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Review Article |

Endoscopy for Acute Nonvariceal Upper Gastrointestinal Tract Hemorrhage: Is Sooner Better?  A Systematic Review FREE

Brennan M. R. Spiegel, MD; Nimish B. Vakil, MD; Joshua J. Ofman, MD, MSHS
[+] Author Affiliations

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).


Arch Intern Med. 2001;161(11):1393-1404. doi:10.1001/archinte.161.11.1393.
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Published online

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.

Figures in this Article

UPPER gastrointestinal tract hemorrhage (UGIH) occurs in 150 per 100 000 people annually, results in up to 300 000 hospitalizations, and costs more than $2.5 billion per year.1,2 Despite earlier studies to the contrary,3,4 endoscopy has been established as being effective for acute nonvariceal UGIH5,6 and is now the standard of care for patients presenting with this frequent and costly condition.7,8 Once a medical intervention is deemed effective, its optimal timing of use in clinical practice must be clearly defined. In many instances, effectiveness and timing are inseparable, as timing alone often dictates clinical success. For example, it is not adequate to simply provide coronary angioplasty for patients with myocardial infarction, but to perform it within 1 hour of presentation.9 Similarly, while tissue plasminogen activator has proved effective in acute ischemic stroke, it must be initiated within 3 hours of onset to maximize outcomes.10

The optimal timing of endoscopy in UGIH, however, has not been clearly established. Well-designed prospective studies, including a trial demonstrating the safety of early refeeding after therapeutic endoscopy11 and a sequential endoscopic confirmation of the low rebleeding risk of clean-based ulcers,12 bolster the argument that early endoscopy may provide clinical benefit by promoting safe patient disposition for both high- and low-risk groups. Moreover, it has been suggested that delayed endoscopy provides no additional benefit over standard medical management.13,14 Nonetheless, mortality rate has remained unchanged despite therapeutic endoscopy,15 and an increased rate of complications with early vs delayed endoscopy has been reported.16,17 The controversy is further confounded by the paucity of literature specifically addressing the timing of endoscopy and by the lack of clear guidelines on the timing of endoscopy in major consensus statements.7,8

In the absence of clear guidelines, early endoscopy is presently an inconsistent practice. For example, the decision to perform early vs delayed endoscopy has been independently associated with sex,18 insurance status,19 and day of the week.19 The definition of "early" endoscopy varies as well, ranging from 120 to 2419 hours after initial presentation. Current evidence suggests that upper gastrointestinal tract endoscopy is performed within 24 hours of admission in 40% to 70% of cases.19,21

How might the effectiveness of early endoscopy be measured? The end point of a successful management strategy may be to ensure patient safety while stemming costs by minimizing unnecessary hospitalizations and reducing length of stay. With the advent of therapeutic potential, the use of early endoscopy may achieve these objectives by allowing prompt diagnosis, risk stratification, and therapeutic hemostasis.22 To prove a benefit from early endoscopy, a link must be established between this practice and significant clinical and economic outcomes. Our objective was to perform a systematic review of the medical literature23,24 to address the following questions: (1) Does early endoscopy allow for safe and prompt discharge of low-risk patients with acute nonvariceal UGIH? (2) Does early endoscopy improve patient outcomes vs delayed endoscopy in high-risk patients with acute nonvariceal UGIH? (3) Does early endoscopy reduce resource utilization vs delayed endoscopy for all comers with acute nonvariceal UGIH?

A structured search of 3 computerized bibliographic databases (MEDLINE, HEALTHSTAR, and the Cochrane Database of Systematic Reviews), along with a CD-ROM–assisted (DDW [Digestive Disease Week] Abstracts-on-Disc; American Gastroenterological Association, Bethesda, Md) review of published abstracts from 3 major subspecialty journals, was performed to identify English-language publications from January 1980 to January 2000. The search strategy, including selection of subject headings and key words, was performed with an expert librarian to maximize search sensitivity for targeted information. Generated titles were assessed for relevancy and were rejected only if they fulfilled explicit exclusion criteria, including (1) not written in English; (2) not concerned with human subjects; (3) not related to UGIH or lesions that can cause UGIH; (4) solely related to variceal bleeding or other complications of portal hypertension; (5) solely related to nonendoscopic interventions or complications thereof; and (6) solely related to occult, subacute, or chronic UGIH. Selected abstracts were reviewed and were rejected if they (1) made no reference to outcome or process measurement, (2) referred only to bleeding severity, but not to the effectiveness of endoscopy, or (3) made no reference to time factors. Disagreements were resolved by consensus. In addition, bibliographies of included studies and key review articles were reviewed for references not captured by the search strategy.

Remaining studies were independently reviewed and included if they had information regarding the effectiveness of early endoscopy, as determined by impact on patient outcomes (mortality, rebleeding, transfusion requirements, need for emergency surgery, endoscopic complications, and readmission) and economic outcomes (length of stay and direct costs). Where methodology was unclear, authors were contacted for additional information. Each included study was independently abstracted for data, and randomized clinical trials were assessed for methodologic quality by means of a standardized instrument focusing on features related to internal validity. Quasi-experimental designs, including interrupted time series and controlled before-and-after trials, were assessed for methodologic quality by means of criteria established by the Cochrane Collaboration on Effective Professional Practice.25

The search strategy identified 933 titles (Figure 1). Of these, 327 were selected for abstract review, of which 97 studies were retained for consideration. Independent review of these remaining studies yielded 23 that met our explicit inclusion criteria. Interrater agreement was high (κ = 0.70).

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Figure 1.

Results of literature search.

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DOES EARLY ENDOSCOPY ALLOW FOR SAFE AND PROMPT DISCHARGE OF LOW-RISK PATIENTS WITH ACUTE NONVARICEAL UGIH?

Risk stratification of patients with nonvariceal UGIH involves a combination of both clinical and endoscopic criteria. Therefore, early endoscopy may potentially assist in the selection of low-risk patients eligible for prompt discharge by rapidly confirming clinical suspicion. Twenty studies were identified that examined the relationship between the timing of endoscopy and outcomes for low-risk patients with nonvariceal UGIH. These reports may be categorized both by study design and by whether early endoscopy was the principal focus of the study intervention (Figure 2).

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Figure 2.

Studies that relate to timing of endoscopy for low-risk patients with nonvariceal upper gastrointestinal tract bleeding. Arrow indicates direction of strongest evidence by study strategy and design. Values indicate number of studies in each subcategory.

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The most direct evidence comes from experimental studies with discharge protocols that explicitly include early endoscopy. Of these, strategies that compare the protocol with a control population undergoing standard medical management provide the strongest evidence. Other study designs examine discharge protocols that do not explicitly involve early endoscopy, but that nonetheless perform post hoc analysis relating the timing of endoscopy to outcomes for low-risk patients.

