EARLY VERSUS STANDARD TIMING OF ENDOSCOPY FOR ADULTS WITH ACUTE UPPER GASTROINTESTINAL BLEEDING: A SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS

Aedrian A. Abrilla, BSc1,*, A. Nico Nahar I. Pajes, MD2, Ruter M. Maralit, MD2, Rowena Natividad F. Genuino, MD, MSc3
1Doctor of Medicine Program, College of Medicine, University of the Philippines Manila 2Division of Gastroenterology, Department of Medicine, College of Medicine and Philippine General Hospital, University of the Philippines Manila 3Department of Anatomy, College of Medicine, University of the Philippines Manila

Significance: While the benefit and safety of endoscopy in the management of adults with acute gastrointestinal bleeding (UGIB) has long been established, the evidence behind recent guidelines on its timing remains scant. Furthermore, the value of conducting endoscopy at timeframes much less than the recommended 24 to 48 hours from admission and/or evaluation is yet to be clarified convincingly. This study aimed to determine whether early endoscopy (EE), performed within at most 12 hours from patient admission or evaluation, improves relevant health outcomes compared to reference-timing endoscopy (RTE) among adults with acute UGIB.

Methodology: We searched PubMed, the Cochrane Library, ClinicalTrials.gov and other sources until 20 June 2022 for randomized controlled trials (RCTs) that compared at least two endoscopy timings (EE and RTE) relative to admission and/or evaluation of adults with acute UGIB. Primary outcomes considered were overall mortality within 30 days from clinical presentation, rate of rebleeding after initial endoscopic therapy and need for emergency surgery. Random-effects model meta-analysis was performed to obtain pooled risk ratio (RR) for dichotomous outcomes and mean difference for continuous outcomes, both accompanied with 95% confidence interval (95% CI).

Results: Six RCTs (N=1350 adults) were deemed eligible for the review. Marked variations across these studies in terms of EE and RTE definition, inclusion and exclusion criteria and concomitant interventions, among others, were identified. Results showed unclear benefit of EE, relative to RTE, in decreasing overall mortality (RR 1.03 [95% CI: 0.64–1.66]), rate of rebleeding after initial endoscopic therapy (RR 1.12 [95% CI: 0.83–1.53]) and need for emergency surgery (RR 0.89 [95% CI: 0.65–1.21]).

Conclusion: Current available evidence from RCTs suggests that it is unclear whether EE confers any clinical advantages over RTE when performed in adults with acute UGIB. Substantial heterogeneity in the characteristics of these few studies should compel the conduct of high-quality trials with consistent features that are feasible in practice.

Keywords: Gastrointestinal Hemorrhage, Endoscopy, Meta-analysis.

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