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If
H. pylori
is present in patients with
functional (inves-
tigated,
non-ulcer)
dyspepsia
,
eradication
therapy
should be provided.
If
symptoms
persist,
treatment
with either a proton pump inhibitor (section 1.3.5) or
a histamine H
2
-receptor antagonist (section 1.3.1) can
be given for 4 weeks. These antisecretory drugs can be
used intermittently to control
symptoms
long term.
However,
most
patients with functional
dyspepsia do
not benefit symptomatically from
H. pylori
eradication
therapy or antisecretory drugs.
Gastro-oesophageal reflux disease
Gastro-oesophageal
reflux disease (including non-ero-
sive
gastro-oesophageal
reflux
and
erosive
oeso-
phagitis)
is associated with heartburn,
acid regurgita-
tion,
and
sometimes,
difficulty
in
swallowing
(dysphagia);
oesophageal
inflammation (oesophagitis),
ulceration, and stricture formation may occur and there
is an association with asthma.
The management of gastro-oesophageal
reflux disease
includes drug treatment, lifestyle changes and, in some
cases, surgery. Initial treatment is guided by the severity
of symptoms and treatment is then adjusted according
to response.
The extent
of
healing depends
on the
severity of
the disease,
the treatment chosen,
and the
duration of therapy.
Patients with gastro-oesophageal
reflux disease should
be advised about lifestyle changes (avoidance of excess
alcohol
and of
aggravating foods such as fats);
other
measures include weight reduction,
smoking cessation,
and raising the head of the bed.
For
mild symptoms
of
gastro-oesophageal
reflux dis-
ease,
initial
management
may
include
the
use
of
antacids and alginates.
Alginate-containing antacids
can form a ‘raft’ that floats on the surface of the stomach
contents to reduce reflux and protect the oesophageal
mucosa.
Histamine H
2
-receptor antagonists (section
1.3.1)
may relieve symptoms and permit
reduction in
antacid consumption.
However,
proton pump inhi-
bitors (section 1.3.5)
provide more effective relief
of
symptoms than H
2
-receptor antagonists.
When symp-
toms abate,
treatment is titrated down to a level which
maintains remission (e.g.
by giving treatment intermit-
tently).
For
severe symptoms
of gastro-oesophageal
reflux dis-
ease or for patients with a proven or severe pathology
(e.g.
oesophagitis, oesophageal ulceration, oesophago-
pharyngeal
reflux,
Barrett’s oesophagus
),
initial
man-
agement involves the use of a proton pump inhibitor
(section 1.3.5);
patients need to be reassessed if symp-
toms persist
despite treatment
for
4–6 weeks with a
proton pump inhibitor.
When symptoms abate,
treat-
ment is titrated down to a level which maintains remis-
sion (e.g.
by reducing the dose of
the proton pump
inhibitor or by giving it intermittently, or by substituting
treatment
with a histamine H
2
-receptor
antagonist).
However,
for endoscopically confirmed
erosive,
ulcer-
ative
,
or
stricturing
disease,
or
Barrett’s oesophagus
,
treatment with a proton pump inhibitor usually needs to
be maintained at the minimum effective dose.
A prokinetic drug such as metoclopramide (section 4.6)
may improve
gastro-oesophageal
sphincter
function
and accelerate gastric emptying.
Children
Gastro-oesophageal
reflux disease is com-
mon in infancy but
most
symptoms resolve without
treatment between 12 and 18 months of age. In infants,
mild or moderate reflux without complications can be
managed
initially
by
changing
the
frequency
and
volume of
feed;
a feed thickener or thickened formula
feed can be used (with advice of a dietitian—see Appen-
dix 7 for
suitable products).
If
necessary,
a suitable
alginate-containing preparation can be used instead of
thickened feeds.
For older children,
life-style changes
similar to those for adults (see above) may be helpful
followed if
necessary by treatment
with an alginate-
containing preparation.
Children who do not respond to these measures or who
have problems such as respiratory disorders or
sus-
pected oesophagitis need to be referred to hospital;
an
H
2
-receptor antagonist (section 1.3.1) may be needed to
reduce acid secretion. If the oesophagitis is resistant to
H
2
-receptor blockade,
the proton pump inhibitor ome-
prazole (section 1.3.5) can be tried.
1.1.1
Antacids and simeticone
Antacids (usually containing aluminium or magnesium
compounds) can often relieve symptoms in
ulcer dys-
pepsia
and in
non-erosive gastro-oesophageal
reflux
(see also section 1.1);
they are also sometimes used in
functional
(non-ulcer)
dyspepsia but
the evidence of
benefit
is
uncertain.
Antacids
are best
given when
symptoms
occur
or
are
expected,
usually between
meals and at bedtime, 4 or more times daily; additional
doses may be required up to once an hour. Conventional
doses e.g. 10 mL 3 or 4 times daily of liquid magnesium–
aluminium antacids promote ulcer healing, but less well
than antisecretory drugs (section 1.3);
proof
of
a rela-
tionship between healing and neutralising capacity is
lacking.
Liquid preparations
are more effective than
tablet preparations.
Aluminium- and magnesium-containing antacids (e.g.
aluminium hydroxide,
and
magnesium carbonate,
hydroxide and trisilicate),
being relatively insoluble in
water,
are long-acting if retained in the stomach.
They
are suitable for
most
antacid purposes.
Magnesium-
containing antacids tend to be laxative whereas alumin-
ium-containing antacids may be constipating;
antacids
containing both magnesium and aluminium may reduce
these
colonic
side-effects.
Aluminium accumulation
does not appear to be a risk if renal function is normal.
The acid-neutralising capacity of preparations that con-
tain more than one antacid may be the same as simpler
preparations.
Complexes such as hydrotalcite confer
no special advantage.
Sodium bicarbonate should no longer be prescribed
alone for the relief of dyspepsia but it is present as an
ingredient
in many indigestion remedies.
However,
it
retains
a place in the management
of
urinary-tract
disorders (section 7.4.3)
and acidosis (section 9.2.1.3
and
section
9.2.2).
Sodium bicarbonate
should
be
avoided in patients on salt-restricted diets.
Bismuth-containing antacids (unless chelates) are not
recommended because absorbed bismuth can be neu-
rotoxic,
causing encephalopathy;
they tend to be con-
stipating.
Calcium-containing antacids (section 1.1.2)
44
1.1.1 Antacids and simeticone
BNF 61
1
Gastro-intestinal system