Is ultra-early endoscopy always beneficial? A systematic review and meta-analysis of timing-dependent outcomes in nonvariceal upper gastrointestinal bleeding.

BACKGROUND: Nonvariceal upper gastrointestinal bleeding (NVUGIB) is a common emergency with substantial morbidity and mortality. Guidelines recommend endoscopy within 24 hours, but the benefit of ultra-early endoscopy (≤6 hours) remains unclear, particularly in high-risk patients. This study aimed to systematically evaluate whether ultra-early endoscopy (≤6 hours) improves clinical outcomes compared with early endoscopy (>6 hours) in adult patients with nonvariceal upper gastrointestinal bleeding, including mortality, rebleeding, healthcare utilization, and outcomes in high-risk subgroups. METHODS: A systematic review and meta-analysis of studies comparing ultra-early and early endoscopy in adults with NVUGIB was conducted. The PubMed, Embase, and Web of Science databases were searched up to January 2026 for relevant studies. Ultra-early endoscopy was defined as endoscopy performed within 6 hours of presentation, admission, or clinical diagnosis, and high-risk patients were defined according to study-level criteria, most commonly a Glasgow-Blatchford score >12 or Rockall Score >5. Pooled odds ratios (ORs) or mean differences (MDs) with 95% confidence intervals (CIs) were calculated using random-effects models, and prespecified subgroup and sensitivity analyses were used to assess the robustness of the findings. RESULTS: Nine studies, comprising 10,785 patients (2,638 ultra-early, 8,147 early), were included in the meta-analysis, and their data analyzed. The findings suggest that ultra-early endoscopy did not significantly reduce mortality (OR 0.88, 95% CI [0.58-1.34]) or rebleeding (OR 1.23, 95% CI [0.90-1.67]), nor affect transfusion, surgical intervention, repeat endoscopy, or the length of hospital stay of the patients. However, intensive care unit (ICU) admission was more frequent in the ultra-early group (OR 1.41, 95% CI [1.20-1.66]). These findings were also consistent for patients in high-risk subgroups. CONCLUSION: Among adults with NVUGIB, ultra-early endoscopy provides no clear advantage over early endoscopy in terms of the key clinical outcomes, although the rate of ICU admission is higher. This suggests that management should focus on providing adequate resuscitation and timely endoscopy within an appropriate therapeutic window. Further prospective studies are warranted to evaluate the potential benefit of ultra-early endoscopy in selected high-risk patients.