What is the role of second-look endoscopy in the treatment of upper gastrointestinal bleeding (UGIB)?

Updated: Sep 01, 2021
  • Author: Bennie Ray Upchurch, III, MD, FACP, AGAF, FACG, FASGE; Chief Editor: BS Anand, MD  more...
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A second attempt at endoscopic control is warranted if the initial endoscopy fails to control the bleeding. Some authorities have concerns about the perils of a second esophagogastroduodenoscopy (EGD), which may result in delayed surgery, perforation, and increased morbidity and mortality. However, this approach has been validated in a large, randomized, controlled trial that showed decreased morbidity and mortality. [89]

Owing to the relatively high rebleeding rate associated with ulcers, some clinicians advocate scheduled second-look endoscopy, with the intent of identifying and proactively managing persistent or recurrent bleeding. This would be a strategy directed at individuals who are very likely to benefit from a second invasive procedure; however, no current guidelines recommend this strategy. A systematic review and meta-analysis of randomized trials assessing otucomes of second-look endoscopy reported a small but significant reduction in rebleeding in patients undergoing the procedure (P< 0.01) but no significant benefit in reducing surgery or death. [126]

In a prospective multicenter study that evaluated the efficacy of scheduled second-look endoscopy (24-36 hours after initial hemostasis) in 319 patients with endoscopically confirmed bleeding peptic ulcer treated unsucessfully with hemoclip application, thermal coagulation, and/or epinephrine injection, investigators found noninferiority of single endoscopy relative to second-look endoscopy for rate of rebleeding (P = 0.132). [127] Independent risk factors for rebleeding included endoscopists’ estimation of poorer success of the initial hemostasis, a patient history of NSAID use, and higher transfusion requirement (4 units of red blood cells). Thus, the researchers concluded that repeat endoscopy may only be beneficial in patients with less-than-satisfactory initial hemostasis at endoscopy, an NSAIDs history, or higher transfusion requirement. [127]

Specific characteristics at endoscopy can predict rebleeding. Rebleeding occurs in 55% of patients who have active bleeding (pulsatile, oozing), in 43% who have a nonbleeding visible vessel, in 22% who have an ulcer with an adherent clot, and in 0-5% who have an ulcer with a clean base.

At endoscopy, the prevalence rate for a clean base is 42%, for a flat spot is 20%, for an adherent clot is 17%, for a visible vessel is 17%, and for active bleeding is 18%. See the images below.

Upper gastrointestinal bleeding (UGIB). Diagram of Upper gastrointestinal bleeding (UGIB). Diagram of an ulcer with a clean base.
Upper gastrointestinal bleeding (UGIB). Ulcer with Upper gastrointestinal bleeding (UGIB). Ulcer with a visible vessel.

Freeman et al have described a pale, visible vessel that appears to have a very high risk for rebleeding. [128] This must be differentiated from the presence of a clean ulcer base.

Good visualization is important. The uncleared fundal pool may obscure an ulcer, mucosal tear, gastric varices, portal gastropathy, or tumor (eg, leiomyoma, adenocarcinoma, lymphoma). Endoscopic therapy is recommended for ulcers at increased risk for rebleeding.

Using a combination of techniques is prudent when re-treating the ulcer site because the first therapy may have produced necrosis and weakening of the intestinal wall. Ulcers on the anterior surface of the stomach and duodenum are at an increased risk for perforation. Using injection as the first step increases the thickness of the submucosal layer, thus providing an extra margin of safety.

Even operative techniques can have a significant rebleeding rate with significant mortality, as noted in the study of Poxon et al. In this investigation, the rebleeding rate was 10% (80% mortality for rebleeders) in patients who underwent a conservative surgical technique in which the ulcer base was undersewn. [129] This more conservative approach was compared with the standard surgical technique (ie, vagotomy and pyloroplasty or partial gastrectomy). The comparison of the conservative approach with a standard gastrectomy resulted in similar mortality rates, ie, 26% versus 19%, respectively, with no rebleeding after partial gastrectomy.

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