Table 1 summarizes the controlled trials that compare early endoscopy with "usual care" for low-risk patients. There were 3 randomized studies. In the largest, Lee et al20 compared a strategy of prompt endoscopy within 2 hours of presentation vs direct hospital admission for clinically "stable" subjects. The study group was retained in the emergency department until endoscopy could be performed, at which point clinically stable patients without stigmas of recent hemorrhage were discharged. The control group was hospitalized and underwent endoscopy within 24 to 48 hours. With this strategy, 46% of the study group avoided hospitalization and had no complications or readmissions at 30 days' follow-up despite the initial impression by the emergency department staff that these patients would require admission. The study is notable for a careful delineation of inclusion and exclusion criteria, a randomized design with concealed allocation (in the form of opaque envelopes), and thorough patient follow-up with a full description of patient dropouts. A potential shortcoming of this study is that patients with suspected variceal bleeding by clinical criteria were excluded before endoscopy. Because patients with clinical signs of portal hypertension frequently bleed from a nonvariceal source, this study may underestimate the true prevalence of nonvariceal hemorrhage.

Table Graphic Jump LocationTable 1. Controlled Trials Relating to Timing of Endoscopy for Low-Risk Patients With Nonvariceal Upper Gastrointestinal Tract Hemorrhage*

Campo et al26 compared a strategy of inpatient vs outpatient care of low-risk subjects undergoing endoscopy within 12 hours of admission. Clinically stable patients without stigmas of recent hemorrhage and with adequate home support were randomly assigned to either discharge on a proton pump inhibitor regimen with daily telephone follow-up for a week or admission for standard inpatient management. In those allocated to outpatient care, there were no deaths and only 1 episode of successfully treated "minor" rebleeding within 1 week. Although the study design was randomized, there was no indication of concealed allocation and no description of withdrawals and dropouts. In addition, the follow-up period of 1 week may have been inadequate to fully account for all postdischarge complications.

Brullet et al27 randomized clinically stable patients to outpatient vs inpatient management after undergoing emergent epinephrine and polidocanol injection of nonbleeding visible vessels within 12 hours of presentation. There were no deaths or episodes of rebleeding in the outpatient group. However, this study suffers from a small sample of only 8 subjects in the outpatient arm, no description of concealed allocation or patient withdrawals, and a potentially inadequate 1-week follow-up. Moreover, the method used (epinephrine alone) is no longer considered adequate for effective hemostasis. Nonetheless, the study is notable for demonstrating safe outpatient management for a group that might normally be deemed high risk by endoscopic criteria.

Almela et al28 compared outpatient vs inpatient care of all comers with UGIH undergoing immediate endoscopy in the emergency department. Clinically stable patients without stigmas of recent hemorrhage were either admitted for inpatient care or discharged with follow-up at 1 month. Those with active bleeding, stigmas of recent hemorrhage, or hemodynamic instability were admitted for inpatient care. Of 201 outpatients, there were 3 deaths (1.5%) and 1 episode of successfully treated gastrointestinal tract bleeding from an aortoenteric fistula vs 20 deaths (2.6%) and 56 episodes of rebleeding (7.3%) in 767 inpatients. The authors conclude that outpatient care of selected patients is a safe alternative to admission. This study is limited by a lack of randomization and by an apparent incompatibility between the control and study groups, because low-risk subjects managed as inpatients were grouped with hospitalized high-risk patients.

The methodologic quality of the 4 trials with concurrent control groups is summarized in Table 2. With the use of a validated scoring scale,31 only the study by Lee et al20 is considered high quality. All of the trials describe explicit inclusion and exclusion criteria, and 3 of the 4 describe the study design as randomized. However, only the study by Lee et al described a concealed randomization process (this refers to measures taken to prevent investigators from influencing the allocation process, such as using serially numbered, opaque, sealed envelopes, or central randomization). None of the studies was blinded. However, in settings where blinding is not possible, outcome can be assessed by individuals blinded to the original treatment allocation. This was not described in any of the studies. Concealment of allocation and blinding are study quality indicators and, when not satisfied, may result in an overestimation of the intervention effect.

Table Graphic Jump LocationTable 2. Quality Assessment of Controlled Trials Relating to Endoscopy for Low-Risk Patients With Nonvariceal Upper Gastrointestinal Tract Bleeding

Two controlled studies compared early endoscopy for low-risk patients with historical or retrospective controls. Rockall et al30 compared outcomes of all comers with UGIH before and after implementation of a national early discharge protocol that encouraged endoscopy within 24 hours. The authors found that, compared with a preintervention control group, patients underwent endoscopy more frequently and earlier after the guidelines were in place, without any impact on severity-adjusted mortality rates. It is unclear whether the study had sufficient power to detect a mortality reduction, or whether this is the most relevant outcome in low-risk patients. Additional relevant outcomes, including rebleeding and readmission, were not reported, nor was there follow-up of outpatients on discharge. Finally, this study included variceal and nonvariceal causes of UGIH, thereby further confounding conclusions specifically regarding nonvariceal hemorrhage.

Hussain et al29 compared outcomes for patients with peptic ulcer bleeding before and after implementation of an early discharge protocol requiring endoscopy within 12 hours of admission. Clinically stable patients with a clean-based ulcer were discharged from the hospital on a histamine2-blocker regimen and contacted for follow-up at 5 to 7 days, while those with active bleeding underwent immediate hemostasis and were hospitalized. Compared with a retrospective control group, fewer patients required surgical intervention in the postguideline period. Although the authors conclude that low-risk patients with clean-based ulcers can be safely managed as outpatients, it is unclear whether the study findings substantiate this conclusion. In particular, the authors did not report any outcomes for the patients discharged, nor did they describe the completeness of outpatient follow-up. While need for emergent surgery is an important patient outcome, it relates more directly to high-risk groups and may not contribute meaningfully to conclusions regarding outpatient management of low-risk subjects.

Six uncontrolled trials examined early endoscopy for low-risk patients (Table 3). Cebollero-Santamaria et al32 evaluated a protocol in which clinically low-risk elderly (age ≥65 years) patients were discharged after immediate endoscopic confirmation in the emergency department. Those with a low risk for rebleeding, as determined by explicit endoscopic and clinical criteria, were discharged and followed up intermittently for 1 month. The authors reported no deaths, rebleeding, or readmissions among 24 outpatients. Although limited by the lack of a control group, this study is notable for focusing on the elderly population, a group that tends to be at higher risk and is often treated more conservatively.

