Erythromycin infusion prior to endoscopy for acute nonvariceal upper gastrointestinal bleeding: a pilot randomized controlled trial

CURRENT PHARMACOLOGICAL MANAGEMENT IN UPPER GASTROINTESTINAL BLEEDING

Upper gastrointestinal bleeding is a common reason for presentation to the hospital. Appropriate resuscitation followed by endoscopic assessment and endotherapy for high-risk lesions (active bleeding or non-bleeding with visible vessels) forms the cornerstone of management. Pharmacological therapies are utilised at each stage of management in both variceal and non-variceal bleeding. Proton pump inhibitors and prokinetic agents can be administered pre-endoscopically with vasoactive medication and antibiotics utilised in suspected variceal bleeding. Epinephrine may be used as a temporising measure to improve visualisation during endoscopy but should not applied as a single agent. Topical endoscopic therapies have also shown promise in achieving haemostasis. Following endoscopy, a high dose of proton pump inhibitor should be given to patients who require endotherapy and vasoactive medications, and antibiotics continued in confirmed variceal bleeds. The timing of resumption of antithrombotic medication is dependent on the agent utilised and underlying thrombotic risk.

Erythromycin Improves the Quality of Esophagogastroduodenoscopy in Upper Gastrointestinal Bleeding: A Network Meta-Analysis

BACKGROUND/AIM

Upper gastrointestinal bleeding (UGIB) usually requires esophagogastroduodenoscopy (EGD) for diagnostic and-potentially-therapeutic purposes. However, blood within the gastric lumen may hinder the procedure. Administration of prokinetics like erythromycin has shown efficacy. This network meta-analysis investigates the efficacy of this intervention prior to EGD.

METHODS

We performed a systematic literature search of Embase, PubMed/Medline, and other databases through March 8, 2022 to include randomized controlled trials (RCTs) comparing prokinetic use in EGD for UGIB. We used the DerSimonian-Laird approach to pool data and compare outcomes including need for repeat endoscopy and blood transfusion. Pooled prevalence of proportional outcomes, 95% confidence interval (CI), and p-values were calculated.

RESULTS

We included eight RCTs with four distinct intervention groups (erythromycin, placebo to erythromycin, nasogastric (NG) lavage and NG lavage + erythromycin) published between 2002 and 2020 with a total of 721 patients (mean age 60.0 ± 3.1 years; 73.2% male). The need for second look endoscopy was significantly lower with erythromycin than placebo (relative risk: 0.42, CI 0.22-0.83, p = 0.01). Using the frequentist approach, the combination of NG lavage and erythromycin (92.2) was rated highest, followed by erythromycin alone (73.1) for higher rates of empty stomach. Erythromycin was rated highest for lower need for packed red blood cell transfusion (72.8) as well as mean endoscopy duration (66.0).

CONCLUSION

Erythromycin improved visualization at EGD, reduced requirements for blood transfusion and repeat EGD, and shortened hospital stay. The combination of erythromycin and NG lavage showed reduced mortality.

Erythromycin prior to endoscopy for acute upper gastrointestinal haemorrhage

BACKGROUND

Upper endoscopy is the definitive treatment for upper gastrointestinal haemorrhage (UGIH). However, up to 13% of people who undergo upper endoscopy will have incomplete visualisation of the gastric mucosa at presentation. Erythromycin acts as a motilin receptor agonist in the upper gastrointestinal (GI) tract and increases gastric emptying, which may lead to better quality of visualisation and improved treatment effectiveness. However, there is uncertainty about the benefits and harms of erythromycin in UGIH.

OBJECTIVES

To evaluate the benefits and harms of erythromycin before endoscopy in adults with acute upper gastrointestinal haemorrhage, compared with any other treatment or no treatment/placebo.

