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#289 Keeping it Simple for Emergency Room Dyspepsia

Should lidocaine or anti-spasmodics be added to antacids when treating emergency room patients with dyspepsia?

Best evidence suggests adding lidocaine and/or anti-spasmodics to antacids is unlikely to add meaningful pain relief compared to antacids alone. Evidence is inconsistent with one study finding antacids alone better, another no added benefit and a third (unblinded, older) showing lidocaine provided additional benefit. Patients (especially females) who present to emergency with new onset dyspepsia should have cardiac diagnosis ruled out.

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Three randomized controlled trials (RCTs) comparing antacid monotherapy to antacid plus lidocaine +/- anti-spasmodics for patients presenting to emergency with dyspeptic-like symptoms. Patients were ~40 years old, 60% female with baseline pain score (where reported) of ~65 on a ~100-point scale (lower=better).
  • 89 patients randomized to antacid (Gastrogel®), antacid + lidocaine solution 2%, or antacid + viscous lidocaine 2%.1 At 30 minutes:
    • Mean pain score improvement: No statistical difference between groups (antacid 24, antacid + lidocaine solution 20, antacid + viscous lidocaine 15 points).
    • Overall acceptability significantly (13-25 points) higher for antacid alone.
    • 14% of patients ultimately had cardiac diagnosis.
  • 113 patients randomized to antacid (Mylanta®), antacid + antispasmodic (Donnatal®), or antacid + antispasmodic + lidocaine. 2 At 30 minutes:
    • Mean pain score improvement: No statistical difference between groups: (antacid 25; antacid + antispasmodic 23; antacid, antispasmodic + lidocaine 24 points).
  • 73 patients randomized to antacid (Mylanta®) or antacid + viscous lidocaine 2%.3 At 30 minutes:
    • Mean pain score improvement: Antacid + lidocaine was greater than antacid alone (41 versus 9 points, statistically different).
    • Patient-reported “acceptable” pain relief: 69% for antacid + lidocaine versus 35% for antacid alone; number needed to treat=3.
    • Limitation: Clinicians not blinded.
  • Dyspepsia affects up to 16% of healthy individuals, with abdominal pain accounting for up to 9% of emergency room visits. 4,5
  • Women with an acute myocardial infarction often experience prodromal symptoms and chest pain is less predictive of coronary artery disease:
    • Up to 45% of women have gastrointestinal symptoms as the presenting symptom compared to 34% in men. 6
  • Response to antacids should not be used for differentiating gastrointestinal or cardiac origin of pain. 7

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  • Jingyi Ma BMSc
  • Michael R Kolber BSc MD CCFP MSc

1. Warren J, Cooper B, Jermakoff A, et al. Acad Emerg Med. 2020; 27(9):905-909.

2. Berman DA, Porter RS, Graber M. J Emerg Med. 2003; 25(3):239-244.

3. Welling LR, Watson WA. Ann Emerg Med. 1990; 19(7):785-788.

4. Ford AC, Mahadeva S, Carbone MF, et al. Lancet. 2020; 396(10263):1689-1702.

5. Emergency Department Visits. Centers for Disease Control and Prevention. Updated November 10, 2020. Available at: Accessed December 2, 2020.

6. Nanna MG, Hajduk AM, Krumholz HM, et al. Circ Cardiovasc Qual Outcomes. 2019; 12(10):e005691.

7. Chan S, Maurice AP, Davies SR et al. Heart Lung Circ. 2014; 23:913–923.

Authors do not have any conflicts of interest to declare.