 |
|
Endoscopy for Acute Nonvariceal Upper Gastrointestinal Tract Hemorrhage: Is Sooner Better?
A Systematic Review
Brennan M. R. Spiegel, MD;
Nimish B. Vakil, MD;
Joshua J. Ofman, MD, MSHS
Arch Intern Med. 2001;161:1393-1404.
Background While the effectiveness of upper endoscopy has been established for
acute nonvariceal upper gastrointestinal tract hemorrhage, its optimal timing
has not been clearly defined. Early endoscopy has been advocated for its ability
to achieve prompt diagnosis, risk stratification, and therapeutic hemostasis.
Objective To determine whether early vs delayed endoscopy improves patient and
economic outcomes for all risk groups with nonvariceal upper gastrointestinal
tract hemorrhage.
Methods A systematic review of 3 computerized databases (MEDLINE, HEALTHSTAR,
and Cochrane Database of Systematic Reviews) was performed along with hand
searching of published abstracts to identify English-language citations from
1980 to 2000.
Results Twenty-three studies met explicit inclusion criteria. The highest-quality
study examining outcomes in low-risk patients found no significant complications
at 1-month follow-up for any outpatients managed with early endoscopy. The
largest randomized trial of high-risk patients showed no mortality benefit
but a significant decrease in transfusion requirements with early endoscopy.
Seven of the 8 studies examining the effect of early endoscopy on length of
stay as a measure of resource utilization demonstrated a significant reduction
compared with that of delayed endoscopy. However, most included studies were
found to suffer from 1 or more potentially significant methodologic shortcomings.
Conclusions The overwhelming majority of existing data suggest that early endoscopy
is safe and effective for all risk groups. The clinical and economic outcomes
of early endoscopy should be confirmed in additional well-designed randomized
controlled trials. Given the strength of the evidence, efforts to develop
a more standardized and time-sensitive approach to acute nonvariceal upper
gastrointestinal tract hemorrhage should be undertaken.
From the Department of Medicine and Health Services Research, Cedars-Sinai
Medical Center, Los Angeles, Calif (Drs Spiegel and Ofman); Department of
Gastroenterology, University of Wisconsin Medical School, Milwaukee (Dr Vakil);
and Zynx Health Incorporated, a Subsidiary of Cedars-Sinai Health System,
Los Angeles (Dr Ofman).
RELATED ARTICLE
Archives of Internal Medicine Reader's Choice: Continuing Medical Education
Arch Intern Med. 2001;161(11):1463-1464.
FULL TEXT
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
Consensus Recommendations for Managing Patients with Nonvariceal Upper Gastrointestinal Bleeding
Barkun et al.
ANN INTERN MED 2003;139:843-857.
ABSTRACT
| FULL TEXT
|