Table Graphic Jump LocationTable 3. Uncontrolled Trials Relating to Timing of Endoscopy for Low-Risk Patients With Nonvariceal Upper Gastrointestinal Tract Hemorrhage*

Of the remaining 6 uncontrolled trials,3338 all showed low complication rates of outpatients triaged by early endoscopy. In particular, there were no deaths and rebleeding occurred in 0%33 to 2.9%36 of patients. All incidents of rebleeding were successfully treated with readmission. The follow-up period ranged from 1 week33,37 to 16 months.34 Five studies focused exclusively on nonvariceal hemorrhage,3337 while the study by Chang et al38 included variceal hemorrhage as well. The trial by Hsu et al33 specifically evaluated peptic ulcer hemorrhage, while Lai et al34 focused only on patients with duodenal ulcer hemorrhage. Patients were selected for outpatient care by a combination of both clinical and endoscopic criteria in all studies. Two studies32,36 excluded potential variceal hemorrhage before endoscopic confirmation by selecting out subjects with evidence of alcoholic liver disease. One study excluded from enrollment patients taking noncorticosteroidal anti-inflammatory drugs.33

There were 2 experimental studies in which early endoscopy was not the primary focus of the intervention, but the authors nonetheless drew corollary findings relating timing of endoscopy to patient outcomes. Hay et al,21 in a prospective controlled time-series study with an alternate-month design, evaluated the safety of a clinical guideline that recommended early discharge for patients with acute UGIH considered to be at low risk for subsequent complications. Recommendations for length of stay were dependent on a combination of validated clinical and endoscopic criteria. The authors found that there were 3 deaths and only 1 episode of rebleeding at 1 month of follow-up among 209 patients deemed low risk by the guideline. The deaths were related to chronic medical conditions and not to complications of UGIH. While early endoscopy was not an explicit component of the intervention guidelines, it was found to be an independent predictor of decreased length of stay for low-risk patients. These data were confirmed by Moreno et al39 in a study using the same discharge guidelines. In contrast to the Hay et al study, this trial covered a continuous period and compared data with retrospective controls. Moreover, during the study period, guidelines were implemented by 1 team in consecutive patients. There were 1 death and 7 episodes of rebleeding among 488 low-risk patients at 1 week of follow-up. The authors conclude that "most" low-risk patients can be safely discharged.

Our review identified 5 observational studies,19,4043 of which 242,43 directly examined the effect of early endoscopy on patient outcomes. In a large retrospective cohort study, Lindenauer et al42 failed to detect a mortality benefit for all comers undergoing early (<24 hours) vs delayed (≥24 hours) endoscopy and extended these conclusions to low-risk patients through multivariate analysis stratifying patients by clinical severity. However, mortality was the only outcome assessed. In a retrospective application of a discharge protocol encouraging early endoscopy, Rockall et al43 projected that 25% of all comers with UGIH could have been safely discharged immediately after prompt endoscopy.

Hay et al,41 in a retrospective validation of the previously described discharge protocol by the same authors, found a 0.6% complication rate for patients deemed low risk. Conversely, in a large retrospective cohort study of consecutive patients with UGIH, Cooper et al19 established through multivariate analysis that early endoscopy was associated with a slightly higher but not statistically significant risk of in-hospital death for patients in the lowest risk group. In a second retrospective study by the same authors,40 early endoscopy was found to be equivocal as a risk factor for poor patient outcomes in low-risk subjects. Because of limitations of study design, it is difficult to draw firm conclusions for low-risk patients from these observational studies, as there was no postdischarge follow-up, no description of additional important patient outcomes beyond mortality and need for surgery, and no distinction between variceal and nonvariceal causes of bleeding.

It appears that the weight of the evidence supports early vs delayed endoscopy for low-risk patients with acute nonvariceal UGIH (Figure 3). If only the highest-quality controlled study is considered, Lee et al20 showed that early endoscopy and prompt discharge of low-risk patients was safe and effective. Of the remaining controlled trials, all showed low complication rates for low-risk subjects managed as outpatients. Furthermore, there were no deaths and only 9 instances of rebleeding of a combined 594 low-risk outpatients in 7 uncontrolled prospective trials.3338 Of the 20 described studies, 16 suggested that early endoscopy for low-risk patients is safe and effective, 3 were equivocal, and only 1 detected a statistically insignificant trend toward increased mortality.

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Figure 3.

Literature synthesis. For each clinical question, the conclusions either support or do not support the effectiveness of early vs delayed endoscopy in the management of acute nonvariceal upper gastrointestinal tract hemorrhage (UGIH).

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DOES EARLY ENDOSCOPY IMPROVE PATIENT OUTCOMES VS DELAYED ENDOSCOPY FOR HIGH-RISK PATIENTS WITH ACUTE NONVARICEAL UGIH?

Although many prospective studies have carefully documented the timing of emergent endoscopy for high-risk patients with nonvariceal UGIH,4447 few have used a control group of patients undergoing delayed endoscopy to compare patient outcomes on the basis of timing alone. Moreover, of the studies that have made this comparison, few have examined the role of early endoscopy as both a diagnostic and a therapeutic tool. These trials are summarized in Table 4.

Table Graphic Jump LocationTable 4. Controlled Trials Comparing Early vs Delayed Endoscopy for High-Risk Patients With Nonvariceal Upper Gastrointestinal Tract Hemorrhage*

In the only randomized trial, Lin et al48 compared early vs delayed endoscopy for diagnostic and therapeutic efficacy in patients with bleeding peptic ulcer presenting with clear, "coffee ground," or bloody nasogastric aspirates. Patient were first randomized to either early (<12 hours) or late (12-24 hours) endoscopy on the basis of the time of arrival at the emergency department. Early endoscopy resulted in a reduction in transfusion requirements in those with bloody aspirates but had no improvement in outcomes measured in those with coffee ground aspirates. Of note, it is unclear whether an intention-to-treat analysis was performed, since patients who were unable to cooperate with endoscopy or who had "massive bleeding" but refused endoscopy were excluded from the trial after randomization. This could overestimate the usefulness of the intervention by excluding a potentially confounding group from one arm of the study but not the other. While the authors note that the randomization envelopes of excluded patients were sealed and returned to the pool, this does not negate the potential effect of narrowing the study arm to a select group at the expense of the comparison group. Nonetheless, this study is notable for its strict delineation of exclusion criteria and for its use of concealed allocation in the form of opaque sealed envelopes.

Yen et al16 examined the effects of emergent (<2 hours) vs delayed (2-24 hours) endoscopy on oxygen saturation for patients presenting to the emergency department with UGIH. The authors found both a significantly higher rate of oxygen desaturation and a decreased recovery of preendoscopic saturation with early endoscopy, and therefore concluded that early endoscopy is associated with more complications than delayed endoscopy. However, the increased complications associated with early endoscopy were more likely a function of increased patient risk in the study arm, as patients with active hematemesis received early endoscopy, while those without it received delayed endoscopy.

There were 4 observational studies that evaluated the role of early vs delayed endoscopy for high-risk patients.19,40,42,49 Cooper et al, in a pair of retrospective multicenter cohort studies,19,40 examined the impact of early (≤24 hours of admission) vs delayed (>24 hours after admission) endoscopy on in-hospital mortality, surgical intervention, and rebleeding for all comers with UGIH. The authors found that early therapeutic endoscopy for high-risk patients resulted in a significant reduction in rebleeding and surgery and a statistically insignificant trend toward reduced mortality. Lindenauer et al,42 in a large retrospective study of Medicare beneficiaries, detected no mortality advantage of early (≤24 hours) vs delayed (>24 hours) endoscopy for high-risk elderly patients. Finally, in a retrospective evaluation of high-risk subjects with peptic ulcer bleeding, Choudari and Palmer49 found no difference in patient outcomes for groups undergoing early (<6 hours), intermediate (>6-12 hours), and delayed (>12-24 hours) endoscopy. However, these were all uncontrolled retrospective studies, had no description of postdischarge complications, and, with the exception of the Choudari and Palmer study, included variceal and nonvariceal causes of hemorrhage.

