From the Guidelines
Intravenous erythromycin is not recommended for routine use as a prokinetic agent before emergency endoscopy (EGD) in patients with upper GI bleeding, but may be considered in selected patients with suspected substantial amounts of blood or clot in their upper gastrointestinal tract. The use of preendoscopy promotility agents like erythromycin may improve diagnostic yield in selected patients, but they are not warranted for routine use in all patients who present with UGIB, as stated in the international consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding 1. A meta-analysis found that use of a prokinetic agent significantly reduced the need for repeated endoscopy in patients suspected of having blood in their stomach, compared with placebo or no treatment 1. However, the groups did not differ in length of stay, units of blood transfused, or need for surgery, and the benefit of erythromycin is most pronounced in patients with active bleeding or those with significant blood in the stomach. Some key points to consider when deciding to use IV erythromycin include:
- The patient's risk for rebleeding and the presence of substantial amounts of blood or clot in their upper gastrointestinal tract
- The potential benefits of improved diagnostic yield and reduced need for repeat procedures
- The potential risks and side effects, such as QT prolongation, especially in patients with cardiac issues or those on other QT-prolonging medications. In general, the decision to use IV erythromycin should be made on a case-by-case basis, taking into account the individual patient's clinical presentation and risk factors, as well as the availability of alternative prokinetic agents like metoclopramide 1.
From the Research
Evidence for Use of IV Erythromycin for Pre-EGD in Patients with Upper GI Bleed
- The use of IV erythromycin before endoscopy in patients with acute upper GI bleeding has been shown to improve the quality of EGD and reduce the need for second-look endoscopy 2, 3, 4, 5.
- Erythromycin infusion prior to endoscopy significantly improves visualization of gastric mucosa, decreases the need for a second endoscopy, and reduces the number of blood units transfused 2, 4.
- A network meta-analysis found that erythromycin improved the quality of EGD, reduced the need for repeat endoscopy and blood transfusion, and shortened hospital stay 3.
- A meta-analysis of four studies found that erythromycin prior to endoscopy in acute UGIB demonstrated a statistically significant improvement in visualization of the gastric mucosa and a decrease in the need for a second endoscopy 4.
- A randomized controlled study found that erythromycin improved the quality of EGD and tended to reduce the need for second-look endoscopy in patients with acute upper GI bleeding 5.
- A Cochrane review found that erythromycin may improve gastric mucosa visualization and result in a slight reduction in blood transfusion, but the evidence is very uncertain about the short-term effects of erythromycin on serious adverse events, all-cause mortality, and rebleeding 6.
Key Findings
- Erythromycin improves the quality of EGD and reduces the need for second-look endoscopy 2, 3, 4, 5.
- Erythromycin reduces the number of blood units transfused 2, 4.
- Erythromycin shortens hospital stay 3.
- The evidence is very uncertain about the short-term effects of erythromycin on serious adverse events, all-cause mortality, and rebleeding 6.
Studies
- 2: Erythromycin decreases the time and improves the quality of EGD in patients with acute upper GI bleeding.
- 3: Erythromycin Improves the Quality of Esophagogastroduodenoscopy in Upper Gastrointestinal Bleeding: A Network Meta-Analysis.
- 4: Erythromycin prior to endoscopy in acute upper gastrointestinal bleeding: a meta-analysis.
- 5: Erythromycin improves the quality of EGD in patients with acute upper GI bleeding: a randomized controlled study.
- 6: Erythromycin prior to endoscopy for acute upper gastrointestinal haemorrhage.