Only two of the six randomized studies were positive: 1) a seven-year-old abstract, still not published in full and 2) a study of 40 extremely high risk patients, mostly active bleeders with a high unexplained delayed bleeding rate. The Marmo meta-analysis may have been flawed, was heavily influenced by the one small positive study in highly selected patients and yet still showed only a very small benefit. It is unclear if patients presenting with active bleeding, or having other comorbid conditions that are associated with higher than usual rebleeding or mortality rates, might benefit from a second look. It is certainly difficult to widely apply the results of this small positive study when Saeed himself wrote an editorial accompanying Messmanns et al’s study entitled “Second thoughts about second look endoscopy for ulcer bleeding?”.
It is clear that further research is needed, including a priori stratified blocking by rebleeding risk, the coadministration of combination endoscopic therapy and high dose intravenous proton pump inhibitor therapy. Such a study might never be undertaken because of the very small reduction of absolute risk, resulting in the requirement for a very large sample size. In the meantime, the currently available evidence does not support the routine use of second look endoscopy for nonvariceal upper gastrointestinal bleeding.