Comparative Effectiveness of Prokinetic Agents with or without Nasogastric Lavage for Improving Endoscopic Visualization in Upper Gastrointestinal Bleeding: A Systematic Review and Network Meta-Analysis

Introduction: Upper gastrointestinal bleeding (UGIB) is a common emergency where poor endoscopic visualization due to retained blood and clots hampers diagnosis and therapy. Prokinetic agents and nasogastric (NG) lavage are used to improve visualization, but their comparative effectiveness remains unclear. This study evaluated the comparative efficacy of prokinetics - with or without NG lavage - versus NG lavage alone, prokinetics alone, or placebo in improving endoscopic visualization in UGIB. METHODS: A systematic search of five databases up to April 2025 identified randomized controlled trials (RCTs) comparing erythromycin, metoclopramide, NG lavage, or combinations against placebo. Network meta-analysis using a frequentist random-effects model assessed the primary outcome of adequate visualization. Secondary outcomes included visualization score, endoscopy duration, and blood transfusion units within 24 h. Risk ratios (RRs) and standardized mean differences (SMDs) were calculated. Treatments were ranked using Surface Under the Cumulative Ranking curve (SUCRA). RESULTS: A total of 10 RCTs (1,083 patients) were included: erythromycin (n = 226), erythromycin+NG lavage (n = 186), metoclopramide (n = 34), metoclopramide+NG lavage (n = 143), NG lavage alone (n = 333), and placebo (n = 161). Erythromycin + NG lavage ranked highest for adequate visualization (RR: 2.49; 95% CI: 1.57-3.95; SUCRA: 92%), followed by erythromycin (RR: 2.24; 95% CI: 1.56-3.21) and NG lavage (RR: 1.70; 95% CI: 1.06-2.73). Erythromycin improved visualization score (SMD: 0.86; 95% CI: 0.36-1.36; SUCRA: 73%). No significant differences were found for endoscopy duration or transfusion units. CONCLUSION: Erythromycin, particularly when combined with NG lavage, appears most effective for improving endoscopic visualization in UGIB. However, this procedural benefit did not translate into reductions in endoscopy duration or 24-h transfusion requirements, and the impact on other patient-centered outcomes remains uncertain. .