Metoclopramide for Acute Upper GI Bleeding

The Efficacy of Metoclopramide for Gastric Visualization by Endoscopy in Patients With Acute Upper Gastrointestinal Bleeding: Double-blind Randomized Controlled Trial

The presence of blood clot in stomach limited quality of endoscopic view ,which affect successful rate of hemostatic endoscopy in patient with acute upper gastrointestinal bleeding. The study is aimed to evaluate the efficacy of metoclopramide, as pro-kinetic agent ,for gastric visualization in the patient with acute UGIB; double-blind randomized controlled trial and two centers study. The patient were randomly assigned to receive either metoclopramide (10mg) intravenously or placebo before endoscopy 30-120 min. The primary endpoint was endoscopic yield, assessed by objective gastric visualized scoring systems. Secondary end points include duration of endoscope, technical success rate, the need for second-look EGD, units of blood transfusion, length of hospital stay and 30-day rebleeding rate.

Study Overview

• Status: Completed
• Conditions: Acute Upper Gastrointestinal Bleeding; Effect of Drug
• Intervention / Treatment: Drug: Metoclopramide; Drug: Normal Saline 10 mL Injection

Detailed Description

• Double-blind, Double centers, RCT
• All endoscopists at two participating sites attend the pre-study meeting for standardization of protocol and scoring system.
• Eligible patients were randomly assigned to either metoclopramide or placebo group in a 1:1 conceal allocation according to a computer-generated randomization list with block randomization in size of four.
• Assigned treatment was kept in opaque sealed envelopes.
• Before EGD, the patients had adequate resuscitation to maintain stable hemodynamics(SBP ≥ 90 mmHg and/or HR < 100 bpm) and blood transfusion to reach Hb> 7g/dL and correct coagulopathy.
• EGD is performed in left lateral position, under local lidocaine anesthesia alone or combined with IV anesthetics
• The standardized set of endoscopic landmarks, including the esophagus, gastro-esophageal junction, fundus, gastric body, incisura, antrum, duodenal bulb, and second part of the duodenum were examined.
• To assess endoscopic gastric visualization, we applied simple validate objective scoring system and estimated coverage of blood clot on mucosa on reference endoscopies view in 4 locations, including fundus, corpus, antrum and duodenal bulb.
• Each location is scored between 0 and 2; Score 0 (worst vision) < 25% of the surface was visible; Score 1 25-75% visible surface; Score 2 (best vision), > 75% visible surface ( total score range 0-8)
• 'Adequate visualization' defined as total score six or higher (out of 8).
• All photos of endoscopic landmark, including the reference endoscopic views of four locations (fundus, corpus antrum and duodenal bulb), were taken and internally validated by another endoscopist who was blinded to the randomization allocation.
• The duration of the endoscopy was recorded from beginning to end of the procedure in minute.

• The 72-hour recurrent GI bleeding was documented and re-EGD was performed to confirm rebleeding if the following conditions were met

  : I) hematemesis or bloody NG > 6 hours after endoscopy; II) melena after normalization of stool color; III) hematochezia after normalization of stool color or melena; IV) development of tachycardia (HR ≥ 110 bpm) or hypotension(SBP ≤ 90 mmHg) after ≥ 1 hour of vital sign stability without other cause; V) hemoglobin drop of ≥ 2 g/dL after two consecutive stable hemoglobin values ( < 0.5 g/dL decrease) ≥ 3 hours apart; VI) tachycardia or hypotension that does not resolve within 8 hours after index endoscopy despite appropriate resuscitation (in the absence of an alternative explanation), associated with persistent melena or hematochezia or; VII) persistently dropping hemoglobin of > 3 g/dL in 24 hours associated with persistent melena or hematochezia.

• 30-day rebleeding is accessed by direct phone call to patient.

