Metoclopromide and emergency endoscopy for upper gastrointestinal bleeding

Nonvariceal upper gastrointestinal bleeding

Nonvariceal upper gastrointestinal bleeding (NVUGIB) is an important condition facing gastroenterologists. The focus of this article is the management of NVUGIB, with a particular emphasis on the endoscopic modalities and techniques that are most effective for various bleeding etiologies. Attention also is given to medical management, risk assessment, and issues pertaining to the timing of endoscopy and need for scheduled second-look endoscopy.

Gastrointestinal hemorrhage: is the surgeon obsolete?

The management of GI hemorrhage has undergone tremendous evolution in recent decades. Once commonly managed by surgeons, the almost continuous introduction of new technologies and pharmacotherapies has dramatically improved clinicians' ability to identify and control sources of bleeding without surgery. Although a gastroenterologist can successfully manage most cases of GI hemorrhage endoscopically, surgical consultation remains an important consideration for the emergency physician in selected cases.

Erythromycin improves the quality of EGD in patients with acute upper GI bleeding: a randomized controlled study

BACKGROUND

The diagnostic and therapeutic value of EGD in patients with upper GI bleeding is often limited by the presence of residual blood or clots. When infused before EGD, erythromycin, a potent gastrokinetic drug, might improve the quality of EGD in patients with upper GI bleeding. The aim of this study was to assess the effect of erythromycin on the quality of the EGD in patients with acute upper GI bleeding.

METHODS

Forty-one patients admitted to the intensive care unit because of acute upper GI bleeding were included in a randomized, endoscopist-blinded, controlled trial, comparing erythromycin (3 mg/kg intravenously over 30 minutes) to no treatment (control patients). EGD was performed 30 to 90 minutes after the end of the infusion. The primary study outcome was quality of EGD examination, as evaluated on a scale of 0 to 3, and the need to perform a second diagnostic EGD within the next 8 days. Secondary outcomes were efficiency of the endoscopic hemostatic therapy and intensity of esophagogastroduodenal contractions, as evaluated on a scale of 0-3.

RESULTS

The characteristics of the patients and lesions found by EGD were similar in both groups. Quality of the EGD examination was significantly better in the erythromycin group (n = 19) compared with the control group (n = 22) (2.5 [0.8] vs. 1.5 [1.3]; p = 0.02). Three patients receiving erythromycin required a second EGD compared with 10 control patients (p = 0.089). Erythromycin did not interfere with the performance of EGD or the efficiency of hemostatic procedures. The intensity of gastroduodenal contractions was similar in both groups. No adverse event was observed.

CONCLUSIONS

In patients with acute upper GI bleeding, infusion of erythromycin before endoscopy significantly improved the quality of EGD and tended to reduce the need for second-look endoscopy.

Clinical usefulness of 3% hydrogen peroxide in acute upper GI bleeding: a pilot study

BACKGROUND

A major problem in the endoscopic management of acute upper gastrointestinal (GI) bleeding is the presence of blood and clots overlying the bleeding source, preventing visualization of the lesion. A simple alternative is to alter the characteristics of blood such that it not only becomes easier to remove but also becomes translucent. We report the results of a pilot study on the use of hydrogen peroxide in patients with acute upper GI bleeding.

METHODS

Patients with acute upper GI bleeding were studied if the presence of blood or clots obscured the site of bleeding. The potential site of bleeding was initially sprayed with 200 mL water and then with 200 mL 3% hydrogen peroxide mixed with simethicone.

RESULTS

In 6 patients with acute upper GI bleeding, hydrogen peroxide spray resulted in good to excellent visualization of the bleeding source. Hemostasis occurred in 2 patients who were actively bleeding. There were no adverse effects or complications.

CONCLUSIONS

Hydrogen peroxide significantly enhanced clot dissolution and endoscopic visualization in patients with acute upper GI bleeding.

The uncleared fundal pool in acute upper gastrointestinal bleeding: implications and outcomes

BACKGROUND

The implications and outcomes of patients with an uncleared fundal pool of blood found at emergent upper endoscopy are not well described.