In summary, the weight of the evidence supports early vs delayed endoscopy for high-risk patients with acute nonvariceal UGIH (Figure 3). If only the highest-quality clinical trial is considered, the study by Lin et al48 showed no mortality benefit but a significant decrease in transfusion requirements for high-risk patients. Of the remaining studies, 2 showed a significant improvement of patient outcomes with early vs delayed endoscopy for high-risk patients, and 2 were equivocal. One study suggested the potential for more complications with emergent nonsedated endoscopy, and no studies detected any significant impact on mortality for high-risk patients.

DOES EARLY ENDOSCOPY IMPROVE UTILIZATION OUTCOMES VS DELAYED ENDOSCOPY FOR ALL COMERS WITH ACUTE NONVARICEAL UGIH?

Early endoscopy may potentially reduce costs both by reducing hospital length of stay50 and by avoiding admission when compared with delayed endoscopy. Table 5 summarizes the studies investigating the impact of early vs delayed endoscopy on costs and utilization.

Table Graphic Jump LocationTable 5. Studies Comparing Resource Utilization for Patients Undergoing Early vs Delayed Endoscopy*

Two randomized trials met our inclusion criteria. Lee et al20 evaluated the effect of early endoscopy on length of stay and total costs for low-risk patients with nonvariceal UGIH. The authors found a decrease in mean hospital stay of 1 day (1 vs 2 days) with the use of early endoscopy. Moreover, they calculated a cost reduction of $1594 per patient ($2068 vs $3662) associated with the use of early endoscopy. This savings reflected both a decreased length of stay and a difference in admission location, as significantly fewer patients in the study group were managed in the intensive care unit but were instead admitted to the less costly medical ward. To investigate the potential of cost shifting to the outpatient arena, the authors monitored postdischarge unplanned physician visits. They found significantly fewer visits in the early endoscopy group, thereby contributing to the overall cost reduction associated with early endoscopy.

Lin et al48 investigated the effect of early endoscopy on length of stay for high-risk patients with nonvariceal UGIH. For the subgroup of patients with a bloody nasogastric aspirate, early endoscopy saved 10.5 days per patient compared with delayed endoscopy (4.0 ± 3.5 vs 14.5 ± 10.8 days). While this represents a dramatic reduction, the small sample size and potential outlier effect may have skewed the results.

There were 2 studies with quasi-experimental designs that addressed costs and utilization. Hay et al,21 in an interrupted time series with alternate-month design, investigated the impact of a management guideline on length of stay for all comers with nonvariceal UGIH. Although the authors did not perform analysis for individual risk groups, they demonstrated an independent association between early endoscopy and shorter length of stay for all patients, and projected a 63% decrease in total inpatient costs with the early discharge guidelines vs usual care. There was no evidence of cost shifting, as an equal number of patients in both groups sought postdischarge physician visits. Hussain et al29 compared length of stay for both low- and high-risk patients before and after instituting a management protocol for peptic ulcer bleeding. They found a reduction of 1.24 days per patient for low-risk and 1.01 days per patient for high-risk patients with the use of early endoscopy.

There were 4 observational studies,19,40,42,43 all of which demonstrated a significant reduction in length of stay with early endoscopy for low-risk patients (range of 1-2 days per patient). Of the 2 studies that specifically examined high-risk patient subgroups, 1 showed a decreased length of stay (2 days saved per patient)40 while 1 demonstrated an insignificant increase in length of stay with early endoscopy.43

Figure 4 displays the composite data on length of stay for the 8 studies as a function of risk group. Of the 4 studies that examined low-risk patients, all demonstrated a decrease in length of stay associated with early vs delayed endoscopy. Of the 4 studies that examined high-risk subgroups, all but 1 detected a shorter length of stay. Finally, each of the 3 studies that performed no risk stratification portrayed an advantage for all comers undergoing early endoscopy. All data in support of early vs delayed endoscopy were statistically significant, although the one instance of increased length of stay failed to achieve statistical significance.

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Figure 4.

Studies comparing length of stay for early vs delayed endoscopy by risk group. For studies with more than 2 risk groups, data are presented for highest and lowest risk group. Studies without subgroup data are presented as "all comers."

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Since no consensus exists regarding the costs and benefits of early endoscopy in UGIH, we sought to identify and critically appraise the evidence in the medical literature regarding the effectiveness of early vs delayed endoscopy on patient and economic outcomes. For all 3 clinical questions, the weight of the evidence favors early endoscopy (Figure 3). For low-risk patients, the evidence clearly supports the claim that early endoscopy promotes safe patient disposition. However, of the studies that directly investigated early vs delayed endoscopy, only the trial by Lee et al20 was deemed high quality by means of a validated scoring scale. While the study by Hay et al21 was also of high quality, it only indirectly examined the association of early vs delayed endoscopy for low-risk patients. The remaining studies were found to suffer from 1 or more potentially significant methodologic shortcomings, including lack of an appropriate comparison group, inadequate patient follow-up, lack of sufficient statistical power, or lack of prospective experimental design.

For high-risk patients, our review suggests that there is a benefit from early vs delayed endoscopy in many patient outcomes, including transfusion requirements, rebleeding, and need for emergency surgery. Furthermore, while there was no evidence that early endoscopy decreases mortality, there was also no evidence that the practice results in patient harm. The data were limited by several methodologic shortcomings, and the only identified randomized control trial did not perform an intention-to-treat analysis.

Regarding resource utilization, the evidence suggests that early endoscopy significantly reduces length of stay compared with delayed endoscopy for all risk groups with nonvariceal UGIH without evidence of cost shifting to the outpatient setting. Of the 2 studies that conducted an absolute cost analysis,20,21 both found a significant savings from early endoscopy. There were no formal cost-effectiveness analyses reporting incremental cost-effectiveness ratios.