• Study Type: Interventional
• Enrollment (Actual): 68
• Phase: Phase 4

Contacts and Locations

• Study Contact: Name: Rapat Pittayanon, MD, MSc; Phone Number: +6622564356; Email: Rapat.P@chula.ac.th
• Study Contact Backup: Name: Thanrada Vimonsuntirungsri, MD; Phone Number: +66853356240; Email: aa_choc@docchula.com

Study Locations

• Thailand
  • Pathum Wan
    • Bangkok, Pathum Wan, Thailand, 10400
      • King Chulalongkorn Memorial Hospital
  • Pathumwan
    • Bangkok, Pathumwan, Thailand, 10330
      • Division of Gastroenterology, Faculty of Medicine, Chulalongkorn University

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years and older (Adult, Older Adult)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

1. Age >= 18 years
2. Active upper GI bleeding ( defined as fresh or bright red hematemesis within 24hr. or presented of blood via NG aspiration )
3. Underwent upper GI endoscopy within 12hr
4. Informed consent obtained

Exclusion Criteria:

1. Known allergy of metoclopramide
2. History of gastric or duodenal surgery
3. Known case esophageal, gastric or duodenal cancer
4. Diagnosed with advanced HIV infection (defined as CD4 cell count <200 cells/mm3 or WHO clinical stage 3 or 4)
5. Pregnancy or lactating
6. NG lavage was done with solution > 50 ml.

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: Triple

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: metoclopramide; Metoclopramide 10mg with normal saline up to 10 ml IV slowly push in 5minutes.	Drug: Metoclopramide; Metoclopramide 10 mg + NSS 10 ml intravenous slowly push in 5min before endoscopy 30-120 min
Placebo Comparator: placebo; Normal saline 10 ml IV slowly push in 5 minutes.	Drug: Normal Saline 10 mL Injection; Normal saline 10 ml intravenous slowly push in 5min before endoscopy 30-120 min

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
percentage of patents with 'adequate visualization'	the efficacy of metoclopramide for gastric visualization by endoscopy in patients with acute upper gastrointestinal bleeding which assess by objective gastric visualized scoring system (score 0-8) ; total score >= 6 consider it as adequate visualization at index EGD	Though study completion , average 2 yr

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
length of hospital stay	length of hospital stay	up to 30days
mean difference in endoscopic visualized gastric score	score 0-2, including total mean score , and at each location of fundus , corpus , antrum and duodenal bulb	Though study completion , average 2 yr
duration of endoscopy	duration of endoscopy	up to 2 hour
immediate hemostasis at index EGD	percentage of succession of procedure by endoscopist for immediate hemostasis of the culprit lesions causing upper gastrointestinal bleeding during index EGD	Though study completion , average 2 yr
the need of second-look EGD	the need of second-look EGD	72 hours
units of red cell transfusion	units of red cell transfusion within 24 hour	up to 30 days
30-day rebleeding rate	30-day rebleeding rate	30 days

Collaborators and Investigators

• Sponsor: King Chulalongkorn Memorial Hospital

Study record dates

Study Major Dates

• Study Start (Actual): April 10, 2021
• Primary Completion (Actual): September 7, 2022
• Study Completion (Actual): October 8, 2022

Study Registration Dates

• First Submitted: February 19, 2021
• First Submitted That Met QC Criteria: February 23, 2021
• First Posted (Actual): February 25, 2021

Study Record Updates

• Last Update Posted (Actual): October 2, 2023
• Last Update Submitted That Met QC Criteria: September 27, 2023
• Last Verified: September 1, 2023

More Information

Terms related to this study

• Keywords: Endoscopy; Metoclopramide; Acute upper gastrointestinal bleeding; Gastric visualization
• Additional Relevant MeSH Terms: Digestive System Diseases; Pathologic Processes; Gastrointestinal Diseases; Hemorrhage; Gastrointestinal Hemorrhage; Physiological Effects of Drugs; Neurotransmitter Agents; Molecular Mechanisms of Pharmacological Action; Autonomic Agents; Peripheral Nervous System Agents; Antiemetics; Gastrointestinal Agents; Dopamine Agents; Dopamine D2 Receptor Antagonists; Dopamine Antagonists; Metoclopramide
• Other Study ID Numbers: RP021

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: NO

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No