Routine Second-Look Endoscopy: Ineffective, Costly, and Potentially Misleading

Abstract

J Romagnuolo. Routine second look endoscopy: Ineffective, costly and potentially misleading. Can J Gastroenterol 2004;18(6):401-404.Despite the best medical and endoscopic efforts, some patients with nonvariceal upper gastrointestinal bleeding suffer recurrences. Because high risk stigmata (visible vessels, active bleeders and adherent clots) often persist despite apparently successful initial hemostasis and have a variable natural history, it would seem reasonable to at least consider a routine second look endoscopy. However, a review of the literature revealed six randomized trials that, in aggregate, do not support such a strategy. In fact, a second look does not appear to be effective and is associated with an increased number of procedures, treatment sessions and possibly retreatment-related complications. In addition, the cointerventions in these trials are already out of date and the potential absolute risk reductions are low when a second look is used with intravenous proton pump inhibitors and/or the application of endoscopic hemoclips or combination endoscopic therapy. Finally, the Forrest classification may provide dangerously misleading estimates of prognosis because it is being used out of context. This review critically analyzes routine second look endoscopy.Key Words: Endoscopic therapy; Gastroscopy; Nonvariceal upper gastrointestinal bleeding; Peptic ulcer disease Une endoscopie de contrôle systématique : inefficace, coûteuse et peut-être trompeuse Malgré les plus grands efforts médicaux et endoscopiques, certains patients souffrant d'hémorragie gastro-intestinale non variqueuse présen-tent des récurrences. Parce que des stigmates à haut risque (vaisseaux visibles, saignées actives et caillots d'adhérence) subsistent souvent malgré une hémostase initiale en apparence réussie et qu'ils ont des antécédents naturels variables, il semblerait raisonnable d'au moins envisager une endoscopie de contrôle systématique. Cependant, une analyse bibliographique révèle que six essais aléatoires n'appuient pas, dans l'ensemble, une telle stratégie. En fait, un contrôle ne semble pas être efficace et s'associe à un plus grand nombre d'interventions, de séances de traitement et, peut-être, de complications reliées au deuxième traitement. En outre, les co-interventions utilisées dans ces essais sont déjà dépassées, et les réduc-tions absolues et potentielles du risque sont faibles lorsque ces interventions sont les inhibiteurs de la pompe à proton par voie intraveineuse ou l'application de pinces hémostatiques endoscopiques. Enfin, la classification de Forrest comporte peut-être des évaluations dangereusement trompeuses du pronostic parce qu'elle est utilisée hors contexte. La présente analyse évalue l'endoscopie de contrôle d'un oeil critique. D espite advances in the endoscopic treatment of bleeding peptic ulcer disease, there remains a significant rebleeding rate of 10% to 20% (1,2). Adjuvant intravenous proton pump inhibitor therapy has been proven to reduce the rebleeding rate when used with successful endos...

Capsule Endoscopy of the Upper Gastrointestinal Tract – The Need for a Second Endoscopy

“…We would like to emphasise that the time spent in viewing the upper GI tract should be similar to the small-bowel tract. The reasons why lesions are missed within the reach of conventional endoscopy are not clear and the question of performing a second endoscopy has been debated in patients with non-variceal upper GI bleeding [23]. This has been mainly due to the costs of a repeat endoscopy.…”

Is routine second-look endoscopy effective after endoscopic hemostasis in acute peptic ulcer bleeding? A meta-analysis

“…This study, however, exhibited some methodological shortcomings limiting its interpretation. 33 In 2009, a review article by Tsoi et al 34 followed by a meta-analysis by the same group 35 examined the available evidence on second-look endoscopy and compared trials using thermal coagulation and injection therapy. It was found that repeat endoscopy with thermal coagulation decreased rebleeding rates, whereas injection therapy alone did not.…”

Endoscopic Approaches to Upper Gastrointestinal Bleeding

“…28 Scheduled secondlook endoscopy with retreatment 24 hours after initial endoscopic treatment may lower the risk of recurrent hemorrhage 29 ; however, a recent meta-analysis questions this practice. 30 A second attempt at endoscopic control, if recurrent hemorrhage occurs after initially successful endoscopic treatment, can reduce the need for surgical control of ulcer bleeding. 31 Patients that were hypotensive on admission or had ulcers greater than 2 cm in diameter were less likely to respond to a second attempt at endoscopic hemostasis.…”