There is controversy regarding the ideal time to perform endoscopy in patients presenting with UGIH. Early endoscopy may provide prompt diagnosis, rapidly confirm clinical suspicion, and serve as an aid to decision making regarding triage and subsequent management. For high-risk patients, early endoscopy may result in rapid hemostasis, while low-risk patients may benefit by safely avoiding hospitalization. A policy of early endoscopy may reduce resource use by minimizing potentially unnecessary admissions, by reducing the length of stay for those who are admitted, and by downgrading the admission location to less costly venues. Moreover, data suggest that delaying endoscopy is of little benefit to patients with nonvariceal UGIH.13,14

Conversely, opponents of early endoscopy contend that there is scant evidence to support the claim that endoscopy provides a mortality benefit, regardless of timing.3,4,15 Moreover, some indirect evidence suggests that early endoscopy may be associated with more complications than delayed endoscopy.16,17 Only 1 study16 directly assessed the safety of early endoscopy, suggesting that it may result in an increased risk of oxygen desaturation. However, this study used early endoscopy disproportionately in a high-risk group, and all other studies identified suggest that early endoscopy is safe. Therefore, while some argue that emergently subjecting low-risk patients to a potentially unhelpful and invasive procedure is not worth the risk of subsequent or preventable complications, supportive evidence is lacking.

Moreover, a policy of early endoscopy may be difficult and expensive to implement in the real world. The associated costs of operating a 24-hour endoscopy service may be substantial, as this not only requires support of additional physicians, nurses, and equipment technicians, but also requires extensive facility investments, particularly for those institutions not well equipped to perform endoscopy in the emergency department. Early endoscopy could further escalate costs by detecting stigmas of recent hemorrhage that might otherwise have resolved by the time of delayed endoscopy, thereby leading to potentially unnecessary interventions.

There are some limitations to this analysis. As with any systematic review, there is a potential for publication bias, which refers to the common practice of publishing only trials with positive outcomes. However, we believe there may be incentive to publish studies that demonstrate negative outcomes for an otherwise time-consuming and potentially costly intervention if it existed. Additionally, there is a paucity of randomized trials, and many of our conclusions are based on uncontrolled and observational studies. The heterogeneity of the study designs, inclusion criteria, timing of endoscopy, and reported end points precluded formal meta-analysis. Nonetheless, where possible, we attempted to weigh the evidence by methodologic rigor and to base our conclusions on the findings from prospective randomized controlled clinical trials.

Although our review identified a substantial number of studies examining the impact of early vs delayed endoscopy, there were few experimental trials and even fewer of high methodologic quality. Additional well-designed, randomized clinical trials comparing early vs delayed endoscopy for all risk groups must be performed before firm conclusions can be reached regarding the impact on long-term patient outcomes. To clarify issues of utilization, there is a need for studies comparing the costs of 24-hour endoscopy services with "usual care." In addition, the definition of early must be elucidated and confirmed in comparative trials. For example, is 4 hours better than 12 hours?

These findings suggest that a more streamlined and standardized approach to acute nonvariceal UGIH—akin to the time-sensitive paradigm of acute myocardial infarction management—may improve patient outcomes. A 24-hour gastrointestinal rapid response team, similar to the "code blue" revascularization service omnipresent in major medical centers, would ensure that patients with UGIH receive prompt and high-quality care. For low-risk patients, an emergency department UGIH observation unit,38,51 similar to recently proposed "chest pain observation units,"52 could serve as a way station for patient triage decisions. The evidence suggests that hesitancy to discharge low-risk patients may be unfounded, and that it should no longer be obligatory to admit all patients with acute nonvariceal UGIH to the hospital. Likewise, high-risk patients may benefit from a more coordinated and timely delivery of endoscopic hemostasis than the often inconsistent and time-insensitive approach currently practiced. Until additional well-designed trials are conducted, it is difficult to draw definitive conclusions. Until then, existing data suggest that early endoscopy may be safe and effective for all risk groups.

Accepted for publication January 11, 2001.

Presented in part in abstract form at Digestive Disease Week 2000, San Diego, Calif, May 22, 2000.

Corresponding author and reprints: Joshua J. Ofman, MD, MSHS, 9100 Wilshire Blvd, Suite 655, Beverly Hills, CA 90212 (e-mail: ofmanj@zynx.com).

