Routine second look endoscopy: Ineffective, costly and potentially misleading (Part 2)
Yang et al studied the natural history of high risk stigmata in 34 patients with or without injection therapy. They found that, within three or four days, more than one-half of the visible vessels had converted to flat spots or clean-based ulcers, and 90% of all high risk lesions were gone by six days. The only type of lesion that appeared to respond to endoscopic injection therapy was the visible vessel, for which progression to a lower risk lesion was accelerated by approximately half a day. Similarly, almost all adherent clots were gone by three or four days. Because this study found that a small percentage of patients still harboured high risk stigmata at the time of planned discharge (72 h), it appears reasonable to at least consider a predischarge endoscopy.
Nonrandomized trials in this area are difficult to interpret for a few reasons. First, the residual rebleeding rate varies with the baseline clinical and endoscopic factors and the type of medical and endoscopic therapy applied. Therefore, it is difficult to confirm a reduction in this rate compared with a nonrandom or historical control group. Second, patients who undergo repeat endoscopic therapy are often those whom one is most worried about at the initial endoscopy, and have a higher residual rebleeding rate.