What is the next step in managing a patient with chronic peptic duodenitis?

Management of Chronic Peptic Duodenitis

For a patient with duodenal biopsy showing chronic peptic duodenitis without sprue-like changes, the next step should be testing for Helicobacter pylori infection followed by appropriate acid suppression therapy with a proton pump inhibitor (PPI).

Initial Assessment and Testing

• Test for Helicobacter pylori infection using either a stool antigen test or carbon-urea breath test, which have similar accuracy to rapid urease testing of biopsies 1
• Avoid H. pylori serology testing as it has lower specificity compared to other non-invasive tests 1
• Consider potential contributing factors such as medications (especially NSAIDs), alcohol consumption, and smoking, which are common etiological factors in duodenitis 2

Treatment Algorithm

Step 1: H. pylori Management

• If H. pylori positive: Provide eradication therapy, which is strongly recommended with high-quality evidence 1
• Eradication therapy is efficacious for H. pylori-positive patients with functional dyspepsia, though adverse events are more common than with control therapy 1
• Confirmation of successful eradication is only recommended in patients with increased risk of gastric cancer 1

Step 2: Acid Suppression Therapy

• For all patients (regardless of H. pylori status): Start proton pump inhibitor (PPI) therapy 1
• PPIs are strongly recommended with high-quality evidence for functional dyspepsia and related conditions 1
• Use the lowest effective dose that controls symptoms as there is no apparent dose-response relationship 1
• Standard dosing (e.g., omeprazole 20mg, lansoprazole 30mg, pantoprazole 40mg, or rabeprazole 20mg daily) for 4-8 weeks is typically effective 3

Step 3: For Persistent Symptoms

• If symptoms persist despite PPI therapy, consider adding histamine-2 receptor antagonists, which are well-tolerated though supported by lower quality evidence 1
• For refractory symptoms, tricyclic antidepressants (TCAs) as gut-brain neuromodulators can be considered as second-line treatment 1
• Start TCAs at a low dose (e.g., amitriptyline 10mg once daily) and titrate slowly to a maximum of 30-50mg once daily 1

Lifestyle Modifications

• Recommend regular aerobic exercise, which is strongly recommended though based on very low-quality evidence 1
• Advise on avoiding specific food triggers that may exacerbate symptoms 1
• Caution against overly restrictive diets that could lead to nutritional deficiencies 1

Follow-up Recommendations

• If symptoms are controlled with initial therapy, consider a trial of withdrawal or reduction to the lowest effective dose 1
• For patients with persistent symptoms despite optimization of therapy, consider referral to gastroenterology in secondary care 1
• Indications for referral include diagnostic doubt, severe symptoms, refractoriness to first-line treatments, or patient request for specialist opinion 1

Important Considerations and Pitfalls

• Avoid unnecessary and repeated endoscopies if the diagnosis is established and there are no alarm symptoms 1
• Gastric emptying testing or 24-hour pH monitoring should not be undertaken routinely in patients with typical symptoms 1
• Opioids and surgery should be avoided in patients with severe or refractory symptoms to minimize iatrogenic harm 1
• Be aware that chronic peptic duodenitis may represent part of the pathophysiological spectrum of duodenal ulcer diathesis rather than a separate disease 4