What to do for a 12-year-old patient still experiencing burping after proton pump inhibitor (PPI) treatment with negative Helicobacter pylori (H. pylori) test?

Management of Persistent Burping in a 12-Year-Old After PPI Treatment with Negative H. pylori

For a 12-year-old with persistent burping despite PPI treatment and negative H. pylori testing, an endoscopy should be considered to evaluate for underlying causes, followed by treatment modifications including prokinetic agents, lifestyle changes, and possibly simethicone for symptomatic relief.

Diagnostic Evaluation

• For patients who fail initial PPI therapy and have persistent symptoms like burping, endoscopy should be considered to rule out structural causes and confirm the diagnosis 1
• During endoscopy, biopsies should be taken to confirm H. pylori status, as false negatives can occur with PPI use 1, 2
• PPIs can cause false-negative H. pylori test results, so consider repeating H. pylori testing after discontinuing PPI for at least 12 days if endoscopy is not immediately performed 2

Treatment Modifications

Medication Adjustments

• Consider increasing PPI dosing to twice daily before meals if once-daily dosing is insufficient 3
• For patients with dysmotility-like symptoms (including bloating and gas), adding a prokinetic agent may be beneficial 1
• Simethicone can provide relief for gas-related symptoms like burping, taken after meals and at bedtime (1-2 softgels as needed, not exceeding 2 softgels in 24 hours) 4
• Antacids can provide rapid, short-term relief for breakthrough symptoms 3
• Alginates can form a physical barrier and may be effective when added to PPI therapy 3

Lifestyle Modifications

• Implement dietary restrictions, including limiting fat intake and avoiding trigger foods such as:
  • Carbonated beverages, which can contribute to burping 3
  • Chocolate, mints, citrus products, and tomatoes 3
  • Coffee, tea, and alcohol 3
• Weight management is recommended for overweight patients 3
• Elevate the head of the bed for nighttime symptoms 3

Special Considerations for Pediatric Patients

• The urea breath test or stool antigen test are preferred noninvasive methods for H. pylori detection in children 5
• If H. pylori testing was performed while on PPI therapy, false negatives are possible, as PPIs can inhibit H. pylori growth and urease activity 2
• For pediatric patients with persistent symptoms despite PPI therapy, triple therapy with a PPI and two antibiotics may be considered if H. pylori is confirmed 5

Follow-up Recommendations

• If symptoms persist despite optimized medical therapy (PPI twice daily, lifestyle modifications, and adjunctive treatments), referral for specialized testing should be considered 3
• Reassess the diagnosis if symptoms continue despite treatment modifications 1
• For patients requiring long-term PPI therapy, be aware of potential risks including fractures, micronutrient deficiencies, and C. difficile infection 6

Important Caveats

• PPIs should be taken 30-60 minutes before meals for optimal effect 3
• H2-receptor antagonists may develop tolerance within 6 weeks of continuous use, potentially limiting their long-term effectiveness 3
• Long-term PPI use in H. pylori-positive patients may induce corpus-predominant pangastritis, which is associated with increased risk of atrophic gastritis 7
• If the patient requires long-term PPI therapy, H. pylori eradication should be considered to prevent potential complications 7, 8