Repeat Endoscopy Is Best, Most Cost-Effective Way to Treat Repeat Upper GI Bleed

The standard of care to stop an initial non-variceal upper gastrointestinal bleed is to treat it through an endoscopy. If the patient then rebleeds, most physicians will perform an angiographic embolization to try to achieve hemostasis, rather than repeating the endoscopy that did not work the first time.

But, Cleveland Clinic researchers have found that not only does repeating an endoscopy have better outcomes for patients, it’s also more cost effective — a benefit for the patient and healthcare system, alike. In fact, it is estimated that non-variceal upper GI bleeding — often from peptic ulcers – exceeds more than $2 billion annually in national healthcare costs.

Gastroenterologist Sunguk Jang, MD, presented these findings today as one of 10 Presidential Plenary sessions at the American College of Gastroenterology’s Annual Scientific Meeting in Honolulu.

Challenging the gold standard

“GI bleeding remains a significant risk to patients,” says Dr. Jang. “More often than not, if a patient rebleeds after initial hemostasis was successful, we end up referring him or her to interventional radiology to provide a different method of treatment. We wanted to see if patients would actually fare better with repeating the endoscopy.”

And, that can be a significant number of patients. Dr. Jang says up to 30 percent of patients can rebleed during the same hospitalization despite successful initial hemostasis.

Surprising results

Dr. Jang and his team conducted a retrospective study looking at 107 patients from January 2008 to November 2011 who experienced a repeat non-variceal upper GI bleed within 30 days of achieving hemostasis with an initial endoscopy. Of those, 43 had an angiographic procedure performed to stop the rebleed.

“What we found is surprising and clinically significant — in terms of both outcome and cost effectiveness,” he explains.

The researchers discovered that upper endoscopy (EGD) is 3.5 times as likely to achieve sustained hemostasis during the first recurrent event when compared with angiography/surgery. Furthermore, given much higher success rate of hemostasis with repeat EGD over other modalities, repeat endoscopy was shown to be much more cost effective than angiographic embolization. This included a substantial reduction in procedural and technical costs based on the higher success rate of sustained hemostasis as well as shorter stays in the intensive care unit.

Additional study needed

While the findings are clinically significant, Dr. Jang says he would like to validate them through a prospective study. In addition, he would like to see his findings validated internally by prospective studies, as well as externally.

Ultimately, Dr. Jang says the results could impact treatment for patients with repeat non-variceal upper GI bleeding, leading to better patient outcomes and cost containment.

“To my knowledge, this has not been looked at before,” says Dr. Jang. “Once this study is validated, this can be translated into the management of patients nationally.”

For more information, please contact Dr. Jang at jangs@ccf.org.