Overlooked lesions at emergency endoscopy for acute nonvariceal upper gastrointestinal bleeding

Background and Study Aims: Excessive blood covering the examination field is a frequent cause of diagnostic failure in emergency endoscopy for acute upper gastrointestinal bleeding. The implications and outcome in these patients have not been well described. Patients and Methods: The records for 1459 consecutive patients who presented at our medical center with acute nonvariceal upper gastrointestinal bleeding during a 15-month period were reviewed. All of the patients underwent emergency endoscopy within 24 h of initial presentation. Patients in whom an identifiable bleeding source was not found in spite of an overtly bloody lumen were designated as having a failure of diagnosis, and these cases were analyzed further. Results: Diagnosis failed in 25 patients (1.7%),16 of whom underwent repeat endoscopy or surgical intervention. Bleeding vessels were identified in 13 of these patients. Gastric and duodenal ulcers were the most commonly overlooked lesions, with locations in the cardia (n = 3), fundus (n = 2), posterior wall of the antrum (n = 1), duodenal bulb (n = 3), second part of the duodenum (n = 2), and in the stoma of a Billroth It gastrectomy (n = 2). The rates for endoscopic complications, recurrent bleeding, surgery, and mortality were significantly higher in the group with diagnostic failure than in patients with acute upper gastrointestinal bleeding in whom diagnosis did not fail (8% vs. 0.4%; 20% vs. 3.1%; 16% vs. 2.9%; and 20% vs. 3.6%, respectively). Conclusions: In acute nonvariceal upper gastrointestinal bleeding, diagnostic failure is associated with higher morbidity and mortality. The data from this study emphasize the importance of good preparation before the procedure and adequate removal of blood during emergency endoscopy procedures.