Routine second look endoscopy: Ineffective, costly and potentially misleading (Part 1)

endoscopic treatmentDespite advances in the endoscopic treatment of bleeding peptic ulcer disease, there remains a significant rebleeding rate of 10% to 20% . Adjuvant intravenous proton pump inhibitor therapy has been proven to reduce the rebleeding rate when used with successful endoscopic hemostasis . Endoscopic hemoclip application also appears to be effective in selected cases. Certainly more controversial, however, is the question of whether a routine second look endoscopy in those patients with high risk lesions, with or without additional endoscopic therapy, would further reduce that rebleeding rate.

Routine second look endoscopy is defined as an endoscopy that is performed 24 h to 48 h after the initial procedure in patients with bleeding peptic ulcer disease and initially high risk stigmata but without evidence of rebleeding, with the intention of either retreating persistent high risk stigmata or, in their absence, of considering early discharge. This does not include repeat endoscopy for other specific reasons such as: clinical signs of rebleeding; inadequate visualization at the first endoscopy (eg, a fundic blood pool); re-evaluation of a gastric ulcer to rule out malignancy or confirm healing; or to take biopsies for Helicobacter pylori.

Why consider a routine second look?

The rationale for second endoscopy for patients with bleeding peptic ulcer disease includes several issues:

•    There is a residual rebleeding rate after medical and endoscopic therapy ;

•    The natural history of high risk stigmata is variable in that some disappear very quickly whereas others persist for days ;

•    Several clinical trials have used this procedure as part of their protocol for assessing effectiveness of the initial endoscopic treatment ; and

•    A second trial of endoscopic therapy is worthwhile in cases of clinical rebleeding.