Thursday, December 23, 2010

Band ligation of bleeding esophageal varices: Erythromycin improves visibility

Erythromycin improves visibility during endoscopy for variceal bleeding

Last Updated: 2010-12-22 9:00:30 -0400 (Reuters Health)

By Karla Gale

NEW YORK (Reuters Health) - Band ligation of bleeding esophageal varices can be impossible when blood obscures the endoscopic view - but giving erythromycin before the procedure will clear the visual field, according to randomized trial results from Saudi Arabia.
Not only does erythromycin pretreatment improve visibility, but it also raises the likelihood of bleeding control by band ligation and shortens patients' hospital stay, according to Dr. Ibrahim H. Altraif and associates at the King Abdul-Aziz Medical City in Riyadh.
Intravenous erythromycin, a potent motilin agonist, induces rapid gastric emptying that lasts for at least two hours, the authors say in their paper, published online December 9th in Gastrointestinal Endoscopy.

Their study involved 90 patients with cirrhosis who had been vomiting blood due to variceal bleeding during the previous 12 hours. The 47 patients randomized to the intervention group received an intravenous bolus infusion of 125 mg erythromycin lactobionate in 50 mL normal saline. The other 43 patients received only the saline. (All patients also received octreotide, esmoprazole, and ceftriaxone.)
"The erythromycin infusion has to be given over 10 minutes (i.e., not fast)," Dr. Altraif cautioned in an email to Reuters Health.

Endoscopies began 30 minutes after the erythromycin infusions were completed. Hepatologists assessed gastric cleansing on a scale of 1 to 16, where a score of at least 15 indicated a clear esophagus and stomach. More patients in the erythromycin group got a score of 15 or 16 (49% vs 23%, p less then 0.01); the mean scores were 12.5 with erythromycin and 9.8 with saline (p less then 0.01).
In fact, on multivariate analysis, erythromycin was the only predictor of an empty stomach.
As a result, the average time needed for endoscopy was also shorter after erythromycin (19 vs 26 min, p < 0.005). The physicians found that with erythromycin, they could control bleeding by band ligation more often (70% vs 49%, p less then 0.04) and that hospital stays were shorter (3.4 vs 5.1 days, p less then 0.002).

"Because of the good visibility, the reduced need to repeat endoscopy, and the confident feeling that the treating physician has seen all parts of the stomach and esophagus and has done what the patient needs, patients can be discharged sooner," Dr. Altraif pointed out.
The need for sclerotherapy was similar in the two groups, however, as were the need for repeat endoscopy and the numbers of units of transfused blood.
No drug-related adverse effects occurred, Dr. Altraif and colleagues report.
Based on these results, Dr. Altraif said, "We routinely give erythromycin to all cirrhotics presenting with bleeding, except those who have contraindications."
He noted that cardiac arrhythmia is the major contraindication to erythromycin use, because it can prolong the Q-T interval.
"There are alternative medicines available, such as pro-kinetics," he continued, "but erythromycin is far more potent, very cheap, well tolerated, it acts quickly and is widely available with little or no side effects in this setting."
He believes that a large, multicenter trial would show other benefits to erythromycin pretreatment in patients with variceal bleeding, including a reduction in transfusion rates, fewer cases of aspiration pneumonia and other complications, and decreased mortality.

Gastrointest Endosc 2010.

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