Routine second look endoscopy: DISCUSSION

endoscopic hemoclippingIt is important to emphasize that 20% to 50% of rebleeding episodes occur in patients who are considered ‘low risk’, as determined by findings at the second endoscopy. Therefore, it may be dangerous to discharge a patient early, based on a favourable (according to the Forrest classification) endoscopic appearance. The rebleeding rate for a low risk lesion that is found one or two days after endoscopic therapy is likely to be much higher than that for the same lesion if found before therapy at the initial endoscopy.

A policy of routine second look endoscopy would lead to many unnecessary procedures that would be associated with significant excess costs and possibly additional complications, and the absence of any significant improvement in outcome. In addition, because many advances have been made since the most recent study was published in 1998, it is very difficult to apply the results to the current situation. For example, all of the studies were undertaken before intravenous proton pump inhibitors, combination endoscopic therapy or endoscopic hemoclipping were well studied. Because these adjuvant therapies reduce the residual rebleeding rate, the absolute benefit of a second look is likely now to be even smaller.