Gastrointestinal bleeding: a peep into the future with stiffness, sprays, and sensors

Erythromycin infusion or gastric lavage for upper gastrointestinal bleeding: a multicenter randomized controlled trial (Pateron et al., Ann Emerg Med 2011 [1])

Gastrointestinal bleeding is a challenging emergency for the endoscopist. The improvement in endoscopic diagnosis and hemostatic techniques has radically changed the management of gastrointestinal bleeding from the administration of “tons” of antacids and emergency surgery to aggressive antisecretory therapy and application of various endoscopic injection, thermal, and mechanical hemostatic methods that reduce the need for emergency surgery. However, the efficacy of the endoscopic treatments depends upon adequate and good visualization of the lumen of the gastrointestinal tract. Nasogastrointestinal tube (NGT) insertion and gastric lavage prior to endoscopy have been shown to be safe and effective in providing better visualization of the stomach [2]. Similarly, erythromycin, a motilin receptor agonist that enhances gastric emptying by inducing antral contractions, has been shown to be more effective than placebo in providing better visualization during endoscopy [3] [4].

In this prospective, randomized, multicenter study by Pateron et al. in patients with acute upper gastrointestinal bleeding, the authors compared the frequency of satisfactory visualization of the stomach on endoscopy after administration of: i) intravenous erythromycin; ii) gastric lavage after insertion of an NGT; or iii) a combination of both modalities (NGT – erythromycin). A total of 253 patients (181 males; mean age 61 years; 84 [33 %] with cirrhosis) were randomized into three parallel groups: (i) erythromycin group (n = 84), in which patients received intravenous infusion of erythromycin (250 mg over 20 minutes) and underwent endoscopy 30 minutes after the end of the infusion; (ii) NGT group (n = 85), in which a 16 – to 20-Fr NGT was inserted and gastric lavage was performed with 500 mL of room temperature water, repeated hourly until the aspirated gastric fluid was clear, and with endoscopy performed 15 minutes after the last lavage; and (iii) NGT – erythromycin group (n = 84), in which the NGT placement and gastric lavage was done as in the NGT group followed by erythromycin infusion as in the erythromycin group. In the erythromycin group, an electrocardiogram (ECG) was performed to ensure that the QTc interval was less than 0.45 seconds, and it was ensured that there were no known allergies or any drug interaction with erythromycin. Following this, endoscopy was performed and quality of visualization of the stomach was scored by an endoscopist who was blinded to the group of patients.

In 85 % of patients there was satisfactory visualization of the stomach on endoscopy, with no significant difference between the three groups (84 %, 82 %, and 88 % for erythromycin, NGT, and NGT – erythromycin groups, respectively). The percentage of patients in whom visualization of the stomach was satisfactory did not differ between the groups in patients who had cirrhosis or who were admitted to the intensive care unit. However, the percentage of transfused patients with satisfactory visualization of the stomach was significantly higher in the combination group compared with the NGT group (93 % vs. 77 %; P = 0.021), whereas there was no significant difference between the NGT and erythromycin groups or between NGT – erythromycin and erythromycin groups. Also, the mean duration of the endoscopic procedure, the need for hemostasis, the ability to identify the source of bleeding, and the need for a second endoscopy did not differ significantly between the three groups. The mean visual analog scale score for pain after NGT placement was 42 and this score exceeded 60, indicative of severe pain, in 28 % of patients in the NGT group and 24 % in the combination group. 

This study has demonstrated that visualization of the gastrointestinal tract by endoscopy in patients with acute upper gastrointestinal bleeding is not influenced by the method of preparation and that the addition of NGT to intravenous erythromycin has no additional benefit and also increases patient discomfort. Thus, this head-to-head comparative study emphasizes that erythromycin infusion alone might be a good substitute for gastric lavage before endoscopy in patients with upper gastrointestinal bleeding.

Previous studies comparing erythromycin with placebo also demonstrated that erythromycin markedly increases the proportion of satisfactory visualization of the stomach during endoscopy for upper gastrointestinal bleeding [3] [4]. This beneficial effect of erythromycin is not limited to patients with nonvariceal bleeding. A recent randomized, double-blind, placebo-controlled trial in 102 patients also showed that 125 mg of erythromycin significantly improves endoscopic visibility and shortens the duration of the procedure [5]. These authors reported that control of bleeding by endoscopic band ligation was possible in a significantly larger number of patients in the erythromycin group than in the placebo group (70.2 % vs. 48.8 %; P < 0.04), as an empty stomach without reflux of blood into the esophagus gave a better view of the esophageal varices.

These studies demonstrate that a single intravenous erythromycin infusion alone offers good visualization during endoscopy in patients with upper gastrointestinal bleeding, whether it be variceal or nonvariceal, thus avoiding the need for placement of an NGT and lavage.

