Chapter 039. Nausea, Vomiting, and Indigestion (Part 8) pptx

Chapter 039. Nausea, Vomiting, and Indigestion (Part 8) Table 39-3 Alarm Symptoms in GERD Odynophagia Unexplained weight loss Recurrent vomiting Occult or gross gastrointestinal bleeding Jaundice Palpable mass or adenopathy Family history of gastrointestinal malignancy Upper endoscopy is performed as the initial diagnostic test in patients with unexplained dyspepsia who are >55 years old or have alarm factors because of the elevated risks of malignancy and ulcer in these groups. The management approach to patients <55 years old without alarm factors is dependent on the prevalence of H. pylori infection in the local population. For individuals who reside in regions with low H. pylori prevalence (<10%), a 4-week trial of a potent acid-suppressing medication such as a proton pump inhibitor is recommended. If this fails, a "test and treat" approach is most commonly applied. H. pylori status is determined with urea breath testing, stool antigen measurement, or blood serology testing. Those who are H. pylori positive are given therapy to eradicate the infection. If symptoms resolve on either of these regimens, no further intervention is required. For patients in areas with high H. pylori prevalence (>10%), an initial test and treat approach is advocated, with a subsequent trial of an acid-suppressing regimen offered for those who fail H. pylori treatment or for those who are negative for the infection. In each of these patient subsets, upper endoscopy is reserved for those who fail to respond to therapy. Further testing is indicated if other factors are present. If bleeding is reported, a blood count is obtained to exclude anemia. Thyroid chemistries or calcium levels screen for metabolic disease, whereas specific serologies may suggest celiac disease. For suspected pancreaticobiliary causes, pancreatic and liver chemistries are obtained. If abnormalities are found, abdominal ultrasound or CT may give important information. Gastric emptying scintigraphy is considered to exclude gastroparesis in patients whose dyspeptic symptoms resemble postprandial distress when drug treatment fails. Gastric scintigraphy also assesses for gastroparesis in patients with GERD, especially if surgical intervention is being considered. Breath testing after carbohydrate ingestion may detect lactase deficiency, intolerance to other dietary carbohydrates, or small-intestinal bacterial overgrowth. Indigestion: Treatment General Principles For mild indigestion, reassurance that a careful evaluation revealed no serious organic disease may be the only intervention needed. Drugs that cause acid reflux or dyspepsia should be stopped if possible. Patients with GERD should limit ethanol, caffeine, chocolate, and tobacco use because of their effects on the LES. Other measures in GERD include ingesting a low-fat diet, avoiding snacks before bedtime, and elevating the head of the bed. Specific therapies for organic disease should be offered when possible. Surgery is appropriate in disorders like biliary colic, while diet changes are indicated for lactase deficiency or celiac disease. Some illnesses such as peptic ulcer disease may be cured by specific medical regimens. However, as most indigestion is caused by GERD or functional dyspepsia, medications that reduce gastric acid, stimulate motility, or blunt gastric sensitivity are indicated. Acid-Suppressing or Neutralizing Medications Drugs that reduce or neutralize gastric acid are most often prescribed for GERD. Histamine H 2 antagonists such as cimetidine, ranitidine, famotidine, and nizatidine are useful in mild to moderate GERD. For severe symptoms or many cases of erosive or ulcerative esophagitis, proton pump inhibitors such as omeprazole, lansoprazole, rabeprazole, pantoprazole, or esomeprazole are needed. These drugs, which inhibit gastric H + , K + -ATPase activity, are more potent than H 2 antagonists. Acid suppressants may be taken continuously or on demand depending on symptom severity. Many patients initially started on a proton pump inhibitor can be stepped down to an H 2 antagonist. Combination therapy with a proton pump inhibitor and an H 2 antagonist has been proposed for some refractory cases. Acid-suppressing drugs are also effective in appropriately selected patients with functional dyspepsia. Meta-analysis of eight controlled trials calculated a risk ratio of 0.86, with a 95% confidence interval of 0.78–0.95, favoring proton pump inhibitor therapy over placebo. The benefits of less potent acid reducing therapies such as H 2 antagonists are unproven. Liquid antacids are useful for short-term control of mild GERD but are less effective for severe disease unless given at high doses that elicit side effects (diarrhea and constipation with magnesium- and aluminum-containing agents, respectively). Alginic acid in combination with antacids may form a floating barrier to acid reflux in individuals with upright symptoms. Sucralfate is a salt of aluminum hydroxide and sucrose octasulfate that buffers acid and binds pepsin and bile salts. Its efficacy in GERD is felt to be comparable to that of H 2 antagonists. . Chapter 039. Nausea, Vomiting, and Indigestion (Part 8) Table 39-3 Alarm Symptoms in GERD Odynophagia Unexplained weight. with upright symptoms. Sucralfate is a salt of aluminum hydroxide and sucrose octasulfate that buffers acid and binds pepsin and bile salts. Its efficacy in GERD is felt to be comparable to that. ethanol, caffeine, chocolate, and tobacco use because of their effects on the LES. Other measures in GERD include ingesting a low-fat diet, avoiding snacks before bedtime, and elevating the head of