Risk factors determining the need for second-look endoscopy for peptic ulcer bleeding after endoscopic hemostasis and proton pump inhibitor infusion

Abstract

Background and study aims: The need for routine second-look endoscopy in cases of peptic ulcer bleeding remains uncertain. We investigated risk factors related to the need for second-look endoscopy after endoscopic hemostasis and proton pump inhibitor (PPI) infusion. Patients and methods: We prospectively enrolled 316 patients with peptic ulcer bleeding after endoscopic hemostasis. Second-look endoscopy was scheduled after 72-hour PPI infusion (Day-3 subgroup) or one day early (Day-2 subgroup). If early rebleeding developed within 3 days, emergent second-look endoscopy was conducted. Risk factors for early rebleeding (use of E2nd score to predict the need for early second-look endoscopy) and persistent major stigmata in the Day-3 subgroup (use of R2nd score to predict the need for routine second-look endoscopy) were analyzed using univariable and multivariable regression. Results: Excluding 10 of 316 patients with early rebleeding, the rate of persistent major stigmata was lower in the Day-3 subgroup than in the Day-2 subgroup (4.8 % vs. 15.4 %, P = 0.002). Endoscopic epinephrine-injection monotherapy and hypoalbuminemia < 3.0 g/dL were two independent risk factors for early rebleeding (P ≤ 0.05). The Forrest Ia-Ib type and hypoalbuminemia < 3.5 g/dL were two independent risk factors for persistent major stigmata on the day-3 second-look endoscopy (P < 0.05). The E2nd score was highly accurate for prediction of early rebleeding (AUROC 0.86; 95 % CI, 0.73~0.99), and the R2nd score could predict persistent major stigmata at second-look endoscopy (AUROC 0.84; 95 % CI, 0.69~0.99). Conclusions: For patients with peptic ulcer bleeding, E2nd and R2nd scores can indicate the need for early and routine second-look endoscopy, respectively(Trial registration identifier: NCT02197039).

Asia-Pacific working group consensus on non-variceal upper gastrointestinal bleeding: an update 2018

“… 112 Another study from Taiwan which enrolled 316 patients receiving a high-dose PPI after endoscopic therapy attempted to formulate a predictive score using endoscopic monotherapy and serum albumin levels. 113 By this score, the receiver operating characteristic curve to predict need for second-look endoscopy appeared promising, but outcome data were lacking. To date, there is still a lack of evidence to suggest that any risk stratification method is effective in selecting patients at high risk who would benefit from second-look endoscopy and pre-emptive treatment.…”

Continuous esomeprazole infusion versus bolus administration and second look endoscopy for the prevention of rebleeding in children with a peptic ulcer

“…Second look endoscopy performed within 24 hours after therapeutic endoscopy appears to reduce the risk of rebleeding in the absence of high dose PPI infusion in adult patients, although study designs and results vary (7,8). Meanwhile, prospective randomized studies in adult patients have demonstrated that high-dose omeprazole infusion after endoscopic hemostasis stabilizes the clot over the bleeding artery and successfully prevents peptic ulcer rebleeding (9,10).…”

Second-Look Endoscopy in Hospitalized Severe Ulcerative Colitis: A Retrospective Cohort Study

“…Although a "second-look" endoscopy is not part of routine clinical care of hospitalized patients with ASUC, it has been extensively studied in upper gastrointestinal bleeding, particularly related to peptic ulcer. [11][12][13][14] The effect of second-look endoscopy performed within 24-48 hours after therapeutic endoscopy has been shown to be useful in identifying patients who are at a lower risk of re-bleeding. 15,16 Adding to the literature, our findings suggest that a second-look endoscopy may have value in a subset of patients with ASUC, identifying those who demonstrate early endoscopic improvement even in the setting of nonimprovement of symptoms.…”