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Routine second look endoscopy: ineffective, costly and potentially misleading
1Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada. j.romagnuolo@ucalgary.ca
Summary
Routine second look endoscopy for nonvariceal upper gastrointestinal bleeding is not supported by evidence. A review of six trials shows it is ineffective and increases procedures and complications.
Area of Science:
- Gastroenterology
- Endoscopic procedures
- Gastrointestinal bleeding management
Background:
- Recurrent nonvariceal upper gastrointestinal bleeding (NVUGIB) poses a clinical challenge despite initial endoscopic hemostasis.
- High-risk stigmata (visible vessels, active bleeding, adherent clots) can persist, suggesting a potential role for repeat endoscopy.
- The natural history of these stigmata is variable, prompting consideration of routine second look endoscopy.
Purpose of the Study:
- To critically analyze the efficacy and safety of routine second look endoscopy for NVUGIB.
- To evaluate the existing evidence from randomized trials regarding second look endoscopy strategies.
- To assess the impact of second look endoscopy in conjunction with modern endoscopic therapies and pharmacologic interventions.
Main Methods:
- Systematic review and critical analysis of six randomized controlled trials (RCTs) comparing routine second look endoscopy with on-demand endoscopy for NVUGIB.
- Evaluation of data on recurrence rates, procedural outcomes, and complications associated with each strategy.
- Assessment of the influence of contemporary interventions (e.g., proton pump inhibitors, hemoclips) on the utility of second look endoscopy.
Main Results:
- Aggregate data from six RCTs do not support the routine use of second look endoscopy for NVUGIB.
- Second look endoscopy was found to be ineffective in reducing rebleeding or improving outcomes.
- Routine second look endoscopy is associated with an increased number of procedures, treatment sessions, and potential retreatment-related complications.
Conclusions:
- Routine second look endoscopy is not a recommended strategy for patients with NVUGIB.
- The benefits of second look endoscopy are outweighed by increased procedural burden and complications.
- The Forrest classification's prognostic value may be limited when used without considering the full clinical context and contemporary management strategies.