METHODS

We reviewed the records of 484 consecutive patients who presented over a 12-month period to our medical center with acute upper gastrointestinal hemorrhage. All patients underwent upper endoscopy within 24 hours of their initial presentation. Patients with an uncleared fundal pool of blood at initial endoscopy were included in this study, and their findings and outcomes were compared with a randomly selected subgroup of these same patients who did not have residual gastric blood.

RESULTS

Sixty-one patients (13%) had uncleared fundal pools despite gastric lavage and patient positioning. Findings on initial endoscopy included esophageal varices in 29 (47%), gastric ulcer in 12 (20%), portal hypertensive gastropathy in 5 (8%), Mallory-Weiss tear in 5 (8%), duodenal ulcer in 5 (8%), gastric varices in 4 (7%), Dieulafoy's lesion in 2 (3%), and other in 7 (11%). Twelve of these 61 patients had multiple findings and 4 (7%) had no lesion identified. Thirty-two of the 61 patients (52%) had at least one follow-up endoscopy, with new fundal lesions identified in 13 (41%): portal hypertensive gastropathy in 8, gastric ulcer in 2, gastric varices in 2, and leiomyoma in 1. Of these 13 new findings, 5 (38%) were judged significant either by the presence of active bleeding or stigmata of recent hemorrhage. Of the 4 patients with no identifiable lesion on initial endoscopy, 3 had a follow-up endoscopy and 2 were found to have a significant new finding in the fundus. The control group had a statistically significant lower percentage of endoscopic findings related to portal hypertension. Recurrent bleeding during the index hospitalization occurred in 54% of the patients with uncleared fundal pools versus 11% of the control group (0 < 0.01). Length of stay, number of units of blood transfused, need for emergent surgery for bleeding, as well as overall and bleeding-related mortality were all significantly greater in the patients with the uncleared fundal pool than in the control patients.

CONCLUSIONS

The inability to clear a fundal pool of blood at emergent upper endoscopy is associated with significant morbidity and mortality. Further, new fundal lesions can be identified in 41% of patients on follow-up examination, with many being clinically significant. These data support the importance of clearing a fundal pool in patients undergoing endoscopy for upper gastrointestinal bleeding.

Metoclopramide: a review of its pharmacological properties and clinical use

Metoclopramide, 4-amino-5-chloro-2-methoxy-N-(2-diethyl-aminoethyl) benzamide, is advocated for use in gastro-intestinal diagnostics, and in treating various types of vomiting and a variety of functional and organic gastro-intestinal disorders. Published data have indicated that metoclopramide assists radiological identification of lesions in the small intestine, facilitates duodenal intubation and small intestine biopsy, and eases emergency endoscopy in upper gastro-intestinal haemorrhage. Metoclopramide reduces post-operative vomiting and radiation sickness, and ameliorates some types of drug-induced vomiting. It may provide symptomatic relief in dyspepsia and possibly in vertigo, reflux oesophagitis and hiccups, but further controlled trials are needed to confirm the efficacy of metoclopramide in these proposed areas of use. It promotes gastric emptying prior to anaesthesia. Its effects in healing gastric ulcer and preventing relapse of duodenal ulcer remain unproven. Side-effects are few and transient, though alarming extrapyramidal reactions can occur in a small proportion of patients receiving therapeutic doses but more usually following excessive doses in young subjects. They respond rapidly to withdrawal of the drug.

Early endoscopy of oesophagus, stomach, and duodenal bulb in patients with haematemesis and melaena

Oesophago-gastro-duodenoscopy was successfully performed in 196 of 208 patients admitted with haematemesis or melaena, or both. A precise visual diagnosis was made in 80% of all patients and in 96% of those where the final diagnosis lay within the oesophagus, stomach, and first two parts of the duodenum. Bleeding oesophagitis was more common and bleeding duodenal ulcer less common than in other series using mainly radiology. Altogether, 26% of all patients with endoscopically-proved duodenal ulcers were bleeding from another site, and 15.4% of all patients had more than one lesion. This fact, and inability to detect surface lesions limits the value of acute barium radiology, which was performed in only 81 patients. Accurate diagnosis should lead to better understanding of individual lesions and more rational management of individual patients. Where a good service is available oesophago-gastro-duodenoscopy should be performed on all bleeding patients within 24 hours of admission.