for lower rebleeding rate especially in the low risk group (GBS <12), while in-hospital comorbidity aggravation was more common in non-urgent endoscopy group (≥6 hours) than in urgent endoscopy group (<6 hours) in high risk group (GBS ≥12). From this results, the authors suggested that delayed endoscopy is sufficient in low risk group patients for NVUGIB management, and urgent endoscopy may be beneficial in reducing comorbidity aggravation during hospital care in high risk patients.
This result is thought to be meaningful in that it reported the results that urgent endoscopy is not required in all NVUGIB patients and suggested the possibility of improving outcome by setting different time points of endoscopic intervention according to the patient’s individual risk, stepping forward from the existing point of view that applying the same criteria for all patients. In addition, this conclusion can be easily applied in the clinical field since this study used GBS for risk assessment, a relatively simple and intuitive scoring system.
This study has some limitations. The data were analyzed retrospectively, and it was impossible to analyze some confounding factors including the competence or experience of the endoscopist and the date of index endoscopy (weekday or weekend). Though, this study included more than 1500 patients from multicenter, a significantly larger number of patients compared to the aforementioned Korean study. Moreover, the possibility of selection bias has been partially overcome as the authors enrolled the patients prospectively. It is expected that both patient prognosis and efficiency could be improved determining the timing of endoscopy according to the patient’s risk in NVUGIB management based on studies like this in the future.
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