Gilbert  DA Epidemiology of upper gastrointestinal bleeding. Gastrointest Endosc. 1990;36 ((5 Suppl)) S8- S13
Graves  EJKozak  LJ Detailed diagnoses and procedures: National Hospital Discharge Survey. Vital Health Stat 13. 1998; ((138)) i- iii1- 151
Graham  DY Limited value of early endoscopy in the management of acute upper gastrointestinal bleeding: a prospective controlled trial. Am J Surg. 1980;140284- 290
Link to Article
Peterson  WLBarnett  CCSmith  HJ  et al.  Routine early endoscopy in upper-gastrointestinal-tract bleeding: a randomized, controlled trial. N Engl J Med. 1981;304925- 929
Link to Article
Sacks  HSChalmers  TCBlum  ABerrier  JPagano  D Endoscopic hemostasis: an effective therapy for bleeding peptic ulcers. JAMA. 1990;264494- 499
Link to Article
Cook  DJGuyatt  GHSalena  BJLaine  L Endoscopic therapy for acute nonvariceal upper gastrointestinal hemorrhage: a meta-analysis. Gastroenterology. 1992;102139- 148
NIH Consensus Conference, Therapeutic endoscopy and bleeding ulcers. JAMA. 1989;2621369- 1372
Link to Article
ASGE Standards of Practice Committee, The role of endoscopy in the management of nonvariceal acute upper gastrointestinal bleeding: guidelines for clinical application. Gastrointest Endosc. 1992;38760- 764
Link to Article
Berger  PBEllis  SGHolmes  DR  et al.  Relationship between delay in performing direct coronary angioplasty and early clinical outcome in patients with acute myocardial infarction: results from the global use of strategies to open occluded arteries in acute coronary syndromes (GUSTO-IIb) trial. Circulation. 1999;10014- 20
Link to Article
The National Institute of Neurological Disorders and Stroke (NINDS) rt-PA Study Group, Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;3331581- 1587
Link to Article
Laine  LCohen  HBrodhead  JCantor  DGarcia  FMosquera  M Prospective evaluation of immediate versus delayed refeeding and prognostic value of endoscopy in patients with upper gastrointestinal hemorrhage. Gastroenterology. 1992;102314- 316
Lau  JYChung  CSLeung  JWLo  KKYung  MYLi  ADC The evolution of stigmata of hemorrhage in bleeding peptic ulcers: a sequential endoscopic study. Endoscopy. 1998;30513- 518
Link to Article
Zierer  STRamirez  FCZiegler  RHMills  MRSanowski  RA Clinical indications for emergent endoscopy in acute upper gastrointestinal hemorrhage [abstract]. Gastrointest Endosc. 1995;41AB312
Link to Article
Cooper  GSChak  AHammar  PJWay  LERosenthal  GE The effectiveness of endoscopy in patients with upper gastrointestinal hemorrhage: a community based study [abstract]. Gastrointest Endosc. 1997;45AB89
Longstreth  GFGeitelberg  SP Hospital care of acute nonvariceal upper gastrointestinal bleeding: 1991 versus 1981. J Clin Gastroenterol. 1994;19189- 192
Link to Article
Yen  DHu  SChen  L  et al.  Arterial oxygen desaturation during emergent nonsedated upper gastrointestinal endoscopy in the emergency department. Am J Emerg Med. 1997;15644- 646
Link to Article
Hill  DBStokes  BDGilinsky  NH Arterial oxygen saturation during emergency endoscopy. J Clin Gastroenterol. 1994;18284- 286
Link to Article
Terdiman  JPLindenauer  PKGebretsadik  TRoll  F Decision to perform early upper endoscopy in the elderly with upper gastrointestinal bleeding is not based on clinical factors that predict mortality [abstract]. Am J Gastroenterol. 1998;93A100
Cooper  GSChak  AConnors  AFHarper  DLRosenthal  GE The effectiveness of early endoscopy for upper gastrointestinal hemorrhage. Med Care. 1998;36462- 474
Link to Article
Lee  JGTurnipseed  SRomano  P  et al.  Endoscopy-based triage significantly reduces hospitalization rates and costs of treating upper GI bleeding: a randomized controlled trial. Gastrointest Endosc. 1999;50755- 761
Link to Article
Hay  JAMaldonado  LWeingarten  SREllrodt  G Prospective evaluation of a clinical guideline recommending hospital length of stay in upper gastrointestinal tract hemorrhage. JAMA. 1997;2782151- 2156
Link to Article
Terdiman  J Update on upper gastrointestinal bleeding: basing treatment decisions on patients' risk level. Postgrad Med. 1998;10343- 63
Link to Article
Mulrow  CCook  D Systematic Reviews: Synthesis of Best Evidence for Health Care Decisions.  Philadelphia, Pa American College of Physicians Press1998;
Clarke  MOxman  AD Cochrane Reviewers' Handbook 4.0 [updated July 1999]. Review Manager (RevMan) [computer program].Version 4.0. Oxford, England Cochrane Collaboration1999;
Not Available, Critical appraisal of studies. Mulrow  CDOxman  ADeds.Cochrane Collaboration Handbook [updated September 1997]. The Cochrane Library [database on disk and CD-ROM]. Oxford, England Cochrane Collaboration1997;96- 109
Campo  RBrullet  ECalvet  X  et al.  Safety of outpatient management of nonvariceal upper gastrointestinal bleeding: preliminary results of a randomized study [abstract]. Gastrointest Endosc. 1998;47AB81Abstract 228
Brullet  ECampo  RCalvet  X  et al.  Outpatient vs. hospital care after endoscopic injection in selected patients bleeding from peptic ulcers: preliminary results of a randomized study [abstract]. Gastrointest Endosc. 1998;47AB81Abstract 227
Almela  PPeiro  SMora  F  et al.  Safety of outpatient control in upper gastrointestinal bleeding not associated with portal hypertension (UGI-NPH) [abstract]. Am J Gastroenterol. 1999;94A111
Hussain  IFarrar  WHSofian  EJ  et al.  A cost effective strategy for managing GI bleeding secondary to peptic ulcer disease [abstract]. Gastroenterology. 1995;108A18
Link to Article
Rockall  TALogan  RFADevlin  HBNorthfield  TC Influencing the practice and outcome in acute upper gastrointestinal haemorrhage. Gut. 1997;41606- 611
Link to Article
Jadad  ARMoore  ACarroll  D  et al.  Assessing the quality of reports of randomised clinical trials: is blinding necessary? Control Clin Trials. 1996;171- 12
Link to Article
Cebollero-Santamaria  FSmith  JGioe  S  et al.  Selective outpatient management of upper gastrointestinal bleeding in the elderly. Am J Gastroenterol. 1999;941242- 1247
Link to Article
Hsu  PLai  KLin  X  et al.  When to discharge patients with bleeding peptic ulcers: a prospective study of residual risk of bleeding. Gastrointest Endosc. 1996;44382- 387
Link to Article
Lai  KHui  WWong  BCing  CLam  S A retrospective and prospective study on the safety of discharging selected patients with duodenal ulcer bleeding on the same day as endoscopy. Gastrointest Endosc. 1997;4526- 30
Link to Article
Longstreth  GFFeitelberg  SP Successful outpatient management of acute upper gastrointestinal hemorrhage: use of practice guidelines in a large patient series. Gastrointest Endosc. 1998;47219- 221
Link to Article
Longstreth  GFFeitelberg  SP Outpatient care of selected patients with acute nonvariceal upper gastrointestinal hemorrhage. Lancet. 1995;345108- 111
Link to Article
Koch  JRockey  DCCello  JP Emergent endoscopy in hemodynamically stable patients with upper gastrointestinal hemorrhage (UGIH) decreases hospital admission rate [abstract]. Gastrointest Endosc. 1996;43AB99Abstract 315
Link to Article
Chang  CFChan  CYLin  HJ  et al.  Endoscopy for upper gastrointestinal bleeding at emergency unit. Zhonghua Yi Xue Za Zhi (Taipei). 1992;49217- 222
Moreno  PJaurrieta  EAranda  H  et al.  Efficacy and safety of an early discharge protocol in low-risk patients with upper gastrointestinal bleeding. Am J Med. 1998;105176- 180
Link to Article
Cooper  GSChak  AWay  LHammar  PHarper  DRosenthal  G Early endoscopy in upper gastrointestinal hemorrhage: associations with recurrent bleeding, surgery, and length of hospital stay. Gastrointest Endosc. 1999;49145- 152
Link to Article
Hay  JALyubashevsky  EElashoff  JMaldonado  LWeingarten  SEllrodt  G Upper gastrointestinal hemorrhage clinical guideline: determining the optimal hospital length of stay. Am J Med. 1996;100313- 322
Link to Article
Lindenauer  PKRoll  FJGebretsadik  TTerdiman  JP Endoscopy improves outcome and reduces length of stay in elderly patients with acute upper gastrointestinal bleeding: results of a statewide population based analysis [abstract]. Am J Gastroenterol. 1999;116A76
Rockall  TALogan  RFADevlin  HBNorthfield  TC Selection of patients for early discharge or outpatient care after acute upper gastrointestinal haemorrhage. Lancet. 1996;3471138- 1190
Link to Article
Stevens  PDFinegold  JGarcia-Carrasquillo  RJ  et al.  Effectiveness of a protocol-based team approach to gastrointestinal hemorrhage [abstract]. Gastrointest Endosc. 1997;45AB102
Finegold  JGarcia-Carrasquillo  RJStevens  PD  et al.  Implementation of a standardized multi-disciplinary treatment protocol for acute GI hemorrhage [abstract]. Gastrointest Endosc. 1996;43350
Link to Article
Arber  NTiomny  EHallak  A  et al.  An eight year experience with upper gastrointestinal bleeding: diagnosis, treatment and prognosis. J Med. 1994;25261- 269
Perng  CLin  HChen  CLee  FLee  SLee  C Characteristics of patients with bleeding peptic ulcer requiring emergency endoscopy and aggressive therapy. Am J Gastroenterol. 1994;891811- 1814
Lin  HJWang  KPerng  CL  et al.  Early or delayed endoscopy for patients with peptic ulcer bleeding: a prospective randomized study. J Clin Gastroenterol. 1996;22267- 271
Link to Article
Choudari  CPPalmer  KR Timing of endoscopy for severe peptic ulcer hemorrhage: out of hours emergency endoscopy is unnecessary [abstract]. Gastroenterology. 1993;104A55
Jiranek  GCKozarek  RA A cost-effective approach to the patient with peptic ulcer bleeding. Surg Clin North Am. 1996;7683- 103
Link to Article
Pretolani  SArienti  VBaigorria  R  et al.  Efficacy of an observational unit in the emergency department on the outcome of patients admitted for upper gastrointestinal bleeding [abstract]. Gastroenterology. 2000;118A464Abstract 2530
Link to Article
Farkouh  MESmars  PAReeder  GS  et al.  A clinical trial of a chest-pain observation unit for patients with unstable angina. N Engl J Med. 1998;3391882- 1888
Link to Article

Figures

Place holder to copy figure label and caption
Figure 1.