SEARCH METHODS

We used standard, extensive Cochrane search methods. The latest search date was 15 October 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that investigated erythromycin before endoscopy compared to any other treatment or no treatment/placebo before endoscopy in adults with acute UGIH.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were 1. UGIH-related mortality and 2. serious adverse events. Our secondary outcomes were 1. all-cause mortality, 2. visualisation of gastric mucosa, 3. non-serious adverse events, 4. rebleeding, 5. blood transfusion, and 5. rescue invasive intervention. We used GRADE criteria to assess the certainty of the evidence for each outcome.  MAIN RESULTS: We included 11 RCTs with 878 participants. The mean age ranged from 53.13 years to 64.5 years, and most participants were men (72.3%). One RCT included only non-variceal haemorrhage, one included only variceal haemorrhage, and eight included both aetiologies. We defined short-term outcomes as those occurring within one week of initial endoscopy. Erythromycin versus placebo Three RCTs (255 participants) compared erythromycin with placebo. There were no UGIH-related deaths. The evidence is very uncertain about the short-term effects of erythromycin compared with placebo on serious adverse events (risk difference (RD) -0.01, 95% confidence interval (CI) -0.04 to 0.02; 3 studies, 255 participants; very low certainty), all-cause mortality (RD 0.00, 95% CI -0.03 to 0.03; 3 studies, 255 participants; very low certainty), non-serious adverse events (RD 0.01, 95% CI -0.03 to 0.05; 3 studies, 255 participants; very low certainty), and rebleeding (risk ratio (RR) 0.63, 95% CI 0.13 to 2.90; 2 studies, 195 participants; very low certainty). Erythromycin may improve gastric mucosa visualisation (mean difference (MD) 3.63 points on 16-point ordinal scale, 95% CI 2.20 to 5.05; higher MD means better visualisation; 2 studies, 195 participants; low certainty). Erythromycin may also result in a slight reduction in blood transfusion (MD -0.44 standard units of blood, 95% CI -0.86 to -0.01; 3 studies, 255 participants; low certainty). Erythromycin plus nasogastric tube lavage versus no intervention/placebo plus nasogastric tube lavage Six RCTs (408 participants) compared erythromycin plus nasogastric tube lavage with no intervention/placebo plus nasogastric tube lavage. There were no UGIH-related deaths and no serious adverse events. The evidence is very uncertain about the short-term effects of erythromycin plus nasogastric tube lavage compared with no intervention/placebo plus nasogastric tube lavage on all-cause mortality (RD -0.02, 95% CI -0.08 to 0.03; 3 studies, 238 participants; very low certainty), visualisation of the gastric mucosa (standardised mean difference (SMD) 0.48 points on 10-point ordinal scale, 95% CI 0.10 to 0.85; higher SMD means better visualisation; 3 studies, 170 participants; very low certainty), non-serious adverse events (RD 0.00, 95% CI -0.05 to 0.05; 6 studies, 408 participants; very low certainty), rebleeding (RR 1.13, 95% CI 0.63 to 2.02; 1 study, 169 participants; very low certainty), and blood transfusion (MD -1.85 standard units of blood, 95% CI -4.34 to 0.64; 3 studies, 180 participants; very low certainty). Erythromycin versus nasogastric tube lavage Four RCTs (287 participants) compared erythromycin with nasogastric tube lavage. There were no UGIH-related deaths and no serious adverse events. The evidence is very uncertain about the short-term effects of erythromycin compared with nasogastric tube lavage on all-cause mortality (RD 0.02, 95% CI -0.05 to 0.08; 3 studies, 213 participants; very low certainty), visualisation of the gastric mucosa (RR 1.19, 95% CI 0.79 to 1.79; 2 studies, 198 participants; very low certainty), non-serious adverse events (RD -0.10, 95% CI -0.34 to 0.13; 3 studies, 213 participants; very low certainty), rebleeding (RR 0.77, 95% CI 0.40 to 1.49; 1 study, 169 participants; very low certainty), and blood transfusion (median 2 standard units of blood, interquartile range 0 to 4 in both groups; 1 study, 169 participants; very low certainty). Erythromycin plus nasogastric tube lavage versus metoclopramide plus nasogastric tube lavage One RCT (30 participants) compared erythromycin plus nasogastric tube lavage with metoclopramide plus nasogastric tube lavage. The evidence is very uncertain about the effects of erythromycin plus nasogastric tube lavage on all the reported outcomes (serious adverse events, visualisation of gastric mucosa, non-serious adverse events, and blood transfusion).

