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Having questioned the value of therapeutic endoscopy, let me question the value of diagnostic endoscopy, having lived through the days from when it was not available to its current status. Having given the matter considerable thought,1 I seriously doubt that it has been of any value. It might even have had an adverse effect on outcome by delaying operative intervention in those who need it and among whom most deaths occur.
If done emergently it is difficult to visualise the bleeding site, especially in those who require surgery and whose rate of blood loss is greatest. Its greatest value may be in excluding the presence of oesophageal bleeding from varices but this is arguably best done on the operating table by the surgeon. In the UK, many centres no longer perform endoscopy emergently preferring to wait until the bleeding has stopped and a better diagnostic evaluation can be made on the daily endoscopy list. This may be good for documentation but is of doubtful benefit in managing patients because of the inevitable delay in surgical intervention in those that need it.
Operative mortality for bleeding ulcers used to be in the order of 15%. I suspect it is very much higher today because surgeons do far less ulcer surgery. This is likely to be especially true if the operations are delegated to registrars in the middle of the night. It might be wise to take a fresh look at the problem.
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