Gastrointestinal bleeding: a peep into the future with stiffness, sprays, and sensors
21 March 2012 (online)
Erythromycin infusion or gastric lavage for upper gastrointestinal bleeding: a multicenter randomized controlled trial (Pateron et al., Ann Emerg Med 2011 )
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 . 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  .
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  . 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 . 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.
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