AUTHORS' CONCLUSIONS

We are unsure if erythromycin before endoscopy in people with UGIH has any clinical benefits or harms. However, erythromycin compared with placebo may improve gastric mucosa visualisation and result in a slight reduction in blood transfusion.

ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding

We performed systematic reviews addressing predefined clinical questions to develop recommendations with the GRADE approach regarding management of patients with overt upper gastrointestinal bleeding. We suggest risk assessment in the emergency department to identify very-low-risk patients (e.g., Glasgow-Blatchford score = 0-1) who may be discharged with outpatient follow-up. For patients hospitalized with upper gastrointestinal bleeding, we suggest red blood cell transfusion at a threshold of 7 g/dL. Erythromycin infusion is suggested before endoscopy, and endoscopy is suggested within 24 hours after presentation. Endoscopic therapy is recommended for ulcers with active spurting or oozing and for nonbleeding visible vessels. Endoscopic therapy with bipolar electrocoagulation, heater probe, and absolute ethanol injection is recommended, and low- to very-low-quality evidence also supports clips, argon plasma coagulation, and soft monopolar electrocoagulation; hemostatic powder spray TC-325 is suggested for actively bleeding ulcers and over-the-scope clips for recurrent ulcer bleeding after previous successful hemostasis. After endoscopic hemostasis, high-dose proton pump inhibitor therapy is recommended continuously or intermittently for 3 days, followed by twice-daily oral proton pump inhibitor for the first 2 weeks of therapy after endoscopy. Repeat endoscopy is suggested for recurrent bleeding, and if endoscopic therapy fails, transcatheter embolization is suggested.

Oral Erythromycin Improves the Quality of Endoscopy in Upper Gastrointestinal Bleeding Patients

Background Upper gastrointestinal bleeding is a life-threatening emergency. Endoscopy is the therapeutic and diagnostic procedure of choice after initial stabilization of the patient. But the presence of retained blood, blood products, and other residual material in the stomach is a big challenge for endoscopists during urgent endoscopy after acute upper gastrointestinal bleeding. Intravenous erythromycin before endoscopy improves the visualization of gastric and duodenal mucosa in these patients. Use of oral erythromycin is more easy and convenient, so the objective of our study was to assess the effects of oral erythromycin on quality of endoscopy in upper gastrointestinal bleeding patients. Methods This interventional study was conducted at the Department of Medicine, POF Hospital Wah Cantt, Pakistan from January 2019 to December 2019. Patients with clinical evidence of acute upper gastrointestinal bleeding within 12 hours were inducted consecutively. Patients were randomly assigned to erythromycin (500 mg) suspension or placebo, orally three hours before endoscopy. One endoscopist performed all the procedures with the same double-channel video endoscope. The primary endpoint was endoscopic quality. The secondary endpoints were the need for second-look endoscopy within 48 hours, endoscopy related complications, therapeutic procedure performed or not during endoscopy, number of blood transfusions, and length of hospital stay. Results A total of 60 patients were included in the study; 30 received erythromycin and 30 received placebo. Out of these, 60% were male and 40% were female. The mean age was 53.68 ± 16.64. Quality of endoscopy was much better in the erythromycin group (83.3%) as compared to placebo (40%). Erythromycin did not shorten the endoscopic duration (15.53 vs. 14.33 minutes in the placebo group; p=0.216) and length of hospital stay (5.23 in erythromycin vs. 5.40 days in placebo group; p=0.807). Statistically no significant association was found between use of erythromycin and establishment of cause of bleed, need for second-look endoscopy, number of blood transfusions and number of endoscopic therapeutic procedures. Conclusion Erythromycin oral suspension before endoscopy in patients with acute upper gastrointestinal bleeding produced good quality of endoscopy in our study. It improved the visualization of gastric and duodenal mucosa significantly. However, it did not shorten the duration of endoscopy or hospital stay. There was no significant difference in number of second-look endoscopies and blood transfusions as well.

