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The importance of the elapsed time between initial presentation of upper gastrointestinal bleeding (UGIB) and the performance of a gastroscopy remains poorly understood, despite being the focus of much research and consistent recommendations across societies.1–4 Furthermore, as in other areas of medicine, the improved efficacy observed in randomised controlled trials (RCTs) of patients presenting with non-variceal UGIB may not translate into similar benefits in a real-life setting. The national audit by Hearnshaw et al published in this issue (see page 1022) thus provides a plethora of important observational information, including insights into after-hours endoscopy.5 These new data need to be interpreted in light of existing guidelines and their supportive evidence. Although the evidence discussed below pertains to all patients presenting with UGIB, for the most part it does not specifically address patients with a high likelihood of bleeding from complications of portal hypertension (usually ∼10–15% of all patients with UGIB6 7).
What outcomes are improved by early endoscopy, if any?
A multidisciplinary approach with timely involvement of a trained endoscopist and endoscopy assistant is widely recommended1–4; such involvement may entail after-hours availability, since early endoscopy is the cornerstone of treatment for patients with acute non-variceal UGIB. Indeed, the performance of an early gastroscopy allows for safe and prompt discharge of patients classified as low risk, improves patient outcomes for patients classified as high risk and reduces resource utilisation for patients classified as either low or high risk.4 The definition of early endoscopy varies widely among studies, from 2 to 24 h after presentation to the emergency department.3 4 8 9 The improvement in outcomes attributable to performing endoscopic haemostasis in patients with high-risk endoscopic lesions has been shown.10–14 Yet it is important to realise that the benefits attributable to early endoscopy relate to both its diagnostic and therapeutic roles in managing …