Gastroesophageal reflux disease

• See Gastroesophageal Reflux Disease: Treatment for details.

Functional dyspepsia

• Reassurance and patient education
• Gas and bloating
  • Dietary exclusion of gas-producing foods such as legumes
  • Use of simethicone or activated charcoal benefits some patients
• Treating H. pylori infection (see below)
• Acid-suppressing medications
  • Meta-analysis of 8 controlled trials calculated a risk ratio of 0.86 (95% confidence interval 0.78–0.95) favoring proton pump inhibitor therapy over placebo.
    
    • The benefits of less potent acid-reducing therapies such as H₂ antagonists are unproved.
  • See Gastroesophageal Reflux Disease: Specific Treatments for doses.
• Prokinetic drugs (see below)
• Low-dose tricyclic antidepressants
  • For patients refractory to acid suppressants or prokinetic drugs
  • Mechanism of action is unknown but may involve blunting of visceral pain processing in the brain.
• Therapies that modify gut flora, including antibiotics and probiotic preparations containing active bacterial cultures, are useful for cases of bacterial overgrowth and functional lower GI disorders.
  • Utility in functional dyspepsia is unproved.
• Psychological treatments may be offered for refractory functional dyspepsia, but no convincing data suggest efficacy.

H. pylori eradication

• H. pylori eradication is indicated for peptic ulcer disease and gastric mucosa–associated lymphoid tissue lymphoma.
• The utility of eradication therapy in functional dyspepsia is less well established, but < 15% of cases relate to this infection.
  
  • Meta-analysis of 13 controlled trials calculated a risk ratio of 0.91 (95% confidence interval 0.87–0.96) favoring H. pylori eradication therapy over placebo.
• Several drug combinations show efficacy; most include 10–14 days of a proton pump inhibitor or bismuth subsalicylate in concert with 2 antibiotics. Examples include:
  • Amoxicillin 1 g PO bid and clarithromycin 500 mg PO bid + PPI (10 days with lansoprazole, omeprazole, pantoprazole, esomeprazole, 7 days with rabeprazole)
  • May substitute metronidazole 400 mg po daily for amoxicillin in the above regimen

Prokinetic medications

• GERD
  • Motor stimulants such as metoclopramide and erythromycin have limited utility in GERD.
  • The γ-aminobutyric acid B agonist baclofen reduces esophageal acid exposure by inhibiting transient LES relaxations; the clinical role of the drug is being studied.

• Functional dyspepsia
  • Several studies have evaluated the effectiveness of motor-stimulating drugs in functional dyspepsia.
  • Convincing evidence of their benefits has not been found.
  • Some clinicians suggest that patients with symptoms resembling postprandial distress may respond preferentially to prokinetic drugs.
  • Metoclopramide has some efficacy in functional dyspepsia.
    • May be given instead of acid suppressants as initial empirical therapy of young patients without alarm factors and without H. pylori infection.
    • These agents should not be used long term as there is a risk of serious side effects with long-term use.
• Dysmotility-like dyspepsia
  • Patients may respond preferentially to motor-stimulating drugs.