From the Institute of Digestive Disease, the Chinese University of Hong Kong, Shatin, Hong Kong.
N Engl J Med. 2020 Apr 2;382(14):1299-1308. doi: 10.1056/NEJMoa1912484.
It is recommended that patients with acute upper gastrointestinal bleeding undergo endoscopy within 24 hours after gastroenterologic consultation. The role of endoscopy performed within time frames shorter than 24 hours has not been adequately defined.
To evaluate whether urgent endoscopy improves outcomes in patients predicted to be at high risk for further bleeding or death, we randomly assigned patients with overt signs of acute upper gastrointestinal bleeding and a Glasgow-Blatchford score of 12 or higher (scores range from 0 to 23, with higher scores indicating a higher risk of further bleeding or death) to undergo endoscopy within 6 hours (urgent-endoscopy group) or between 6 and 24 hours (early-endoscopy group) after gastroenterologic consultation. The primary end point was death from any cause within 30 days after randomization.
A total of 516 patients were enrolled. The 30-day mortality was 8.9% (23 of 258 patients) in the urgent-endoscopy group and 6.6% (17 of 258) in the early-endoscopy group (difference, 2.3 percentage points; 95% confidence interval [CI], -2.3 to 6.9). Further bleeding within 30 days occurred in 28 patients (10.9%) in the urgent-endoscopy group and in 20 (7.8%) in the early-endoscopy group (difference, 3.1 percentage points; 95% CI, -1.9 to 8.1). Ulcers with active bleeding or visible vessels were found on initial endoscopy in 105 of the 158 patients (66.4%) with peptic ulcers in the urgent-endoscopy group and in 76 of 159 (47.8%) in the early-endoscopy group. Endoscopic hemostatic treatment was administered at initial endoscopy for 155 patients (60.1%) in the urgent-endoscopy group and for 125 (48.4%) in the early-endoscopy group.
In patients with acute upper gastrointestinal bleeding who were at high risk for further bleeding or death, endoscopy performed within 6 hours after gastroenterologic consultation was not associated with lower 30-day mortality than endoscopy performed between 6 and 24 hours after consultation. (Funded by the Health and Medical Fund of the Food and Health Bureau, Government of Hong Kong Special Administrative Region; ClinicalTrials.gov number, NCT01675856.).
建议在消化科就诊后 24 小时内对急性上消化道出血患者进行内镜检查。但在 24 小时内进行内镜检查的时间窗口的作用尚未得到充分明确。
为了评估对有进一步出血或死亡高风险的患者行紧急内镜检查是否能改善结局，我们将有明显急性上消化道出血表现且 Glasgow-Blatchford 评分为 12 分或更高（评分范围为 0 至 23 分，分数越高提示进一步出血或死亡的风险越高）的患者随机分为内镜检查在消化科就诊后 6 小时内（紧急内镜组）或 6 至 24 小时内（早期内镜组）进行。主要终点是随机分组后 30 天内任何原因导致的死亡。
共纳入 516 例患者。紧急内镜组 258 例患者中有 8.9%（23 例）在 30 天内死亡，早期内镜组 258 例患者中有 6.6%（17 例）（差异，2.3 个百分点；95%置信区间[CI]，-2.3 至 6.9）。紧急内镜组 28 例（10.9%）和早期内镜组 20 例（7.8%）在 30 天内再次出血（差异，3.1 个百分点；95%CI，-1.9 至 8.1）。在紧急内镜组的 158 例消化性溃疡患者中，105 例（66.4%）和在早期内镜组的 159 例患者中 76 例（47.8%）在初始内镜检查时发现有活动性出血或可见血管的溃疡。在紧急内镜组的 155 例（60.1%）和早期内镜组的 125 例（48.4%）患者在初始内镜检查时进行了内镜止血治疗。
在有进一步出血或死亡高风险的急性上消化道出血患者中，与消化科就诊后 6 至 24 小时内进行内镜检查相比，就诊后 6 小时内进行内镜检查与 30 天内死亡率较低无关。（由香港特别行政区食物及卫生局卫生及医疗基金资助；ClinicalTrials.gov 编号，NCT01675856。）
