alone an endoscopy performed.
Although some delay
EDITORIAL
Urgent endoscopy: Does it matter if they
dont listen to us?
Non-variceal upper-GI bleeding is still a signifi-
cant problem in the United States despite major
advances in endoscopy, pharmacotherapy, and sur-
gery. It remains one of the most common diagnoses
that account for admission to the intensive care
unit, and the leading reason for urgent consultation
with a gastroenterologist. It is now clear that early
endoscopy is the most accurate method of determin-
ing the cause of bleeding and that endoscopic
therapy significantly reduces transfusion require-
ment, need for urgent surgery, hospital stay, and
(probably) mortality from non-variceal upper-GI
bleeding. In addition, the findings at endoscopy are
a powerful prognostic indicator of ultimate outcome;
for example, patients with an ulcer with a clean
base have a negligible risk of recurrent bleeding
and other adverse outcomes. Given these benefits of
endoscopy, it seems intuitively obvious that patients
with non-variceal upper-GI bleeding should undergo
endoscopy as soon as possible for diagnosis and ther-
apy, and to establish prognosis. There are alterna-
tives, of course, but transfusion and treatment with
a proton pump inhibitor or exploratory laparotomy
can hardly be justified in most cases.
What then is the problem? Is there a problem with
the management of non-variceal upper-GI bleeding?
The problem I believe is the flow of the patient.
Although this is mainly a GI problem that requires
GI endoscopy for resolution, the patient first is eval-
uated by emergency medicine physicians and then
cared for by intensivists or hospitalists, so that the
gastroenterologist is not brought into the loop for
many hours or even days after the onset of bleeding.
This delay tends to be magnified in academic in-
stitutions, because a prerequisite for a consultation
with a gastroenterologist is that the patient first be
evaluated by the emergency department resident
and then presented to the attending physician,
admitted, evaluated by the medical resident team,
presented to the ward attending, and then a consul-
tation is requested, all before the patient is seen by
the gastroenterologist. Even then, the patient is
usually first seen by the resident, then the fellow,
and then the attending, before a decision is made, let
Copyright 2004 by the American Society for Gastrointestinal
Endoscopy 0016-5107/$30.00
PII: S0016-5107(04)01533-0
94 GASTROINTESTINAL ENDOSCOPY
is inevitable in every system, delay, nevertheless,
increases health care costs and workload, and is
inconvenience for the patient. One logical solution to
this ingrained system problem of flow is to perform
endoscopy early so that an accurate diagnosis is
made, the problem is treated, and the patient is
triaged to an appropriate level of care in the most
efficient, evidence-based manner possible. Bjorkman
et al.1 report the results of such an intervention in
the current issue of the journal.
These investigators from two university medical
centers and a Veterans Affairs hospital randomized
93 hemodynamically stable patients with upper-GI
bleeding to early endoscopy (within 6 hours of
admission) or routine endoscopy (as late as 48 hours
after admission). As expected, the two groups were
similar with mean Rockall scores of less than 2, (age
\80; absence of comorbidity and hypotension). Ulcer
was the cause of the bleeding in 61% and 70% of the
elective and the urgent endoscopy patients, respec-
tively. Bjorkman et al.1 recommended that 19 of
47 patients (40%) without high-risk lesions after
urgent endoscopy be discharged; in actuality, the
emergency department physicians discharged only 4
such patients. Consequently, there were no signifi-
cant differences in final resource utilization for the
two groups, because both were hospitalized for about
3 days, regardless of the results of the endoscopy. We
are not told why the emergency department physi-
cians did not follow through with the recommenda-
tion of the gastroenterologists, but Bjorkman et al.1
speculate that a part of the reason could have been
that the study was an effectiveness study in which
endoscopy results are used as part of the decision-
marking process by the attending physician, instead
of the sole determinant of a therapeutic approach.
The study did not address what was done during the
hospitalization for patients with low-risk endoscopic
lesions, all of whom were hemodynamically stable,
without serious comorbid conditions, able to follow
discharge instructions, and relatively young (mean
age of 57). Intravenous infusion of a proton pump
inhibitor is one possibility; if so, however, this was
inappropriate because this form of therapy is only
effective in patients with high-risk lesions. Blood
transfusion could have been another explanation
for admission, but the urgent-endoscopy group had
a higher than Hb level at presentation, with only 40%
of the total group requiring transfusion. The 19
patients with low-risk lesions on endoscopy did not
require endoscopic therapy or surgery, by definition.
