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Three Part Question

In [patients with dyspepsia who present to the emergency department] is the [GI Cocktail better than Antacid alone] in [relieving pain].

Clinical Scenario

A 35-year-old man presents to the emergency department with a history of burning pain radiating from his epigastric area up through his mediastinum that started after dinner. The patient had a history of gastro-oesophageal reflux disease and was placed on prilosec treatment last year, but has stopped taking this for 3 months. You decide to treat this probable case of dyspepsia with a gastrointestinal cocktail, a mixture of lidocaine and antacid, but wonder if adding the lidocaine yields any benefit.

Search Strategy

Medline 1966-6/06 using Ovid interface.
[exp Antacids/or exp Lidocaine/ or gi cocktail.mp or exp Anesthetics, Local/] AND [dyspepsia.mp or exp Dyspepsia/]

Search Outcome

Altogether 325 papers were found which 2 were relevant to the three part question

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Berman, D and Porter, R 2003 USA	120 adult patients who presented to an urban tertiary care center emergency department where the treating physician ordered a "GI Cocktail". Patients either given Donnatal-viscous lidocaine-antacid, Donnatal-antacid, or antacid alone. Pain was measured on visual analogue scale. 113 patients completed the study.	Prospective Double Blind Randomized Trial	pain relief in antacid alone group	25 mm decrease in pain	Well conducted study, but there was no standardized inclusion criteria for the ordering of the "GI Cocktail" and no specific diagnosis were found in each patient.
			pain relief in antacid + donnatal group	23 mm decrease in pain
			pain relief in antacid + donnatal group + viscous lidocaine	24mm decrease in pain
			Statistical analysis of results	There was no statistically significant difference in pain relief between the three groups on univariate or multivariate regression analysis.
Larry Welling, William Watson 1990 USA	76 patients in an urban emergency department with symptoms consistent with dyspepsia. 34 receiving antacid alone (Mylanta II), and 39 receiving GI cocktail (Mylanta II plus 30ml 2% viscous lidocaine) with 3 excluded. Pain was measured on an 11cm scale prior to, and 30 mins post treatment.	Randomized control trial	pain at baseline	6.4 in the antacid group vs 6.7 in the lidocaine group. p>0.5	Interviewers were not blinded to study patients which may lead to bias. No clinically defined symptoms of dyspepsia to enroll patients.
			Improvement in pain at 30 mins post treatment	0.9 in the antacid group vs 4 in the lidocaine group. p<0.0001

Comment(s)

The papers above give different opinions on the most effective treatment of dyspepsia in the emergency department. Both treatments have been used for years in the emergency department for treating dyspepsia. The addition of lidocaine and sometimes donnatal to make the gastrointestinal cocktail in theory could possibly increase the efficacy of the treatment with the addition of the local anaesthesia and anti-spasmodic agent. The risk of these additions is low with both agents being very well tolerated, and the additional cost of adding these agents is minimal as well. However, with any drug addition there is some added risk and cost. which. with the frequency that the gastrointestinal cocktail is used, could add up substantially. The findings in Watson's study of no clinically relevant reduction in pain with antacid alone goes against previous studies on the treatment of dyspepsia. A bias in the interviewer or population could have skewed their finding that the gastrointestinal cocktail is more effective. With this added the best evidence shows no clinical diiference in either treatment.

Clinical Bottom Line

Antacid alone should be preferred in treatment of dyspesia. The addition of lidocaine and donnatal can be used on doctor's discretion in patients without contraindications to these agents.

References

1. Berman D, Porter R, Graber M. The GI Cocktail is no more effective than plain liquid Antacid: A randomized, double blind clinical trial. The Journal of Emergency Medicine Volume 25, No. 3, pp. 239-244.
2. Welling L, Watson W. The Emergency Department Treatment of Dyspepsia with Antacids and Oral Lidocaine. Annals of Emergency Medicine 1990;19:785-788.