Dyspepsia management

Increase pH of stomach to neutralise stomach acid, bind to and inactivate pepsin

1st line: aluminium hydroxide, magnesium carbonate, magnesium trisilicate

Aluminium salts may cause constipation

Magnesium salts may cause diarrhoea

Hydroxides are contraindicated in people with hypophosphataemia

Examples: ranitidine, (cimetidine)

Competitively block action of histamine to decrease acid production.

Cimetidine is a CYP450 inhibitor

Proton pump inihibitors

Examples: omeprazole, lansoprazole

Irreverible inhibition of H/K ATPase responsible for H secretion

Issues:

• C. difficile risk with PPIs and Abx
• electrolyte disturbance
• drug interactions (e.g. with clopidogrel)

Test for H. pylori with carbon 13 urea breath test (can also do faecal Ag, serum Ab or rapid urease test on endoscopic samples)

Triple therapy = PPI/amoxicillin/clarithromycin OR PPI/amoxicillin/metronidazole

If eradication failure, quadruple therapy = omeprazole/tetracycline/metronidazole/bismuth chelate

Heal ulcer:

• antisecretory medication (PPI): 4-8wks if H. pylori negative, 8wks if H. pylori positive
• IV PPI if upper GI bleed
• gastric ulcer: repeat endoscopy 6-8wks post-treatment (risk of gastric cancer)
• duodenal ulcer: no repeat endoscopy required

H. pylori eradication: reduces recurrence, retest for H. pylori 6-8wks post-treatment

Stop NSAID use if possible

Surgery if: failed medical/endoscopic management in upper GI bleed, complications of PUD

May need long-term PPI if using NSAIDs and: age >65, history of PUD (especially with complications), high-dose NSAIDs (especially in combo with aspirin/SSRIs/anticoagulants), or in any elderly patient taking aspirin

Full-dose PPI for 4-8wks then low-dose PPI maintenance

Long-term full-dose PPI maintenance if:

• severe oesophagitis
• oesophageal stricture

Consider OGD surveillance of patients with Barrett's oesophagus with evidence of dysplasia