Minutes to Save a Life in Acute GI Bleeding: A Systematic Review of Early vs. Delayed Endoscopy

Non-variceal upper gastrointestinal bleeding (NVUGIB) is a common and potentially life-threatening emergency that presents major clinical and logistical challenges worldwide, making the timing of endoscopic management particularly important. Endoscopy remains the cornerstone of diagnosis and therapy in NVUGIB, allowing identification of the bleeding source and delivery of hemostatic therapy, yet the optimal timing, urgent within 6-12 hours versus early within 24 hours, continues to be debated, particularly when deciding between hemodynamically unstable or otherwise high-risk patients and more stable, low-risk presentations. This systematic review, conducted in accordance with Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) 2020 guidelines, evaluated the effect of endoscopy timing on mortality, rebleeding, therapeutic interventions, and health-system outcomes, with special consideration for elderly and anticoagulated patients, in whom endoscopy may be more challenging. Evidence synthesized from randomized trials, cohort studies, and large database analyses indicates that early endoscopy within 24 hours is consistently associated with shorter hospital stays, lower costs, and better discharge outcomes, particularly in patients at higher clinical risk. These differences likely reflect the divergent risk profiles of high-risk compared with low-risk patients. While urgent endoscopy within 6-12 hours may offer advantages in high-risk or hemodynamically unstable patients, routine use in low-risk cases does not improve survival. It may also increase rebleeding. Overall, performing endoscopy within 24 hours provides the best balance of safety and efficiency and should be considered the preferred standard of care, with urgent procedures reserved for selected high-risk patients.