Chapter 039. Nausea, Vomiting, and Indigestion (Part 9) ppsx

The utility of eradication therapy in functional dyspepsia is less well established, but... pylori eradication in GERD patients have been offered.. Several studies have evaluated the eff

Chapter 039 Nausea, Vomiting,

and Indigestion

(Part 9)

Helicobacter pylori Eradication

H pylori eradication is clearly indicated only for peptic ulcer and

mucosa-associated lymphoid tissue gastric 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, with

a 95% confidence interval of 0.87–0.96, favoring H pylori eradication therapy

over placebo Several drug combinations show efficacy in eliminating the infection (Chap 287); most include 10–14 days of a proton pump inhibitor or

bismuth subsalicylate in concert with two antibiotics H pylori infection is

associated with reduced prevalence of GERD, especially in the elderly However, eradication of the infection does not worsen GERD symptoms To date, no

consensus recommendations regarding H pylori eradication in GERD patients

have been offered

Gastrointestinal Motor Stimulants

Motor stimulants (also known as prokinetics) such as metoclopramide, erythromycin, domperidone, and tegaserod have limited utility in GERD The γ-aminobutyric acid B (GABA-B) agonist baclofen reduces esophageal acid exposure by inhibiting transient LES relaxations; the clinical benefits of this drug are yet to be defined in large trials Several studies have evaluated the effectiveness of motor-stimulating drugs in functional dyspepsia; however, 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

Other Options

Antireflux surgery (fundoplication) is offered to GERD patients who are young and may require lifelong therapy, have typical heartburn and regurgitation, and are responsive to proton pump inhibitors Individuals who may respond less well to operative therapy include those with atypical symptoms, those with poor response to proton pump inhibitors, and those who have esophageal motor disturbances Fundoplications are performed laparoscopically when possible and include the Nissen and Toupet procedures in which the proximal stomach is partly

or completely wrapped around the distal esophagus to increase LES pressure Dysphagia, gas-bloat syndrome, and gastroparesis may be long-term complications of these procedures Endoscopic therapies for increasing the barrier function of the gastroesophageal junction, including radiofrequency energy delivery, suturing, biopolymer implantation, and gastroplication, have been investigated in patients with refractory GERD with variable results and some adverse consequences

Some patients with functional heartburn and functional dyspepsia refractory

to standard therapies may respond to low-dose tricyclic antidepressants Their mechanism of action is unknown but may involve blunting of visceral pain processing in the brain Gas and bloating are among the most troubling symptoms

in some patients with indigestion and can be difficult to treat Dietary exclusion of gas-producing foods such as legumes and use of simethicone or activated charcoal provide symptom benefits in some patients Therapies that modify gut flora, including antibiotics and probiotic preparations containing active bacterial cultures, are useful for cases of bacterial overgrowth and functional lower gastrointestinal disorders, but their utility in functional dyspepsia is unproven Psychological treatments may be offered for refractory functional dyspepsia, but

no convincing data suggest their efficacy

Further Readings

Abell TL et al: Treatment of gastroparesis: A multidisciplinary clinical review Neurogastroenterol Motil 18:263, 2006 [PMID: 16553582]

DeVault KR, Castell DO: American College of Gastroenterology Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease Am

J Gastroenterol 100:190, 2005 [PMID: 15654800]

Galmiche JP et al: Functional esophageal disorders Gastroenterology 130:1459, 2006 [PMID: 16678559]

Hasler WL, Chey WD: Nausea and vomiting Gastroenterology 125:1860,

2003 [PMID: 14724837]

Kahrilas PJ, Lee TJ: Pathophysiology of gastroesophageal reflux disease Thor Surg Clin 15:323, 2005 [PMID: 16104123]

Parkman HP et al: American Gastroenterological Association technical review on the diagnosis and treatment of gastroparesis Gastroenterology 127:1592, 2004 [PMID: 15521026]

Schwartzberg LS: Chemotherapy-induced nausea and vomiting: Clinician

and patient perspectives J Support Oncol 5(suppl 1):5, 2007

Tack J et al: Functional gastroduodenal disorders Gastroenterology 130:1466, 2006 [PMID: 16678560]

Talley NJ et al: American Gastroenterological Association technical review

on the evaluation of dyspepsia Gastroenterology 129:1756, 2005 [PMID: 16285971]

Talley NJ et al: Guidelines for the management of dyspepsia Am J Gastroenterol 100:2324, 2005 [PMID: 16181387]

Bibliography

Quigley EM et al: American Gastroenterological Association technical review on nausea and vomiting Gastroenterology 120:263, 2001 [PMID: 11208736]