Urgent vs. Early Endoscopy in High Risk Patients With Upper Gastrointestinal Bleeding (UGIB)
Urgent vs. Early Endoscopy in High Risk Patients With Upper Gastrointestinal Bleeding (UGIB)
Acute upper gastrointestinal bleeding (UGIB) is one of the commonest medical emergencies. The
 condition accounts for 150 per 100,000 populations. A National United Kingdom reported a
 crude overall mortality rate of 10%. While bleeding stops spontaneously in majority of
 patients at their presentation, there remains a subgroup of patients who continue to bleed or
 develop recurrent bleeding. In these patients, the mortality increases manifolds. If these
 high-risk patients can be identified, early interventions may improve their outcomes.

 Several prognostic indices are in use for the purpose of patient stratification. They include
 the Rockall, Glasgow-Blatchford (GBS) and the Baylor scores. The Rockall score is a composite
 score which incorporates clinical parameters as well as findings during endoscopy which was
 derived to predict mortality. The GBS is a pre-endoscopy or a clinical score for the
 prediction for the need of further intervention loosely defined as the need for transfusion,
 endoscopy or surgery. It has been shown to be accurate in identifying low risk patients for
 early discharge.
The GBS, being a pre-endoscopy score with clinical parameters, is more suitable for patient
 triage leading to urgent endoscopy and a higher level of care. A GBS of 0 has been shown to
 identify patients with upper gastrointestinal bleeding who may be managed safely as
 outpatients. The proportion of patients requiring endoscopic therapy increases with a higher
 score. A cut-off score that identifies "high-risk" patients who may benefit from urgent
 intervention however has not been determined. Guidelines from Societies around the world
 recommend early endoscopy within 24 hours of presentation for acute upper gastrointestinal
 bleeding (AUGIB). The guidelines also state that a proportion of patients need emergency
 "out-of-hours" endoscopy, without defining the "high-risk" group. A recent international
 consensus on the management of NVUGIB recommended early endoscopy within 24 hours for
 Non-Variceal Upper Gastro Intestinal Bleeding (NVUGIB), and noted no additional benefit
 associated with urgent endoscopy (<12 hours) vs. early endoscopy (>12 hours) in unselected
 patients with NVUGIB. However, there are only limited data on the role of urgent endoscopy in
 the "selected" subgroup of patients with high-risk NVUGIB.
Inclusion Criteria:

 1. Overt signs of upper gastrointestinal bleeding (i.e., melena or hematemesis with or
 without hypotension)

 2. GBS of ≥12

 3. In-patients admitted for reasons other than AUGIB who develop bleeding are also
 considered for trial enrollment.

 4. Patients in Hypotensive shock (SBP ≤90 mmHg or pulse ≥110 bpm) are initially
 resuscitated and then considered for trial entry if their condition can be stabilized.

 Exclusion Criteria:

 1. continued shock despite initial volume resuscitation (refractory shock) undergo urgent
 endoscopy

 2. < 18 years of age

 3. Unable to provide written informed consent

 4. Pregnant or lactating women

 5. Moribund patients from terminal illnesses. (active treatment not considered)