Outcomes of Upper Gastrointestinal Bleeding Based on Time to Endoscopy: A Retrospective Study

Introduction Non-variceal upper gastrointestinal bleeding (UGIB) is a major burden on the health care system. The timing of endoscopy has been an ongoing debate and data on the association of early endoscopy with a better or worse clinical outcome are conflicting. In our study, we aimed to identify the benefits versus the risks of performing an urgent endoscopy in regards to the number of endoscopic interventions, length of hospital stay, number of packed red blood cells (PRBCs) transfused, and mortality.  Methodology This is a retrospective record-based study. A total of 806 charts were reviewed and 251 patients with the signs and symptoms of UGIB on presentation were included in the study. Patients with variceal bleeding, lower gastrointestinal bleeding, insignificant bleeds with no drop in H/H, GI bleed not being the presenting complaint on admission, and patients on anticoagulation were excluded. Results Out of the patients who underwent an urgent esophagogastroduodenoscopy (EGD), 26.2% needed a second-look EGD 48 hours after the first EGD when compared to 4% and 2% in the early (12-24 hours) and late (>24 hours) endoscopy groups, respectively. In patients who underwent urgent EGD, 23% had active bleeding and it was statistically significant when compared to the other groups. The active bleeding limited the visualization during the endoscopy, which led to a repeat EGD in the urgent EGD group. If an endoscopic intervention was received, patients having EGD >24 hours received a smaller number of interventions. There was no statistical difference in the Blatchford scores between the three groups, indicating that the groups were similar in morbidity. No difference in mortality, hospital length of stay, or number of blood transfusions received, surgical or interventional radiology-guided interventions was found between the three groups. Conclusion Patients who underwent urgent endoscopy had more procedures, with no difference in mortality, number of units of blood transfused, or length of hospitalization when compared to the early or late endoscopy groups.

Role of endoscopy in acute gastrointestinal bleeding in real clinical practice: An evidence-based review

Although upper gastrointestinal bleeding is usually segregated from lower gastrointestinal bleeding, and guidelines for gastrointestinal bleeding are divided into two separate sections, they may not be distinguished from each other in clinical practice. Most patients are first observed with signs of bleeding such as hematemesis, melena, and hematochezia. When a patient with these symptoms presents to the emergency room, endoscopic diagnosis and treatment are considered together with appropriate initial resuscitation. Especially, in cases of variceal bleeding, it is important for the prognosis that the endoscopy is performed immediately after the patient stabilizes. In cases of suspected lower gastrointestinal bleeding, full colonoscopy after bowel preparation is effective in distinguishing the cause of the bleeding and treating with hemostasis. The therapeutic aspect of endoscopy, using the mechanical method alone or injection with a certain modality rather than injection alone, can increase the success rate of bleeding control. Therefore, it is important to consider the origin of bleeding and how to approach it. In this article, we aim to review the role of endoscopy in diagnosis, treatment, and prognosis in patients with acute gastrointestinal bleeding in a real clinical setting.

Advances in management of nonvariceal upper gastrointestinal bleeding

PURPOSE OF REVIEW

To review new advances in managing nonvariceal upper gastrointestinal hemorrhage.

RECENT FINDINGS

Implementation of various scoring systems in combination with video capsule endoscopy assists in stratifying and managing nonvariceal upper gastrointestinal bleeding. New techniques such as thermocoagulation and hemoclips are useful to treat bleeding.

SUMMARY

The advancement of methods and procedures in managing nonvariceal upper gastrointestinal bleeding has decreased mortality of patients presenting with this type of hemorrhage. In this chapter, we will be discussing various scores to stratify nonvariceal upper gastrointestinal bleeding and techniques to stop bleeding.