Results of literature search.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Studies that relate to timing of endoscopy for low-risk patients with nonvariceal upper gastrointestinal tract bleeding. Arrow indicates direction of strongest evidence by study strategy and design. Values indicate number of studies in each subcategory.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Literature synthesis. For each clinical question, the conclusions either support or do not support the effectiveness of early vs delayed endoscopy in the management of acute nonvariceal upper gastrointestinal tract hemorrhage (UGIH).

Graphic Jump Location
Place holder to copy figure label and caption
Figure 4.

Studies comparing length of stay for early vs delayed endoscopy by risk group. For studies with more than 2 risk groups, data are presented for highest and lowest risk group. Studies without subgroup data are presented as "all comers."

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Controlled Trials Relating to Timing of Endoscopy for Low-Risk Patients With Nonvariceal Upper Gastrointestinal Tract Hemorrhage*
Table Graphic Jump LocationTable 2. Quality Assessment of Controlled Trials Relating to Endoscopy for Low-Risk Patients With Nonvariceal Upper Gastrointestinal Tract Bleeding
Table Graphic Jump LocationTable 3. Uncontrolled Trials Relating to Timing of Endoscopy for Low-Risk Patients With Nonvariceal Upper Gastrointestinal Tract Hemorrhage*
Table Graphic Jump LocationTable 4. Controlled Trials Comparing Early vs Delayed Endoscopy for High-Risk Patients With Nonvariceal Upper Gastrointestinal Tract Hemorrhage*
Table Graphic Jump LocationTable 5. Studies Comparing Resource Utilization for Patients Undergoing Early vs Delayed Endoscopy*

