What is the recommended management for acid peptic disease?

Management of Acid Peptic Disease

The recommended management for acid peptic disease begins with a 4-8 week trial of single-dose proton pump inhibitor (PPI) therapy for patients with typical reflux symptoms and no alarm symptoms, with escalation to twice-daily dosing or switching to a more potent acid suppressive agent if symptoms persist. 1

Initial Assessment and Diagnosis

Alarm Symptoms Requiring Immediate Evaluation

• Age ≥55 years with weight loss
• Age >40 years from an area with increased risk of gastric cancer or family history of gastroesophageal cancer
• Patients aged ≥60 years with abdominal pain and weight loss (urgent abdominal CT to exclude pancreatic cancer) 1
• Treatment-resistant dyspepsia with raised platelet count, nausea, or vomiting
• Regular NSAID use

Diagnostic Approach

1. H. pylori Testing: All patients without alarm symptoms should be offered non-invasive testing for H. pylori ("test and treat") 1
2. Endoscopy Indications:
   • PPI non-response
   • Presence of alarm symptoms
   • Isolated extra-esophageal symptoms
   • Patients meeting criteria for Barrett's esophagus screening 1

Treatment Algorithm

First-Line Management

1. H. pylori Positive Patients:

   • Eradication therapy (combination of PPI plus antibiotics) 1
   • Confirmation of successful eradication only needed in patients with increased risk of gastric cancer 1

2. H. pylori Negative or Post-Eradication:

   • For GERD/Reflux Symptoms:

     • PPI therapy (e.g., omeprazole 20mg, lansoprazole 30mg, pantoprazole 40mg, or rabeprazole 20mg daily) for 4-8 weeks 1, 2
     • PPIs are more effective than H2-receptor antagonists for symptom control 1

   • For Peptic Ulcer Disease:

     • Duodenal ulcers: Standard PPI dose for 2-4 weeks 2, 3
     • Gastric ulcers: Standard PPI dose for 4-8 weeks 2, 3
     • Discontinue NSAIDs if possible (heals 95% of ulcers) 3

   • For Functional Dyspepsia:

     • Ulcer-like dyspepsia (epigastric pain): PPI therapy 1
     • Dysmotility-like dyspepsia (fullness, bloating): Consider prokinetic agents 1
     • Regular aerobic exercise recommended 1

PPI Response Assessment

• If symptoms controlled: Titrate to lowest effective dose 1
• If inadequate response: Increase to twice-daily dosing or switch to more potent acid suppressive agent 1
• For long-term PPI therapy: Evaluate appropriateness within 12 months and consider objective reflux testing 1

Second-Line Management

1. For Persistent Symptoms:

   • Consider switching treatment approach (e.g., from prokinetic to PPI or vice versa) 1
   • Consider high-dose PPI trial 1
   • For functional dyspepsia: Tricyclic antidepressants (e.g., amitriptyline 10mg daily, titrated to 30-50mg) 1

2. Refractory Cases:

   • Refer for endoscopy if not previously done 1
   • Consider 24-hour pH-impedance monitoring on PPI for persistent symptoms 1
   • Multidisciplinary approach for severe/refractory functional dyspepsia 1

Special Considerations

Long-term PPI Therapy

• Generally safe but monitor for potential side effects (osteoporosis, GI infections, pneumonia) 1
• Use lowest effective dose 1, 2
• PPIs have different drug interaction profiles (omeprazole and lansoprazole have greater potential for interactions than pantoprazole and rabeprazole) 4, 5

NSAID Users

• Add PPI for gastroprotection when NSAIDs cannot be discontinued 3
• Consider changing to less ulcerogenic NSAID if possible 3
• Eradicate H. pylori if present 3

Barrett's Esophagus

• PPIs indicated for healing of associated ulceration
• No conclusive evidence that PPIs lead to resolution of Barrett's esophagus or reduce adenocarcinoma development 2

Common Pitfalls to Avoid

• Failing to test for H. pylori before initiating long-term PPI therapy
• Continuing full-dose PPI without attempting to reduce to lowest effective dose
• Not recognizing that patients with functional dyspepsia may not respond to acid suppression
• Overlooking potential drug interactions with PPIs, particularly in elderly patients on multiple medications 5
• Performing unnecessary gastric emptying testing or 24-hour pH monitoring in patients with typical dyspepsia symptoms 1