It seems unlikely that the emergency department
physicians did not understand the significance of
a highly favorably endoscopy result, inasmuch as the
VOLUME 60, NO. 1, 2004
Editorials
recommendation was that these patients be dis-
charged. Perhaps it was easier and faster for the
emergency department to admit instead of discharge
the patient and take a chance that the recommenda-
tion of the gastroenterologist was wrong. I dont know
the reason. However, it is only necessary to look to
the inappropriate use of H2-receptor antagonists to
understand that physicians do not necessarily prac-
tice evidence-based medicine in caring for patients
with GI bleeding.2 Bjorkman et al.1 intentionally did
not attempt to influence the decision of the emer-
gency department physician to mimic the typical
clinical setting where primary care providers or
emergency room physicians are the decision makers
and gastroenterologists are consultants who only
provide recommendations for care.
We examined a similar strategy of early endos-
copy.3 Forty-six percent of the patients in the early
endoscopy group in our study met similar criteria
for discharge after endoscopy and were discharged,
which significantly reduced the cost and the use of
resources for patients randomized to early endos-
copy. There are several important differences be-
tween our study and that of Bjorkman et al.1 that
could explain the variation in discharge rates.
Our study was carried out in a single center,
whereas, the current study was multicenter, which
likely increased the variation in physician attitudes,
beliefs, and practice styles. Although this may
have decreased compliance with an evidence-
based approach, experience from a single center is
not necessarily generalizable, and, thus, the
results of Bjorkman et al.1 may be more realistic.
They performed endoscopy within 6 hours, either in
the emergency department or the endoscopy unit,
whereas we performed endoscopy in the emergency
department within 1 to 2 hours of presentation. It is
possible that even a small delay in performing
endoscopy could reduce the efficiency of a busy
emergency department and thereby increase dissat-
isfaction with the process and, consequently, non-
compliance with the recommendations of the
gastroenterologists. Finally, the study of Bjorkman
et al.1 was conducted by gastroenterologists, whereas
our study combined the efforts of gastroenterol-
ogists and emergency medicine physicians; as such,
the latter group enthusiastically supported the
prompt discharge of patients from the emergency
department.
VOLUME 60, NO. 1, 2004
J Lee
The results of Bjorkman et al.1 seemingly suggest
that it is unrealistic to expect widespread support in
clinical practice for the early discharge of patients
with non-variceal upper-GI bleeding who are at low
risk for adverse outcomes based on endoscopic and
other findings. However, the emergency department
physicians were unaware of the study hypothesis
and, thus, presumably, the rationale and the
evidence supporting early discharge. It could, there-
fore, be concluded that the results of Bjorkman
et al.1 are probably the worst-case scenario and that
the true clinical results probably lay somewhere
between 25% and 100% compliance with early
discharge.
So what can be concluded from these two studies:
(1) early endoscopy identifies slightly less than half
of the stable patients with non-variceal upper-GI
bleeding who can be discharged safely from the
emergency department, (2) early discharge reduces
health care costs and resource utilization, and (3)
emergency department physicians may or may not
accept the recommendation of the gastroenterologist
to discharge the patient.
As for my question, does it matter if they dont
listen to us. It matters. Clearly, it is possible to
improve the care of patients with non-variceal
upper-GI bleeding. But doing so will take much
more than a one-time recommendation. I believe it
to be our responsibility to educate our non-gastro-
enterologist colleagues as to the growing body of
evidence supporting early discharge. When this is
accomplished, and it must be accomplished, the
management of patients with non-variceal upper-GI
bleeding is certain to improve.
John G. Lee, MD
Orange, California
REFERENCES
1. Bjorkman DJ, Zaman A, Fennerty MB, Lieberman D, DiSario
JA, Guest-Warnick G. Urgent vs. elective endoscopy for acute
non-variceal upper gastrointestinal bleeding: an effectiveness
study. Gastrointest Endosc 2004;60:1-8.
2. Dettmer RM, Riley TH, Byfield F, Green PH. The use of
intravenous H2-receptor antagonists in a tertiary care hospi-
tal. Am J Gastroenterol 1999;94:3473-7.
3. Lee JG, Turnipseed S, Romano PS, Vigil H, Azari R, Melnikoff
N, et al. Endoscopy-based triage significantly reduce hospi-
talization rates and costs of treating upper GI bleeding:
a randomized controlled trial. Gastrointest Endosc 1999;50:
755-61.
GASTROINTESTINAL ENDOSCOPY 95