• References

• 1 Pateron D, Vicaut E, Debuc E et al. Erythromycin infusion or gastric lavage for upper gastrointestinal bleeding: a multicenter randomized controlled trial. Ann Emerg Med 2011; 57: 582-589
• 2 Lee SD, Kearney DJ. A randomized controlled trial of gastric lavage prior to endoscopy for acute upper gastrointestinal bleeding. J Clin Gastroenterol 2004; 38: 861-865
• 3 Frossard JL, Spahr L, Queneau PE et al. Erythromycin intravenous bolus infusion in acute upper gastrointestinal bleeding: a randomized, controlled, double-blind trial. Gastroenterology 2002; 123: 17-23
• 4 Carbonell N, Pauwels A, Serfaty L et al. Erythromycin infusion prior to endoscopy for acute upper gastrointestinal bleeding: a randomized, controlled, double-blind trial. Am J Gastroenterol 2006; 101: 1211-1215
• 5 Altraif I, Handoo FA, Aljumah A et al. Effect of erythromycin before endoscopy in patients presenting with variceal bleeding: a prospective, randomized, double-blind, placebo-controlled trial. Gastrointest Endosc 2011; 73: 245-250
• 6 Sung JJY, Luo D, Wu JCY et al. Early clinical experience of the safety and effectiveness of Hemospray in achieving hemostasis in patients with acute peptic ulcer bleeding. Endoscopy 2011; 43: 290-294
• 7 Kurt M, Kacar S, Onal IK et al. Ankaferd Blood Stopper as an effective adjunctive hemostatic agent for the management of life-threatening arterial bleeding of the digestive tract. Endoscopy 2008; 40 (Suppl. 02) E262
• 8 Giday SA, Kim Y, Krishnamurty DM et al. Long-term randomized controlled trial of a novel nanopowder hemostatic agent (TC-325) for control of severe arterial upper gastrointestinal bleeding in a porcine model. Endoscopy 2011; 43: 295-208
• 9 Weusten B, Bergman JJ. A hemostatic spray: the easy way out for upper gastrointestinal bleeding?. Endoscopy 2011; 43: 343-344
• 10 Agrawal JR, Travis AC, Mortele KJ et al. Diagnostic yield of dual-phase CT enterography in patients with obscure gastrointestinal bleeding and a non diagnostic capsule endoscopy. J Gastroenterol Hepatol In press 2012. DOI: 10.1111/J.1440–1746.2011.06959
• 11 Rana SS, Bhasin DK. Gastrointestinal bleeding: capsules, balloons, and spirals!. Endoscopy 2010; 42: 53-57
• 12 Khalife S, Soyer P, Alatawi A et al. Obscure gastrointestinal bleeding: preliminary comparison of 64-section CT enteroclysis with video capsule endoscopy. Eur Radiol 2011; 21: 79-86
• 13 Huprich JE, Fletcher JG, Fidler JL et al. Prospective blinded comparison of wireless capsule endoscopy and multiphase CT enterography in obscure gastrointestinal bleeding. Radiology 2011; 260: 744-751
• 14 Zhang BL, Jiang LL, Chen CX et al. Diagnosis of obscure gastrointestinal hemorrhage with capsule endoscopy in combination with multiple-detector computed tomography. J Gastroenterol Hepatol 2010; 25: 75-79
• 15 Ryou M, Nemiroski A, Azagury D et al. An implantable wireless biosensor for the immediate detection of upper GI bleeding: a new fluorescein-based tool for diagnosis and surveillance (with video). Gastrointest Endosc 2011; 74: 189-194 e1
• 16 Kim BK, do Kim Y, Han KH et al. Risk assessment of esophageal variceal bleeding in B-viral liver cirrhosis by a liver stiffness measurement-based model. Am J Gastroenterol 2011; 106: 1654-1662
• 17 Vizzutti F, Arena U, Romanelli RG et al. Liver stiffness measurement predicts severe portal hypertension in patients with HCV-related cirrhosis. Hepatology 2007; 45: 1290-1297
• 18 Pritchett S, Cardenas A, Manning D et al. The optimal cut-off for predicting large oesophageal varices using transient elastography is disease specific. J Viral Hepat 2011; 18: e75-80
• 19 Kim BK, Han KH, Park JY et al. A liver stiffness measurement-based, noninvasive prediction model for high-risk esophageal varices in B-viral liver cirrhosis. Am J Gastroenterol 2010; 105: 1382-1390
• 20 Hirooka M, Koizumi Y, Hiasa Y et al. Hepatic elasticity in patients with ascites: evaluation with real-time tissue elastography. Am J Roentgenol 2011; 196: W766-771