The optimal timing for endoscopy in cirrhotic patients with EVB has been a longstanding subject of debate. While most guidelines have suggested performing endoscopy within 12 h since arrival at the hospital [5, 6, 7, 8], there remains a lack of robust clinical evidence to firmly support this recommendation. Furthermore, these guidelines seem to rely more on “expert opinion” rather than solid clinical data. Here, our data did not support the above recommendation and found no significant benefit of early endoscopy (< 12 h) on the outcomes of cirrhotic patients with EVB. Specifically, we concluded that the endoscopy timing did not correlate with short-term outcomes regarding 5-day treatment failure, in-hospital mortality, need for ICU, total blood units transfused, hemoglobin decrease requiring transfusion, and hospital duration in these patients.
In this study, the baseline characteristics of all eligible patients showed some variation due to the complexity of real-world clinical settings, posing challenges for further analysis. To correct this imbalance, we applied propensity score matching (PSM) using a 1:1 nearest-neighbour method to pair patients from the two distinct endoscopy groups. After matching, no substantial differences were found in the baseline characteristics between the 90 matched pairs of patients. Despite this, we also observed no significant correlation between the timing of endoscopy (before or after 12 h) and the clinical outcomes of patients with EVB.
Aside from the ongoing debate regarding selecting the timing of endoscopy in acute variceal bleeding, the definition of endoscopy time is also heterogeneous across different studies and guidelines. This inconsistency underscores the challenges in assessing the effectiveness of endoscopic procedures. While some studies classify endoscopy performed within 12 h of admission as urgent and after 12 h as non-urgent [13, 19, 20], others use terms like early endoscopy for procedures conducted within 12 h and delayed endoscopy for those performed after 12 h [2, 15, 16, 21]. Moreover, a study from China even considered procedures done within 6 h as urgent and those done between 6 and 24 h as early endoscopy [12]. Here, we followed the most common classification: endoscopy performed < 12 h as early and ≥ 12 h as delayed.
In our research, despite no significant differences, patients experiencing delayed endoscopy (≥ 12 h) appeared to have lower risks of treatment failure, in-hospital mortality, and ICU care than those with early endoscopy (< 12 h). This challenges the conventional belief that early endoscopy could improve outcomes by enabling faster hemostasis [22]. However, performing endoscopy too early may disrupt essential resuscitation efforts, increase the risk of ischemic complications, and shorten the action duration of vasoactive drugs or antibiotics before endoscopy [11, 23]. Moreover, patients who undergo early endoscopy tend to have more active bleeding, which means there is often a larger volume of blood and stomach contents present. This can obscure the source of bleeding and make it more difficult to obtain a clear view during the procedure, giving rise to technical challenges as well as complications such as aspiration or perforation [24], possibly resulting in worse outcomes. On the other hand, delayed endoscopy may be safer, providing a clearer visual field, especially after vasoactive drugs have had time to reduce portal pressure [13].
Although contrary to guideline recommendations, our data is consistent with recent cohort studies [11, 12, 13]. A recent retrospective study on 534 cirrhotic patients with acute variceal bleeding by Peng et al. also reported no significant association between the timing of endoscopy and clinical outcomes, when comparing treatment failure rates and in-hospital mortality between different endoscopy timing groups (before and after 12 h, before and after 24 h, before and after 48 h) [11]. Similarly, another multi-centre study with a larger patient population also yielded similar results, indicating that conducting endoscopy within 6–12 h or up to 24 h after presentation led to comparable outcomes in terms of treatment failure, death, and ICU care [12]. In a meta-analysis of 5 studies, Jung et al. [15] concluded that the timing of endoscopy (before and after 12 h) did not significantly impact mortality or rebleeding rates in cirrhotic patients with variceal bleeding. Therefore, selecting an appropriate time for endoscopy based on the patient’s condition is more important than performing an emergency endoscopy.
