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. 2023 Feb 1;2(2):CD013176.
doi: 10.1002/14651858.CD013176.pub2.

Erythromycin prior to endoscopy for acute upper gastrointestinal haemorrhage

Diego Adão  1 , Aecio Ft Gois  2 , Rafael L Pacheco  2 , Carolina Fmg Pimentel  1 , Rachel Riera  3
Affiliations

Erythromycin prior to endoscopy for acute upper gastrointestinal haemorrhage

Diego Adão et al. Cochrane Database Syst Rev. .

Abstract

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.

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Conflict of interest statement

DA: no relevant interests; Federal University of Sao Paulo, Brazil – Academic Coordinator of the General Surgery Emergency at the University Hospital. AG: author deceased. Declarations of interest published in the Cochrane Review: no relevant interests; worked as Emergency Physician at the Federal University of Sao Paulo. RP: none. CP: none. RR: none.

Figures

1
1
Study flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study. Empty spaces mean the study did not assess the outcome.
1.1
1.1. Analysis
Comparison 1: Erythromycin versus placebo, Outcome 1: Serious adverse events
1.2
1.2. Analysis
Comparison 1: Erythromycin versus placebo, Outcome 2: All‐cause mortality
1.3
1.3. Analysis
Comparison 1: Erythromycin versus placebo, Outcome 3: Visualisation of gastric mucosa (mean endoscopic score)
1.4
1.4. Analysis
Comparison 1: Erythromycin versus placebo, Outcome 4: Visualisation of gastric mucosa (empty stomach yes/no)
1.5
1.5. Analysis
Comparison 1: Erythromycin versus placebo, Outcome 5: Non‐serious adverse events
1.6
1.6. Analysis
Comparison 1: Erythromycin versus placebo, Outcome 6: Rebleeding
1.7
1.7. Analysis
Comparison 1: Erythromycin versus placebo, Outcome 7: Blood transfusion
1.8
1.8. Analysis
Comparison 1: Erythromycin versus placebo, Outcome 8: Rescue invasive intervention
2.1
2.1. Analysis
Comparison 2: Erythromycin plus nasogastric tube lavage versus no treatment/placebo plus nasogastric tube lavage, Outcome 1: All‐cause mortality
2.2
2.2. Analysis
Comparison 2: Erythromycin plus nasogastric tube lavage versus no treatment/placebo plus nasogastric tube lavage, Outcome 2: Visualisation of gastric mucosa (mean endoscopic score)
2.3
2.3. Analysis
Comparison 2: Erythromycin plus nasogastric tube lavage versus no treatment/placebo plus nasogastric tube lavage, Outcome 3: Visualisation of gastric mucosa (empty stomach yes/no)
2.4
2.4. Analysis
Comparison 2: Erythromycin plus nasogastric tube lavage versus no treatment/placebo plus nasogastric tube lavage, Outcome 4: Non‐serious adverse events
2.5
2.5. Analysis
Comparison 2: Erythromycin plus nasogastric tube lavage versus no treatment/placebo plus nasogastric tube lavage, Outcome 5: Rebleeding
2.6
2.6. Analysis
Comparison 2: Erythromycin plus nasogastric tube lavage versus no treatment/placebo plus nasogastric tube lavage, Outcome 6: Blood transfusion
2.7
2.7. Analysis
Comparison 2: Erythromycin plus nasogastric tube lavage versus no treatment/placebo plus nasogastric tube lavage, Outcome 7: Rescue invasive intervention
3.1
3.1. Analysis
Comparison 3: Erythromycin versus nasogastric tube lavage, Outcome 1: All‐cause mortality
3.2
3.2. Analysis
Comparison 3: Erythromycin versus nasogastric tube lavage, Outcome 2: Visualisation of gastric mucosa (empty stomach yes/no)
3.3
3.3. Analysis
Comparison 3: Erythromycin versus nasogastric tube lavage, Outcome 3: Non‐serious adverse events
3.4
3.4. Analysis
Comparison 3: Erythromycin versus nasogastric tube lavage, Outcome 4: Rebleeding
3.5
3.5. Analysis
Comparison 3: Erythromycin versus nasogastric tube lavage, Outcome 5: Rescue invasive intervention
4.1
4.1. Analysis
Comparison 4: Erythromycin plus nasogastric lavage versus metoclopramide plus nasogastric lavage, Outcome 1: Visualisation of gastric mucosa (empty stomach yes/no)
See this image and copyright information in PMC

Update of

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