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evident
Original paper
2020NEJMGastroenterology/Hepatology

Lau UGIB endoscopy timing trial

Timing of Endoscopy for Acute Upper Gastrointestinal Bleeding

RCTGI bleed

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Overview

In high-risk acute UGIB (GBS 12 or higher), endoscopy within 6 hours did not lower 30-day death versus endoscopy at 6 to 24 hours.

Clinical takeaway

In high-risk acute UGIB, endoscopy within 6 hours of consultation did not lower 30-day death compared with endoscopy at 6 to 24 hours. Urgent endoscopy found more high-risk ulcer stigmata and led to more hemostatic treatment, without a mortality benefit.

Key result

30-day death was 8.9% (23 of 258) with endoscopy within 6 hours versus 6.6% (17 of 258) at 6 to 24 hours (difference 2.3 percentage points, 95% CI -2.3 to 6.9).

Practice impact

Do not rush endoscopy to under 6 hours in high-risk UGIB expecting a 30-day survival gain over 6 to 24 hours.

Evidence

Study design

Randomized trial comparing endoscopy within 6 hours with endoscopy between 6 and 24 hours after gastroenterologic consultation.

Enrollment

516

Follow-up

30 days after randomization.

Geography

Hong Kong

Clinical question

Does endoscopy within 6 hours after gastroenterologic consultation lower 30-day death compared with endoscopy between 6 and 24 hours in high-risk acute upper GI bleeding?

Population

  • 516 enrolled patients with overt signs of acute upper gastrointestinal bleeding and a Glasgow-Blatchford score of 12 or higher (range 0 to 23).

Intervention

Endoscopy within 6 hours after gastroenterologic consultation (urgent-endoscopy group, 258 patients).

Comparator

Endoscopy between 6 and 24 hours after gastroenterologic consultation (early-endoscopy group, 258 patients).

Primary outcome

Death from any cause within 30 days after randomization.

Endoscopy within 6 hours was not associated with lower 30-day mortality than endoscopy between 6 and 24 hours. The confidence interval included no difference.

Risk difference / 2.3 / 95% CI -2.3 to 6.9 percentage points

Key results

  • 30-day mortality was 8.9% (23 of 258) in the urgent-endoscopy group versus 6.6% (17 of 258) in the early-endoscopy group (difference 2.3 percentage points, 95% CI -2.3 to 6.9).
  • Further bleeding within 30 days occurred in 28 patients (10.9%) with urgent endoscopy versus 20 (7.8%) with early endoscopy (difference 3.1 percentage points, 95% CI -1.9 to 8.1).
  • Among patients with peptic ulcers, active bleeding or a visible vessel was found in 105 of 158 (66.4%) with urgent endoscopy versus 76 of 159 (47.8%) with early endoscopy.
  • Endoscopic hemostatic treatment was given at initial endoscopy in 155 patients (60.1%) versus 125 (48.4%).

Harms

Not listed.

Clinical Use

Practice impact

  • In high-risk acute UGIB, plan endoscopy within 24 hours of consultation; do not treat a 6-hour target as proven to save lives compared with 6 to 24 hours.

Applicability

  • Most applicable to patients with overt acute upper GI bleeding and a Glasgow-Blatchford score of 12 or higher. The comparator was endoscopy at 6 to 24 hours, not delayed endoscopy after 24 hours.

Limitations

  • No P value was reported for the primary mortality comparison.
  • Single-center trial in Hong Kong; all 516 enrolled patients were randomized (258 per group), and the mortality counts use all 258 in each group.
  • The abstract does not report variceal versus nonvariceal source as an inclusion filter.

Common misinterpretations

  • This does not show that urgent endoscopy is harmful; the mortality confidence interval included no difference.
  • This is not a license to delay endoscopy beyond 24 hours after consultation.
  • Finding more high-risk ulcer stigmata at urgent endoscopy did not translate into lower 30-day death.

Related evidence

Villanueva UGIB transfusion trial - Earlier TrialHALT-IT - Same Disease

Citation

Lau JYW, Yu Y, Tang RSY, et al. Timing of Endoscopy for Acute Upper Gastrointestinal Bleeding. N Engl J Med. 2020;382(14):1299-1308. doi:10.1056/NEJMoa1912484

In patients with acute upper gastrointestinal bleeding who were at high risk for further bleeding or death, endoscopy performed within 6 hours after gastroenterologic consultation was not associated with lower 30-day mortality than endoscopy performed between 6 and 24 hours after consultation.