Role of prokinetic drugs prior to endoscopy in acute upper gastrointestinal bleeding: a systematic review and meta-analysis

Background: Acute upper gastrointestinal bleeding (UGIB) is a common gastrointestinal emergency in which retained blood and clots may impair endoscopic visualization, delay diagnosis, and increase the need for repeat endoscopy. Pre-endoscopic prokinetic therapy, particularly erythromycin, may improve gastric clearance before endoscopy, but its effects on clinical outcomes remain uncertain. Objective: To evaluate the efficacy and safety of pre-endoscopic prokinetic therapy in adults with acute UGIB, with attention to the strength of evidence for erythromycin and metoclopramide. Methods: We conducted a systematic review and meta-analysis of randomized controlled trials evaluating pre-endoscopic prokinetic therapy in adults with acute UGIB. The primary outcome was adequate gastric emptying or adequate endoscopic visualization. Secondary outcomes included repeat endoscopy, mortality, endoscopy duration, blood transfusion requirement, length of hospital stay, endoscopic visualization score, bleeding-source identification, rebleeding, and adverse events. Dichotomous outcomes were pooled as odds ratios (ORs), and continuous outcomes as mean differences (MDs). Because visualization scores were measured using different scales, this outcome was pooled using standardized mean difference (SMD). Certainty of evidence was assessed using GRADE. Results: = 62.1%). No clear benefit was demonstrated for mortality (OR 0.59, 95% CI 0.32-1.09), rebleeding (OR 1.12, 95% CI 0.64-1.97), blood transfusion requirement (MD -0.64 units, 95% CI -1.44 to 0.15), or endoscopy duration (MD -1.67 minutes, 95% CI -5.59 to 2.25) under random-effects models. Length of hospital stay was shorter with prokinetic therapy (MD -1.30 days, 95% CI -2.11 to -0.49), although this outcome may be influenced by healthcare-system factors. Safety reporting was limited and inconsistent; no consistent serious safety signal was identified, but the trials were not powered to detect uncommon adverse events such as QT prolongation, arrhythmia, or extrapyramidal reactions. Conclusion: Pre-endoscopic prokinetic therapy, supported mainly by erythromycin-based randomized evidence, improves gastric emptying/endoscopic visualization and probably reduces repeat endoscopy in adults with acute UGIB. These findings should be interpreted primarily as procedural benefits rather than evidence of improved hard clinical outcomes. Evidence for metoclopramide remains limited and less consistent, and current data do not support a definitive class effect for all prokinetic drugs.