Erythromycin vs. NG Tube and Gastric Lavage Preparation for Endoscopy in Upper GI Bleeding
Paterson, et al. Erythromycin Infusion or Gastric Lavage for Upper Gastrointestinal Bleeding: A Multicenter Randomized Controlled Trial. Annals of Emergency Medicine. 2011; 57(6): 582-589.
Upper GI bleeding is a common medical emergency associated with significant morbidity and mortality and typically requires endoscopy to determine the cause of bleeding and for hemostasis. A reliable endoscopy requires clear visualization of the GI tract. Nasogastric tubes with gastric lavage and erythromycin infusion as a promotility agent have both been used for patient preparation to clear the GI tract prior to endoscopy. The purpose of the study is to determine whether satisfactory stomach visualization was different after IV erythromycin, NG tube placement with gastric lavage, or both.
A prospective, randomized multicenter clinical trial was performed in 6 emergency departments in France between October 2005 and December 2007 for adult patients with acute upper GI bleeds presenting with hematemesis or melena. Patients were randomized into 3 parallel groups: erythromycin IV infusion only, NG tube and gastric lavage only, or combined IV erythromycin and NG tube placement with gastric lavage.
The primary endpoint was the quality of visualization of the GI tract during endoscopy measured using a scoring system performed by the endoscopist. The analysis was performed as a superiority trial to demonstrate difference between the 3 treatment groups with a goal of detecting a 15% absolute difference in the proportion of satisfactory stomach visualization.
Secondary endpoints included: patient outcomes until day 30, duration of endoscopy, number of endoscopic hemostasis procedures, ability to identify the source of bleeding, adverse effects related to erythromycin infusion or NG tube placement, number of transfused blood units, re-bleeding, and death.
For the primary outcome of satisfactory stomach visualization after intervention with erythromycin infusion, NG tube placement and gastric lavage, or combined therapies, the mean endoscopic score was not significantly different between groups. 85% of all patients had satisfactory stomach visualization. The percentage of patients with satisfactory stomach visualization did not differ between groups in patients with cirrhosis or those admitted to an ICU. The only difference was the percentage of transfused patients with satisfactory stomach visualization was significantly higher in the combined NG tube/erythromycin group. Endoscopy length, time between bleeding onset and endoscopy, frequency of hemostasis treatment, need for second endoscopy, ability to identify source of bleeding, or endoscopic findings did not differ significantly between groups. Outcome studies of the mean number of blood units transfused, re-bleeding, and mortality were not significantly different between groups.
There was no statistical difference between NG tube placement and gastric lavage, erythromycin infusion, or combined therapy on satisfactory stomach visualization during endoscopy or secondary outcomes. Therefore, erythromycin infusion may be a good substitute for gastric lavage, avoiding NG tube placement before endoscopy in ED patients with acute upper GI bleeding presenting with hematemesis or melena.