***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: BACKGROUND  Urgent endoscopy in patients with acute upper-GI bleeding identifies many patients who may be safely treated without hospitalization . The aim of this multicenter trial was to determine whether urgent endoscopy effectively decreases health care re source utilization in a real-life setting where primary care providers determine the course of care . METHODS Ninety-three out patients with acute upper-GI bleeding were r and omized to either urgent endoscopy ( before hospitalization ) or elective endoscopy after admission . The results of urgent endoscopy and a recommendation regarding patient disposition were provided to the attending physician . Medical outcomes and re source utilization were measured . RESULTS The timing of endoscopy did not affect re source utilization or patient outcomes . Length of stay was similar ( urgent endoscopy , OR 3.98 days : 95 % CI[2.84 , 5.11 ] vs. elective endoscopy , OR 3.26 days : 95 % CI[2.32 , 4.21 ] , p=0.45 ) . The mean number of days in an intensive care unit was the same ( 1.2 days ) . The urgent endoscopy group had more high-risk endoscopic lesions ( 15 vs. 9 ; p=0.031 ) . Outpatient care was recommended for 19 patients ( 40 % ) . Only 4 patients were discharged . CONCLUSIONS Urgent endoscopy did not reduce hospitalization or re source utilization because the results of early endoscopy did not impact the decision by attending physicians regarding admission . For early ( triage ) endoscopy to impact re source utilization , the results of endoscopy must change subsequent patient care DESCRIPTION A multidisciplinary group of 34 experts from 15 countries developed this up date and expansion of the recommendations on the management of acute nonvariceal upper gastrointestinal bleeding ( UGIB ) from 2003 . METHODS The Appraisal of Guidelines for Research and Evaluation ( AGREE ) process and independent ethics protocol s were used . Sources of data included original and published systematic review s ; r and omized , controlled trials ; and abstract s up to October 2008 . Quality of evidence and strength of recommendations have been rated by using the Grading of Recommendations Assessment , Development , and Evaluation ( GRADE ) criteria . RECOMMENDATIONS Recommendations emphasize early risk stratification , by using vali date d prognostic scales , and early endoscopy ( within 24 hours ) . Endoscopic hemostasis remains indicated for high-risk lesions , whereas data support attempts to dislodge clots with hemostatic , pharmacologic , or combination treatment of the underlying stigmata . Clips or thermocoagulation , alone or with epinephrine injection , are effective methods ; epinephrine injection alone is not recommended . Second-look endoscopy may be useful in selected high-risk patients but is not routinely recommended . Preendoscopy proton-pump inhibitor ( PPI ) therapy may downstage the lesion ; intravenous high-dose PPI therapy after successful endoscopic hemostasis decreases both rebleeding and mortality in patients with high-risk stigmata . Although selected patients can be discharged promptly after endoscopy , high-risk patients should be hospitalized for at least 72 hours after endoscopic hemostasis . For patients with UGIB who require a nonsteroidal anti-inflammatory drug , a PPI with a cyclooxygenase-2 inhibitor is preferred to reduce rebleeding .  Patients with UGIB who require secondary cardiovascular prophylaxis should start receiving acetylsalicylic acid ( ASA ) again as soon as cardiovascular risks outweigh gastrointestinal risks ( usually within 7 days ) ; ASA plus PPI therapy is preferred over clopidogrel alone to reduce rebleeding BACKGROUND AND STUDY AIMS Despite the established efficacy of therapeutic endoscopy , the optimum timeframe for performing endoscopy in patients with nonvariceal upper gastrointestinal bleeding ( NVUGIB ) remains unclear . The aim of the current audit study was to examine the relationship between time to endoscopy and clinical outcomes in patients presenting with NVUGIB . PATIENTS AND METHODS This study was a prospect i ve national audit performed in 212 UK hospitals . Regression models examined the relationship between time to  endoscopy and mortality , rebleeding , need for surgery , and length of hospital stay . RESULTS In 4478 patients , earlier endoscopy ( < 12 hours ) was not associated with a lower mortality or need for surgery compared with later ( > 24 hours ) endoscopy ( odds ratio [ OR ] for mortality 0.98 , 95 % confidence interval [ CI ] 0.88 - 1.09 for endoscopy > 24 hours vs. < 12 hours ; P = 0.70 ) . In patients receiving therapeutic endoscopy  , there was a nonsignificant trend towards an increase in rebleeding associated with later endoscopy ( OR 1.13 , 95 % CI 0.97 - 1.32 for endoscopy > 24 hours vs. < 12 hours ) , with the converse seen in