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

Table 39-3 Alarm Symptoms in GERDOdynophagiaUnexplained weight lossRecurrent vomitingOccult or gross gastrointestinal bleedingJaundicePalpable mass or adenopathyFamily history of gastrointestinal malignancyUpper 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.
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Chapter 039. Nausea, Vomiting, and Indigestion (Part 8) Chapter 039. Nausea, Vomiting, and Indigestion (Part 8)Table 39-3 Alarm Symptoms in GERDOdynophagiaUnexplained weight lossRecurrent vomitingOccult 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 withunexplained dyspepsia who are >55 years old or have alarm factors because of theelevated risks of malignancy and ulcer in these groups. The management approachto patients infection. In each of these patient subsets, upper endoscopy is reserved for thosewho fail to respond to therapy. Further testing is indicated if other factors are present. If bleeding isreported, a blood count is obtained to exclude anemia. Thyroid chemistries orcalcium levels screen for metabolic disease, whereas specific serologies maysuggest celiac disease. For suspected pancreaticobiliary causes, pancreatic andliver chemistries are obtained. If abnormalities are found, abdominal ultrasound orCT may give important information. Gastric emptying scintigraphy is consideredto exclude gastroparesis in patients whose dyspeptic symptoms resemblepostprandial distress when drug treatment fails. Gastric scintigraphy also assessesfor gastroparesis in patients with GERD, especially if surgical intervention isbeing considered. Breath testing after carbohydrate ingestion may detect lactasedeficiency, intolerance to other dietary carbohydrates, or small-intestinal bacterialovergrowth. Indigestion: Treatment General Principles For mild indigestion, reassurance that a careful evaluation revealed noserious organic disease may be the only intervention needed. Drugs that cause acidreflux or dyspepsia should be stopped if possible. Patients with GERD shouldlimit ethanol, caffeine, chocolate, and tobacco use because of their effects on theLES. Other measures in GERD include ingesting a low-fat diet, avoiding snacksbefore 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 areindicated for lactase deficiency or celiac disease. Some illnesses such as pepticulcer disease may be cured by specific medical regimens. However, as mostindigestion is caused by GERD or functional dyspepsia, medications that reducegastric 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 forGERD. Histamine H2 antagonists such as cimetidine, ranitidine, famotidine, andnizatidine are useful in mild to moderate GERD. For severe symptoms or manycases of erosive or ulcerative esophagitis, proton pump inhibitors such asomeprazole, lansoprazole, rabeprazole, pantoprazole, or esomeprazole are needed.These drugs, which inhibit gastric H+, K+-ATPase activity, are more potent thanH2 antagonists. Acid suppressants may be taken continuously or on demanddepending on symptom severity. Many patients initially started on a proton pumpinhibitor can be stepped down to an H2 antagonist. Combination therapy with aproton pump inhibitor and an H2 antagonist has been proposed for some refractorycases. Acid-suppressing drugs are also effective in appropriately selected patientswith functional dyspepsia. Meta-analysis of eight controlled trials calculated a riskratio of 0.86, with a 95% confidence interval of 0.78–0.95, favoring proton pumpinhibitor therapy over placebo. The benefits of less potent acid reducing therapiessuch as H2 antagonists are unproven. Liquid antacids are useful for short-term control of mild GERD but are lesseffective 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 floatingbarrier to acid reflux in individuals with upright symptoms. Sucralfate is a salt ofaluminum hydroxide and sucrose octasulfate that buffers acid and binds pepsinand bile salts. Its efficacy in GERD is felt to be comparable to that of H 2antagonists.