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#289 Keeping it Simple for Emergency Room Dyspepsia


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


BOTTOM LINE
RÉSULTAT FINAL
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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EVIDENCE
DONNÉES PROBANTES
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.
Context
  • 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


karen day June 3, 2021

This confirms my experience

Gilbert Bretecher June 6, 2021

use antacids only inthese cases okay

Qussay Alshahabi June 6, 2021

Pink lady is still good

Philippe ROHE August 17, 2021

This confirms my experience too

Olukayode Fawole August 29, 2021

Very Educative

Jason Price September 12, 2021

Not Applicable


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Author(s)
Auteur(s)
  • 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: https://www.cdc.gov/nchs/fastats/emergency-department.htm 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.

Les auteurs n’ont aucun conflit d’intérêts à déclarer.