patients not requiring therapeutic endoscopy ( OR 0.83 , 95 % CI 0.73 - 0.95 for endoscopy > 24 hours vs. < 12 hours ; interaction P = 0.003 ) . Later endoscopy ( > 24 hours ) was associated with an increase in risk-adjusted length of hospital stay ( 1.7 days longer , 95 % CI 1.39 - 1.99 vs. < 12 hours ; P < 0.001 ) . CONCLUSIONS Earlier endoscopy was not associated with a reduction in mortality or need for surgery . However , it was associated with an increased efficiency of care and potentially improved control of hemorrhage in higher risk patients , supporting the routine use of early endoscopy unless specific contraindications exist . These results may help inform the debate about emergency endoscopy service provision The benefit of early endoscopy in the management of peptic ulcer bleeding remains controversial . In this study we looked at the role of early endoscopy in bleeding peptic ulcer patients with clear , " coffee grounds , " or bloody nasogastric aspirate . A consecutive series of 325 patients with peptic ulcer bleeding were included ( 218 patients with clear aspirate , 77 patients with coffee-grounds aspirate , and 30 patients with bloody aspirate ) . They were r and omized to receive early endoscopy ( within 12 h of arrival at the emergency room ) or delayed endoscopy ( 12 h after arrival at the emergency room ) . Early endoscopy did not benefit patients with clear or coffee-grounds aspirate . However , combined with endoscopic therapy , it did significantly benefit patients with bloody aspirate in reducing the need for blood transfusion ( mean , 450 ml vs. 666 ml ; p < 0.001 ) and hospital stay ( mean , 4 vs. 14.5 days , p < 0.001 ) .  Early endoscopy and endoscopic therapy  are not needed in bleeding peptic ulcer patients with clear or coffee-grounds nasogastric aspirate . However , early endoscopy and endoscopic therapy  benefit patients with bloody nasogastric aspirate BACKGROUND AND STUDY AIMS The role of urgent endoscopy in high-risk nonvariceal upper gastrointestinal bleeding ( NVUGIB ) is unclear . The aim of this study was to determine whether esophagogastroduodenoscopy ( EGD ) performed sooner than the currently recommended 24 h in high-risk patients presenting with NVUGIB is associated with lower all-cause in-hospital mortality . METHODS All adult patients undergoing EGD for the indications of coffee-grounds vomitus , hematemesis or melena at a university hospital over an 18-month period were enrolled . Patients with variceal and lower gastrointestinal bleeding were excluded . Data were prospect ively collected . RESULTS A total of 934 patients were included . The area under the receiver operating characteristic curve ( AUROC ) for the Glasgow-Blatchford score ( GBS ) was 0.813 for predicting all-cause in-hospital mortality , with a cut-off score of ≥ 12 result ing in 90 % specificity . In low-risk patients with GBS < 12 , presentation-to-endoscopy time in those who died and in those who survived was similar . In high-risk patients with GBS of ≥ 12 , presentation-to-endoscopy time was significantly longer in those who died than in those who survived . Multivariate analysis of the high-risk cohort showed presentation-to-endoscopy time to be the only factor associated with all-cause in-hospital mortality . For high-risk patients , the AUROC for presentation-to-endoscopy time in predicting all-cause in-hospital mortality was 0.803 , with a sensitivity of 100 % at the cut-off time of 13 h. All-cause in-hospital mortality in high-risk patients was significantly higher in those with presentation-to-endoscopy time of > 13 h compared with those undergoing endoscopy in < 13 h from presentation ( 44 % vs. 0 % ; P < 0.001 ) . CONCLUSIONS Endoscopy within 13 h of presentation was associated with lower mortality in high-risk but not low-risk NVUGIB 
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The authors of the review concluded , based on observational and prospect i ve uncontrolled trials , that in high risk patients ( a definition that also varied across studies ) rebleeding and surgical rates were improved when early endoscopy was provided but no change to mortality was observed .
Even though no effect was observed in the mortality or surgery rate , earlier endoscopy did increase the efficiency of care : a substantial reduction in risk-adjusted length of hospital stay and potentially improved control of hemorrhage in higher risk patients were observed , which may support the routine use of early endoscopy with potential savings .
This supports previous reports that in all risk groups early endoscopy significantly reduces the length of hospital stay [ 7 ] .
It was also noted that early endoscopy ( sooner than 24 hours ) was effective , but in high-risk patients ( those who will need endoscopic therapy ) , an even earlier endoscopy seems to be beneficial in terms of rebleeding .