Urgent endoscopy is associated with lower mortality in high-risk but not low-risk nonvariceal upper gastro- intestinal bleeding Authors L. G. Lim 1 , K. Y. Ho 1 , Y. H. Chan 2 , P. L. Teoh 3 , C. J. L. Khor 1 , L. L. Lim 1 , A. Rajnakova 1 , T. Z. Ong 4 , K. G. Yeoh 1 Institutions 1 Department of Gastroenterology and Hepatology, National University Health System, Singapore 2 Biostatistics Unit, National University Health System, Singapore 3 Health Research Services, National University Health System, Singapore 4 KPJ Kajang Specialist Hospital, Kajang, Selangor, Malaysia submitted 31 March 2010 accepted after revision 5 September 2010 Bibliography DOI http://dx.doi.org/ 10.1055/s-0030-1256110 Published ahead of print Endoscopy © Georg Thieme Verlag KG Stuttgart · New York ISSN 0013-726X Corresponding author K. G. Yeoh, MD Department of Gastro- enterology and Hepatology University Medicine Cluster National University Health System 5 Lower Kent Ridge Road Main Building 1, Level 6 Singapore 119074 Fax: +65-67751518 khay_guan_yeoh@nuhs.edu.sg Original article Introduction ! Acute upper gastrointestinal bleeding is a com- mon indication for esophagogastroduodenoscopy (EGD) [1], with a large audit reporting 14 % mor- tality [2]. Triage can identify patients who may benefit from early intervention. Several prognos- tic indices are available, including the Rockall [3] and Baylor [4] scores, which include clinical and endoscopic components, and are therefore unsui- table for pre-endoscopic triage. The Glasgow- Blatchford score (GBS) [5], which may be used for pre-endoscopic triage, compares favorably with the pre-endoscopic component of the Rockall score [6, 7]. A GBS of 0 has been shown to identify patients with upper gastrointestinal bleeding who may be managed safely as outpatients [6]. However, a cut-off score that identifies very sick “high-risk” patients who may benefit from early intervention has not been determined. Guidelines from the American Society For Gastro- intestinal Endoscopy [8] and the British Society of Gastroenterology Endoscopy Committee [9] re- commend early endoscopy within 24 h of presen- tation for nonvariceal upper gastrointestinal bleeding (NVUGIB), with a proportion needing emergency “out-of-hours” endoscopy, without defining the “high-risk” group. Numerous studies have shown that urgent endoscopy (defined in different studies as ranging from within 2 to within 12 h after presentation) in “unselected NVUGIB” did not decrease mortality [10 – 13]. A recent international consensus on the manage- ment of NVUGIB recommended early endoscopy within 24 h for NVUGIB, and noted no additional benefit associated with urgent endoscopy (< 12 h) vs. early endoscopy (> 12 h) in unselected patients with NVUGIB [14]. However, there are only limited data on the role of urgent endoscopy Background and study aims: The role of urgent endoscopy in high-risk nonvariceal upper gastro- intestinal bleeding (NVUGIB) is unclear. The aim of this study was to determine whether esopha- gogastroduodenoscopy (EGD) performed sooner than the currently recommended 24 h in high- risk patients presenting with NVUGIB is associat- ed with lower all-cause in-hospital mortality. Methods: All adult patients undergoing EGD for the indications of coffee-grounds vomitus, hema- temesis or melena at a university hospital over an 18-month period were enrolled. Patients with variceal and lower gastrointestinal bleeding were excluded. Data were prospectively collected. Results: A total of 934 patients were included. The area under the receiver operating character- istic curve (AUROC) for the Glasgow-Blatchford score (GBS) was 0.813 for predicting all-cause in- hospital mortality, with a cut-off score of ≥ 12 re- sulting in 90 % specificity. In low-risk patients with GBS < 12, presentation-to-endoscopy time in those who died and in those who survived was similar. In high-risk patients with GBS of ≥ 12, presentation-to-endoscopy time was signifi- cantly longer in those who died than in those who survived. Multivariate analysis of the high-risk cohort showed presentation-to-endoscopy time to be the only factor associated with all-cause in- hospital mortality. For high-risk patients, the AUROC for presentation-to-endoscopy time in predicting all-cause in-hospital mortality was 0.803, with a sensitivity of 100 % at the cut-off time of 13 h. All-cause in-hospital mortality in high-risk patients was significantly higher in those with presentation-to-endoscopy time of > 13 h compared with those undergoing endos- copy in < 13 h from presentation (44 % vs. 0 %; P < 0.001). Conclusions: Endoscopy within 13 h of presenta- tion was associated with lower mortality in high- risk but not low-risk NVUGIB. Lim LG et al. Urgent endoscopy for nonvariceal UGIB … Endoscopy