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

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 diagnosi
s 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. Gastroen
terology 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 d
isorders. 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]