Guideline 14.1.2 The use of a gastro intestinal cocktail for the diagnosis of acute coronary syndrome in adult emergency department patients presenting with chest pain
The Gastrointestinal (GI) cocktail (a mixture of liquid antacid, viscous lignocaine, and often an anticholinergic agent) or ‘pink lady’ has been suggested to be effective in treating symptoms of dyspepsia in patients presenting to the emergency department1. The GI cocktail however, has been proposed to be useful not only for the therapy of patients with indigestion (gastro oesophageal reflux), but has also been used as a diagnostic aid for differentiating cardiac ischemic chest pain from chest pain of gastroesophageal origin.
Accuracy of Diagnosis
It is important that health care professionals, patients who are at risk and their families should be able to recognise characteristic symptoms that may be indicative of ACS. The signs and symptoms alone are neither sensitive nor specific2. (Class B;LOE IV). (See Guideline 9.2.1 Recognition and First Aid Management of Heart Attack, Guideline 14.1 ACS: Presentation with ACS).
Distinguishing ischemic from oesophageal chest pain can be difficult on clinical grounds. Both ischemic cardiac chest pain and the pain associated with gastro oesophageal reflux can share very similar characteristics such as sense of dyspepsia and response to nitrates or antacid cocktail3 4.
The available evidence to support the use of a GI cocktail (oral viscous lignocaine/antacid/ +/- anticholinergic) compared with standard diagnostic protocols (Serial ECG and biomarkers and provocative testing or imaging) to improve accuracy of diagnosis is sparse and inconclusive1-14.
In patients with chest pain and suspected ACS, the use of a GI cocktail (oral viscous lignocaine/antacid/ +/- anticholinergic) compared with standard diagnostic protocols (Serial ECG and biomarkers and provocative testing or imaging) is not proven to improve the accuracy of diagnosis.
A number of these studies suggest a potential for harm in using antacid cocktail to improve the accuracy of diagnosis of ACS because myocardial ischaemia may be incorrectly excluded from the diagnosis4 7 9 11. A symptomatic response to a GI cocktail in proven ACS has been well documented.
The signs and symptoms alone should not be used without other data for making the diagnosis of ACS. (Class B;LOE IV) (See Guideline 14.1).
These symptoms cannot be used in isolation but may be useful when used in combination with other information such as biomarkers, risk factors, an ECG and other diagnostic tests, in making triage and some treatment decisions in the out of hospital and emergency department (ED) setting. (Guideline 14.1)
It is recommended that the GI cocktail not be used in the emergency department to assist in the diagnosis of ACS.
Level of Evidence
III Case series and observational studies
Class of Recommendation
Class A - Recommended
- Teece S, Crawford I. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Antacids and diagnosis in patients with atypical chest pain. Emerg Med J 2003;20(2):170-1.
- Goodacre SW, Angelini K, Arnold J, Revill S, Morris F. Clinical predictors of acute coronary syndromes in patients with undifferentiated chest pain. QJM 2003;96(12):893-8.
- Schultz T, Mannheimer C, Dellborg M, Pilhall M, Borjesson M. High prevalence of gastroesophageal reflux in patients with clinical unstable angina and known coronary artery disease. Acute Card Care 2008;10(1):37-42.
- Henderson RD, Wigle ED, Sample K, Marryatt G. Atypical chest pain of cardiac and esophageal origin. Chest 1978;73(1):24-7.
- Bennett JR, Atkinson M. The differentiation between oesophageal and cardiac pain. Lancet 1966;2(7473):1123-27.
- Berman DA, Porter RS, Graber M. The GI Cocktail is no more effective than plain liquid antacid: a randomized, double blind clinical trial. J Emerg Med 2003;25(3):239-44.
- Dickinson MW. The "GI Cocktail" in the evaluation of chest pain in the emergency department. J Emerg Med 1996;14(2):245-6.
- Friday Jr AD. Xylocaine visous for diagnosis of chest pain. JACEP 1977;6(5):224.
- Guda NM, Prasad GA, Affi A, Truppe RE, Puetz T. Utility of GI cocktail in an emergency room setting. Gastroenterology 2000;118(4, Part 1):A459.
- Schwartz GR. Xylocaine viscous as an aid in the differential diagnosis of chest pain. J Am Coll Emerg Phys 1976;5(12):981-3.
- Servi RJ, Skiendzielewski JJ. Relief of myocardial ischemia pain with a gastrointestinal cocktail. Am J Emerg Med 1985;3(3):208-9.
- Wrenn K, Slovis CM, Gongaware J. Using the "GI cocktail": a descriptive study. Ann Emerg Med 1995;26(6):687-90.
- Simpson FG, Kay J, Aber CP. Chest pain--indigestion or impending heart attack? Postgrad Med J 1984;60(703):338-40.
- Davies HA, Page Z, Rush EM, Brown AL, Lewis MJ, Petch MC. Oesophageal stimulation lowers exertional angina threshold. Lancet 1985;1(8436):1011-4.