For variceal bleeding, ASG and Bavinum recommends very clearly that we should do the endoscopy within 12 hours of presentation of the patient. For the non-variceal bleeding, also the American Society as well as the ESG are very clear stating that after hemodynamic stabilization, upper GI bleeding, upper GI endoscopy should be done within 24 hours. And if the patient will persist to be instable, we should do it as urgent as 12 hours. However, the $1 million question, is it possible? Globally, the answer is no. So you cannot have a therapeutic endoscopist everywhere, 24 hours basis. Number one, due to the lack of experience endoscopists worldwide, not only the endoscopists, the nurses, the staff, to have an endoscopy unit which is able to manage bleeding 24-7, it's really not easy. So this is why doing this every day, anytime, is not easy worldwide. So still the debate is going. Should we do it as early as possible? Or we should wait till tomorrow morning after 24 hours? Or within 24 hours? So this is a very good piece of information. When they compared band ligation, for example, within four hours, more than four hours, less than eight hours, more than eight hours, and then 12 hours, they showed that there's significantly more band ligation had been used in the group of patients less than four hours. The only explanation for this, that at that time, when you don't see it really, you put more bands because you really cannot see a very well or a very clear vision. So you simply put more bands to be safe. Another recent randomized control trial compared urgent, with the mean of 10 hours versus early, with the mean of 24 hours, and you can see there was no difference in mortality between the two groups. And this was a very specific group of patients, of higher risk patients with upper GI bleeding. Another retrospective study on 250 patients, again, comparing urgent within 12 hours versus early from 12 to 24 versus late, more than 24. And in this study, they showed that urgent endoscopy, they have 23%, they have active bleeding during the endoscopy, which limit the visualization of the bleeding site and how to control it. And in this group of patients, they have to repeat the endoscopy in a second look endoscopy. Another retrospective work on 300 patients, again, showing that delayed endoscopy more than 50 hours, it's another independent risk factor of increasing mortality. So you can see, literature is really controversial, so you can see people supporting that we should go early, as early as possible to do it. But sometimes you don't see, you cannot really identify where is the bleeding site. And if you leave the patient too much, the patient have a higher risk of mortality. For variceal bleeding, again, as I said, it's clear that we should go within the 12 hours, which I know that it's not always possible. This is another recent study on 274 patients, where they compared urgent endoscopy less than 12 hours versus non-urgent or early after 12 hours. And we have no difference in mortality between the two groups. So it's clear that there is a debate, there is a gap of the literature in this part. But the only thing which I know and which I believe that resuscitation and having the patient stable while you are doing for him the endoscopy is one of the milestones of treating this patient correctly.

endoscopy

variceal bleeding

non-variceal bleeding

therapeutic endoscopists

urgent endoscopy