Dr. Voigt is a PGY-2 in Emergency Medicine
Dr. Froke is a PGY-1 in Emergency Medicine
Chest pain in the ED is all too often a chief complaint that carries vague associated symptoms and inconclusive workups. Despite EM providers’ best efforts to determine a cause, chest pain is often left without a definitive diagnosis and symptomatic strategies are pursued. Although far from a best-practice, the use of a “GI-cocktail” or other forms of oral analgesia has become somewhat commonplace for providers. The most effective formulation for this strategy has not been well published and use of lidocaine is often included in a treatment regimen.
We discussed a recent FOAMed piece from First10EM1 that critically reviewed a 2020 double-blinded RCT publication by Warren et al assessed efficacy of antacid alone versus antacid/lidocaine “GI cocktail” mixture in patients presenting with epigastric discomfort. Overall, the sample size of this trial was small (89 total enrollees), and there did not appear to be statistically-significant differences in pain score improvement between antacid alone versus “GI cocktail” use (primary outcome). Tolerance of treatment (secondary outcome) was also assessed and did show statistically-significant favorability in terms of taste, bitterness, and overall acceptability of antacid alone versus lidocaine-containing options. Also of note, amongst patients enrolled in this trial, epigastric discomfort was ultimately found to be cardiac in origin 14% of the time; use of antacid or “GI cocktail” should be for therapeutic benefit and not diagnostic purposes.1
We also reviewed “Treatment of Uncomplicated Acute Diverticulitis Without Antibiotics: A Systematic Review and Meta-analysis” as published in the journal Disease of the Colon & Rectum 2. This article investigates the debate whether treatment of diverticulitis requires antibiotics, as it is thought the disease may be the result of an inflammatory etiology rather than infectious. The authors found that a higher percentage of patients in the no antibiotic group required additional intervention or treatment in the initial episode compared to antibiotic group, however there was no statistical difference between the two groups. This means that there may be a questionable effectiveness of treatment. The group discussion was helpful as Dr. Homme felt this research allowed for joint decision making with the patient when considering treatment options. This study had significant shortcomings as this article included a RCT which demonstrated both performance and selection bias. The secondary outcomes had high heterogeneity and it is difficult to interpret the reliability of the data.
1. Justin Morgenstern, "Don’t use lidocaine for epigastric pain", First10EM blog, July 27, 2020. Available at: https://first10em.com/dont-use-lidocaine-for-epigastric-pain/
2. Au S, Aly EH. Treatment of Uncomplicated Acute Diverticulitis Without Antibiotics: A Systematic Review and Meta-analysis. Dis Colon Rectum. 2019 Dec;62(12):1533-1547. doi: 10.1097/DCR.0000000000001330. PMID: 30663999.