References

Gilbert  DA Epidemiology of upper gastrointestinal bleeding. Gastrointest Endosc. 1990;36 ((5 Suppl)) S8- S13
Graves  EJKozak  LJ Detailed diagnoses and procedures: National Hospital Discharge Survey. Vital Health Stat 13. 1998; ((138)) i- iii1- 151
Graham  DY Limited value of early endoscopy in the management of acute upper gastrointestinal bleeding: a prospective controlled trial. Am J Surg. 1980;140284- 290
Link to Article
Peterson  WLBarnett  CCSmith  HJ  et al.  Routine early endoscopy in upper-gastrointestinal-tract bleeding: a randomized, controlled trial. N Engl J Med. 1981;304925- 929
Link to Article
Sacks  HSChalmers  TCBlum  ABerrier  JPagano  D Endoscopic hemostasis: an effective therapy for bleeding peptic ulcers. JAMA. 1990;264494- 499
Link to Article
Cook  DJGuyatt  GHSalena  BJLaine  L Endoscopic therapy for acute nonvariceal upper gastrointestinal hemorrhage: a meta-analysis. Gastroenterology. 1992;102139- 148
NIH Consensus Conference, Therapeutic endoscopy and bleeding ulcers. JAMA. 1989;2621369- 1372
Link to Article
ASGE Standards of Practice Committee, The role of endoscopy in the management of nonvariceal acute upper gastrointestinal bleeding: guidelines for clinical application. Gastrointest Endosc. 1992;38760- 764
Link to Article
Berger  PBEllis  SGHolmes  DR  et al.  Relationship between delay in performing direct coronary angioplasty and early clinical outcome in patients with acute myocardial infarction: results from the global use of strategies to open occluded arteries in acute coronary syndromes (GUSTO-IIb) trial. Circulation. 1999;10014- 20
Link to Article
The National Institute of Neurological Disorders and Stroke (NINDS) rt-PA Study Group, Tissue plasminogen activator for acute ischemic stroke. N Engl J Med. 1995;3331581- 1587
Link to Article
Laine  LCohen  HBrodhead  JCantor  DGarcia  FMosquera  M Prospective evaluation of immediate versus delayed refeeding and prognostic value of endoscopy in patients with upper gastrointestinal hemorrhage. Gastroenterology. 1992;102314- 316
Lau  JYChung  CSLeung  JWLo  KKYung  MYLi  ADC The evolution of stigmata of hemorrhage in bleeding peptic ulcers: a sequential endoscopic study. Endoscopy. 1998;30513- 518
Link to Article
Zierer  STRamirez  FCZiegler  RHMills  MRSanowski  RA Clinical indications for emergent endoscopy in acute upper gastrointestinal hemorrhage [abstract]. Gastrointest Endosc. 1995;41AB312
Link to Article
Cooper  GSChak  AHammar  PJWay  LERosenthal  GE The effectiveness of endoscopy in patients with upper gastrointestinal hemorrhage: a community based study [abstract]. Gastrointest Endosc. 1997;45AB89
Longstreth  GFGeitelberg  SP Hospital care of acute nonvariceal upper gastrointestinal bleeding: 1991 versus 1981. J Clin Gastroenterol. 1994;19189- 192
Link to Article
Yen  DHu  SChen  L  et al.  Arterial oxygen desaturation during emergent nonsedated upper gastrointestinal endoscopy in the emergency department. Am J Emerg Med. 1997;15644- 646
Link to Article
Hill  DBStokes  BDGilinsky  NH Arterial oxygen saturation during emergency endoscopy. J Clin Gastroenterol. 1994;18284- 286
Link to Article
Terdiman  JPLindenauer  PKGebretsadik  TRoll  F Decision to perform early upper endoscopy in the elderly with upper gastrointestinal bleeding is not based on clinical factors that predict mortality [abstract]. Am J Gastroenterol. 1998;93A100
Cooper  GSChak  AConnors  AFHarper  DLRosenthal  GE The effectiveness of early endoscopy for upper gastrointestinal hemorrhage. Med Care. 1998;36462- 474
Link to Article
Lee  JGTurnipseed  SRomano  P  et al.  Endoscopy-based triage significantly reduces hospitalization rates and costs of treating upper GI bleeding: a randomized controlled trial. Gastrointest Endosc. 1999;50755- 761
Link to Article
Hay  JAMaldonado  LWeingarten  SREllrodt  G Prospective evaluation of a clinical guideline recommending hospital length of stay in upper gastrointestinal tract hemorrhage. JAMA. 1997;2782151- 2156
Link to Article
Terdiman  J Update on upper gastrointestinal bleeding: basing treatment decisions on patients' risk level. Postgrad Med. 1998;10343- 63
Link to Article
Mulrow  CCook  D Systematic Reviews: Synthesis of Best Evidence for Health Care Decisions.  Philadelphia, Pa American College of Physicians Press1998;
Clarke  MOxman  AD Cochrane Reviewers' Handbook 4.0 [updated July 1999]. Review Manager (RevMan) [computer program].Version 4.0. Oxford, England Cochrane Collaboration1999;
Not Available, Critical appraisal of studies. Mulrow  CDOxman  ADeds.Cochrane Collaboration Handbook [updated September 1997]. The Cochrane Library [database on disk and CD-ROM]. Oxford, England Cochrane Collaboration1997;96- 109
Campo  RBrullet  ECalvet  X  et al.  Safety of outpatient management of nonvariceal upper gastrointestinal bleeding: preliminary results of a randomized study [abstract]. Gastrointest Endosc. 1998;47AB81Abstract 228
Brullet  ECampo  RCalvet  X  et al.  Outpatient vs. hospital care after endoscopic injection in selected patients bleeding from peptic ulcers: preliminary results of a randomized study [abstract]. Gastrointest Endosc. 1998;47AB81Abstract 227
Almela  PPeiro  SMora  F  et al.  Safety of outpatient control in upper gastrointestinal bleeding not associated with portal hypertension (UGI-NPH) [abstract]. Am J Gastroenterol. 1999;94A111
Hussain  IFarrar  WHSofian  EJ  et al.  A cost effective strategy for managing GI bleeding secondary to peptic ulcer disease [abstract]. Gastroenterology. 1995;108A18
Link to Article
Rockall  TALogan  RFADevlin  HBNorthfield  TC Influencing the practice and outcome in acute upper gastrointestinal haemorrhage. Gut. 1997;41606- 611
Link to Article
Jadad  ARMoore  ACarroll  D  et al.  Assessing the quality of reports of randomised clinical trials: is blinding necessary? Control Clin Trials. 1996;171- 12
Link to Article
Cebollero-Santamaria  FSmith  JGioe  S  et al.  Selective outpatient management of upper gastrointestinal bleeding in the elderly. Am J Gastroenterol. 1999;941242- 1247
Link to Article
Hsu  PLai  KLin  X  et al.  When to discharge patients with bleeding peptic ulcers: a prospective study of residual risk of bleeding. Gastrointest Endosc. 1996;44382- 387
Link to Article
Lai  KHui  WWong  BCing  CLam  S A retrospective and prospective study on the safety of discharging selected patients with duodenal ulcer bleeding on the same day as endoscopy. Gastrointest Endosc. 1997;4526- 30
Link to Article
Longstreth  GFFeitelberg  SP Successful outpatient management of acute upper gastrointestinal hemorrhage: use of practice guidelines in a large patient series. Gastrointest Endosc. 1998;47219- 221
Link to Article
Longstreth  GFFeitelberg  SP Outpatient care of selected patients with acute nonvariceal upper gastrointestinal hemorrhage. Lancet. 1995;345108- 111
Link to Article
Koch  JRockey  DCCello  JP Emergent endoscopy in hemodynamically stable patients with upper gastrointestinal hemorrhage (UGIH) decreases hospital admission rate [abstract]. Gastrointest Endosc. 1996;43AB99Abstract 315
Link to Article
Chang  CFChan  CYLin  HJ  et al.  Endoscopy for upper gastrointestinal bleeding at emergency unit. Zhonghua Yi Xue Za Zhi (Taipei). 1992;49217- 222
Moreno  PJaurrieta  EAranda  H  et al.  Efficacy and safety of an early discharge protocol in low-risk patients with upper gastrointestinal bleeding. Am J Med. 1998;105176- 180
Link to Article
Cooper  GSChak  AWay  LHammar  PHarper  DRosenthal  G Early endoscopy in upper gastrointestinal hemorrhage: associations with recurrent bleeding, surgery, and length of hospital stay. Gastrointest Endosc. 1999;49145- 152
Link to Article
Hay  JALyubashevsky  EElashoff  JMaldonado  LWeingarten  SEllrodt  G Upper gastrointestinal hemorrhage clinical guideline: determining the optimal hospital length of stay. Am J Med. 1996;100313- 322
Link to Article
Lindenauer  PKRoll  FJGebretsadik  TTerdiman  JP Endoscopy improves outcome and reduces length of stay in elderly patients with acute upper gastrointestinal bleeding: results of a statewide population based analysis [abstract]. Am J Gastroenterol. 1999;116A76
Rockall  TALogan  RFADevlin  HBNorthfield  TC Selection of patients for early discharge or outpatient care after acute upper gastrointestinal haemorrhage. Lancet. 1996;3471138- 1190
Link to Article
Stevens  PDFinegold  JGarcia-Carrasquillo  RJ  et al.  Effectiveness of a protocol-based team approach to gastrointestinal hemorrhage [abstract]. Gastrointest Endosc. 1997;45AB102
Finegold  JGarcia-Carrasquillo  RJStevens  PD  et al.  Implementation of a standardized multi-disciplinary treatment protocol for acute GI hemorrhage [abstract]. Gastrointest Endosc. 1996;43350
Link to Article
Arber  NTiomny  EHallak  A  et al.  An eight year experience with upper gastrointestinal bleeding: diagnosis, treatment and prognosis. J Med. 1994;25261- 269
Perng  CLin  HChen  CLee  FLee  SLee  C Characteristics of patients with bleeding peptic ulcer requiring emergency endoscopy and aggressive therapy. Am J Gastroenterol. 1994;891811- 1814
Lin  HJWang  KPerng  CL  et al.  Early or delayed endoscopy for patients with peptic ulcer bleeding: a prospective randomized study. J Clin Gastroenterol. 1996;22267- 271
Link to Article
Choudari  CPPalmer  KR Timing of endoscopy for severe peptic ulcer hemorrhage: out of hours emergency endoscopy is unnecessary [abstract]. Gastroenterology. 1993;104A55
Jiranek  GCKozarek  RA A cost-effective approach to the patient with peptic ulcer bleeding. Surg Clin North Am. 1996;7683- 103
Link to Article
Pretolani  SArienti  VBaigorria  R  et al.  Efficacy of an observational unit in the emergency department on the outcome of patients admitted for upper gastrointestinal bleeding [abstract]. Gastroenterology. 2000;118A464Abstract 2530
Link to Article
Farkouh  MESmars  PAReeder  GS  et al.  A clinical trial of a chest-pain observation unit for patients with unstable angina. N Engl J Med. 1998;3391882- 1888
Link to Article

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