When COVID-19 reached the United States, emergency departments had one of two experiences. In places with large outbreaks, every ounce of energy went into taking care of critically ill patients. Everywhere else, emergency visits plummeted by 42 percent.1 It was actually a quiet time.
Explore This IssueACEP Now: Vol 39 – No 09 – September 2020
Now, patient volumes are starting to return to normal in many areas. That means that the usual culprits are back in steady force. Depending on whether your emergency department is in a COVID-19 hotspot, you may feel the need either to rush patients to endoscopy (ie, keeping the emergency department and observation units as empty as possible) or delay the procedures out of a concern for the safety of everyone involved. Regardless of COVID-19, where do we stand on the question of how quickly patients with suspected upper gastrointestinal bleeding (UGIB) must have an endoscopy?
Best Timing for Endoscopy
The first of two important related articles released during the COVID-19 pandemic (and perhaps flying under the radar) looks at this.2 Do GI consultants really need to answer our 2 a.m. pages and rally the team of nurses and equipment for endoscopy immediately?
The answer is surprising, especially considering how ill the patients enrolled in the first trial we’ll discuss were. The authors recruited and enrolled patients with Glasgow-Blatchford Bleeding Scores (GBS) of 12 or above, which is considered “high risk” for an UGIB likely to require a medical intervention (transfusion, endoscopy, or surgery).
The median enrolled hemoglobin level was 7.4 g/dL, a third had tachycardia, and about a sixth were already hypotensive. Virtually all (90 percent) received a transfusion of packed red blood cells, with a mean requirement of 2.4 units. Patients were excluded if they were in hypotensive shock and unstable despite initial resuscitation (ie, the need for a procedure meant that waiting was not an option). In short, these were genuinely the sort of patients who are worrying to emergency physicians but not clearly in extremis.
The 516 patients randomized in this trial were sorted to either an “urgent endoscopy,” endoscopy within six hours, or “early endoscopy,” an endoscopy within 24 hours. All patients were treated with continuous infusion of high-dose proton-pump inhibitors, while those suspected of having variceal bleeding received vasoactive agents and antibiotics. The primary outcome of the study was mortality at 30 days following enrollment, with secondary measures of clinical progression, recurrence, and resource utilization.
The quick answer: Mortality was not significantly different between groups. The difference favored waiting for endoscopy, but the trial was not large enough to claim any sort of hidden trend. As might be expected, delaying endoscopy meant fewer patients with active bleeding identified and subsequently fewer interventions. Neither transfusion requirements nor occurrences of rebleeding were different, and there were no signs of potential hazard associated with waiting.
It should be noted there were 20 patients in the “early” endoscopy cohort who converted to “urgent” as a result of new hypotension, hematemesis, melena, or otherwise failing to respond to initial resuscitation. While these data indicate it is clearly safe to delay endoscopic evaluation, vigilance regarding possible deterioration is required. A little fewer than one in 10 patients may necessitate a change in plans.