Ulcera Pepetica

Abstract
The main issue regarding the approach to the patient with uninvestigated dyspepsia are whether the symptoms are the result of important clinical illness which then determines the appropriate management strategy for treatment of the symptoms. A initial trial of empiric anti-secretory drugs is recommended for those without H. pylori infection and no alarm symptoms whereas H. pylorieradication is recommended for those with an active H. pylori infection. Treatment expectations for H. pylori infections should theoretically be similar to other common infectious diseases. In most regions clarithromycin resistance has undermined traditional triple therapy such that it is no longer a suitable choice as an empiric therapy. Four drug therapies such as sequential, concomitant, andbismuth-quadruple therapy are generally still acceptable choices as empiric therapies. Post eradication testing is highly recommended to provides early identification of otherwise unrecognized increasing antimicrobial resistance. However, despite the ability to successfully cure H. pylori infections, a symptomatic response can be expected in only a minority of those with dyspepsia not associated withulcers (so called non-ulcer dyspepsia). Overall, from the patients stand point, symptomatic relief is often difficult to achieve and physicians must relay on reassurance along with empiric and individualized care.

Keywords Dyspepsia; Helicobacter pylori; diagnosis; non-ulcer dyspepsia; gastric ulcer; H. pylori therapy

Case vignette
Scenario 1 A 57 year old Korean-American man presented with a 6month history of daily epigastric discomfort relieved by eating. He had not experienced this problem previously. There were no aggravating factors. He was otherwise healthy, had no other gastrointestinal complaints, and had not lost weight. He did not smoke and was a social drinker. He took no drugs. He had been born in Korea and had come to the United States at age 6 as an adoptee. The familyhistory was unknown. Physical examination and basic laboratory tests (complete blood count, basic metabolic panel, and urinalysis) were normal. The stool guaiac was negative.

Correspondence to: David Y Graham, M.D., Michael E. DeBakey Veterans Affairs Medical Center, Rm 3A-320 (111D), 2002 Holcombe Boulevard, Houston, USA-TX 77030, dgraham@bcm.tmc.edu, 713-795-0232.

Graham and Rugge

Page 2Scenario 2 same patient but 25 years old

NIH-PA Author Manuscript NIH-PA Author Manuscript NIH-PA Author Manuscript

The clinical problem
Dyspepsia (bad digestion) is a common (ie, 15 to 40% of the population) and perplexing global problem with a broad differential. Initially, patients are characterized as having “uninvestigated” dyspepsia which simply means that the patient has notundergone specific diagnostic investigations most especially upper gastrointestinal endoscopy. After an appropriate evaluation the patient would be recharacterized as either having dyspepsia associated with a specific disease (eg, peptic ulcer disease), condition (eg, NSAID use), or as functional dyspepsia. Dyspepsia like gastritis is a term has had variable use by both clinicians and patients. Someorder was introduced by the ROME meetings on functional gastrointestinal disorders which have since 1988 grappled with bringing order to a variety of common gastrointestinal symptom complexes (1;2). The ROME II criteria defined functional dyspepsia as pain or discomfort centered in the upper abdomen without a definite structural or biochemical explanation. More recent iterations have separatedpatients with substernal discomfort and typical heartburn from those with dyspepsia. The most recent ROME III criteria reclassified functional dyspepsia with two new symptom entities: epigastric pain syndrome and meal-related symptoms termed postprandial pain syndrome (3;4). These working definitions are expected to continue to evolve as new etiological conditions are identified allowing symptom...