In Vietnam, there are currently no official guidelines as well as research on the optimal timing of endoscopy and this study represents the first attempt to bridge this gap. Clinical decisions regarding endoscopy timing are primarily guided by physician experience and recommendations from major gastroenterology societies. Although our facility is equipped with adequate resuscitation and intensive care resources, challenges remain when compared to healthcare systems in developed countries. Factors such as patient overload can impact the ability to provide optimal treatment and resuscitation care, potentially influencing clinical outcomes. This may explain why the overall treatment failure and in-hospital mortality rates in our data were higher than those reported in other studies [11, 12, 19]. By doing so, our findings contribute to the ongoing discussion on endoscopy timing, offering valuable perspectives tailored to Vietnam’s healthcare conditions. We hope this research will serve as a foundation for future guidelines, ultimately improving patient care and outcomes in this setting.
Variceal bleeding is a severe complication in cirrhotic patients with high mortality despite advances in treatment [25]. In our study, the in-hospital mortality rate reached 8.3%, emphasising the ongoing clinical challenge. Identifying predictors of mortality is crucial for early risk assessment, optimizing treatment strategies, and improving patient survival. Through logistic regression analysis, we identified three independent risk factors for in-hospital mortality. First, low systolic blood pressure (SBP) at admission was associated with an increased risk of in-hospital mortality in EVB patients (OR = 0.959, CI: 0.927–0.992), aligning with Chirapongsathorn et al. [26], who also found an inverse relationship between SBP and mortality risk. Low SBP may signal inadequate compensation for blood loss, increasing the risk of organ failure and mortality. Second, hepatorenal syndrome (HSR) not only has high morbidity and mortality rates but also significantly increases the burden on healthcare resources [27, 28]. In EVB, acute blood loss worsens renal perfusion, triggering HRS. Several studies have linked elevated serum creatinine levels with short-term mortality [29, 30], and our study also identified increased serum creatinine as an independent predictor of in-hospital mortality (OR = 1.026, CI: 1.004–1.047). Lastly, Child-Pugh type C was strongly associated with in-hospital mortality (OR = 7.516, CI: 1.538–36.721), consistent with prior studies [29, 31]. These findings emphasise the importance of Child-Pugh not only for risk stratification but also for guiding treatment strategies and enabling early and timely interventions. Unlike the Child-Pugh score, the MELD score did not show significant predictive value in in-hospital death through multivariate analysis. While both scores are widely recognized for predicting outcomes in cirrhotic patients [32, 33], the Child-Pugh score includes clinical parameters, which may provide a more comprehensive assessment of acute decompensation in patients with EVB. In contrast, the MELD score, which relies primarily on laboratory values, may not fully capture the complex clinical deterioration that occurs in this patient population.
In addition to the multivariate regression analysis, our comparison between survivors and non-survivors also revealed that non-survivors presented with worse hemodynamic and biochemical profiles. Specifically, higher heart rate, lower systolic blood pressure, elevated AST and creatinine levels, hyponatremia, and significantly higher severity scores (Child-Pugh, MELD, MELD-Na, and GBS) were all associated with in-hospital mortality. These findings are consistent with the logistic regression results and further emphasize the importance of early identification and aggressive management of high-risk patients with poor liver and kidney function. Recognizing these factors at admission may assist clinicians in prioritizing care and improving outcomes in patients with EVB.
We are aware of several limitations in our study. First, as a single-centre retrospective study, selection bias and incomplete treatment details may have influenced our findings. Although our findings revealed numerically higher rates of 5-day treatment failure, in-hospital mortality, and ICU admissions in the early endoscopy group, these differences did not reach statistical significance. However, this lack of significance may be partly attributed to the limited sample size, which might reduce the statistical power to detect clinically meaningful differences. Larger prospective or multi-centre studies are needed to provide a more comprehensive evaluation of endoscopy timing in cirrhotic patients with variceal bleeding. While a randomized controlled trial would offer the highest level of evidence, ethical concerns make it challenging to conduct, as delaying endoscopy in high-risk patients could compromise their outcomes. Additionally, we excluded patients with gastric variceal bleeding due to the unavailability of histoacryl injections at our hospital during the study period. This may affect the generalizability of our results compared to studies that included such cases. Finally, due to limitations in electronic medical records, our analysis was restricted to short-term outcomes in the two endoscopy groups. Long-term follow-up studies are essential for a more thorough assessment of treatment efficacy and a better comparison of outcomes across different endoscopy timing strategies.