Timing of endoscopy for acute variceal bleeding in patients with cirrhosis (CHESS1905): A nationwide cohort study
Authors: Zhang Wenhui , Huang Yifei , Xiang Huiling , Zhang LiYao , Yuan Lili , Wang Xing , Dang Tong , Zhang Guo , Hu Shengjuan , Liu Chuan , Zhang Xiuping , Peng Lijun , Gao Min , Xia Dongli , Li Jia , Song Ying , Zhou Xiqiao , Qi Xingsi , Zeng Jing , Tan Xiaoyan , Deng Mingming , Fang Haiming , Qi Shenglin , He Song , He Yongfeng , Ye Bin , Wu Wei , Shao Jiangbo , Wei Wei , Hu Jianping , Yong Xin , He Chaohui , Bao Jinlun , Zhang Yuening , Ji Rui , Bo Yang , Yan Wei , Li Hongjiang , Wang Yong , Wang Yanling , Li Mengmeng , Lian Jia , Liu Chang’en , Wu Yunhai , Gu Ye , Wang Yan , Cao Ping , Wu Bin , Ren Limei , Pan Hongduo , Liang Yunxiao , Tian Shuni , Lu Lin , Fang Yanfei , Jiang Pan , Liu Zhenbei , Liu Aimin , Zhao Lili , Li Shuang , Qiao Jinggui , Sun Lihui , Li Mengyu , Fang Chengwen , Chen Hao , Tian Zibin , Lin Gaoyang , Huang Xuanhui , Chen Jitao , Deng Ying , Lv Muhan , Liao Jingyuan , Zhang Lijiu , Lu Junyu , Wu Suhua , Yang Xiaocui , Guo Wenwei , Wang Jianbo , Chen Chao , Huang Erjiong , Yu Yuehua , Yang Ming , Cheng Shuangping , Yang Yang , Wu Xiaoli , Rang Limaocai , Han Ping , Zhang Yanmin , Li Xiaoguo , Wang Fengmei , McAlindon Mark Edward , Seto Wai-Kay , Lv Chuanzhu , Rockey Don C. , Qi Xiaolong 
Published: May 2023

Background:
Endoscopy plays an important role in the management of acute variceal bleeding (AVB) in patients with cirrhosis. This study aimed at determining the optimal endoscopy timing for cirrhotic AVB.

Methods:
Patients with cirrhosis with AVB across 34 university hospitals in 30 cities from February 2013 to May 2020 who underwent endoscopy within 24 hours were included in this study. Patients were divided into an urgent endoscopy group (endoscopy <6 h after admission) and an early endoscopy group (endoscopy 6–24 h after admission). Multivariable analysis was performed to identify risk factors for treatment failure. Primary outcome was the incidence of 5-day treatment failure. Secondary outcomes included in-hospital mortality, need for intensive care unit, and length of hospital stay. A propensity score matching analysis was performed. In addition, we performed an analysis, in which we compared the 5-day treatment failure incidence and the in-hospital mortality among patients with endoscopy performed at <12 hours and 12–24 hours.

Results:
A total of 3319 patients were enrolled: 2383 in the urgent endoscopy group and 936 in the early endoscopy group. After propensity score matching, on multivariable analysis, Child-Pugh class was identified as an independent risk factor for 5-day treatment failure (HR, 1.61; 95% CI: 1.09–2.37). The incidence of 5-day treatment failure was 3.0% in the urgent endoscopy group and 2.9% in the early group (p = 0.90). The in-hospital mortality was 1.9% in the urgent endoscopy group and 1.2% in the early endoscopy group (p = 0.26). The incidence of need for intensive care unit was 18.2% in the urgent endoscopy group and 21.4% in the early endoscopy group (p = 0.11). The mean length of hospital stay was 17.9 days in the urgent endoscopy group and 12.9 days in the early endoscopy group (p < 0.05). The incidence of 5-day treatment failure in the <12-hour group was 2.3% and 2.2% in the 12–24 hours group (p = 0.85). The in-hospital mortality was 2.2% in the <12-hour group and 0.5% in the 12–24 hours group (p < 0.05).

Conclusions:
The data suggest that performance of endoscopy within 6–12 or within 24 hours of presentation among patients with cirrhosis with AVB led to similar treatment failure outcomes.