What is the treatment of choice for a 19-year-old patient presenting with symptoms of indigestion?

Treatment of Indigestion in a 19-Year-Old

For a 19-year-old with indigestion symptoms, test for H. pylori infection first (stool or breath test), and if positive, treat with antibiotics; if negative or symptoms persist after eradication, initiate a 4-8 week trial of a proton pump inhibitor (PPI) such as omeprazole 20 mg once daily before meals. 1, 2

Initial Diagnostic Approach

At age 19 without alarm features, you can make a clinical diagnosis of functional dyspepsia or GERD based on typical symptoms without requiring endoscopy. 1 Alarm features that would mandate immediate specialist referral and endoscopy include:

• Family history of esophageal or gastric cancer 1
• Unintended weight loss
• Progressive dysphagia
• Persistent vomiting
• Evidence of gastrointestinal bleeding

The likelihood of finding serious pathology like cancer in this age group remains extremely low, even with further investigation. 1

First-Line Management: H. pylori Testing

All patients with dyspepsia should be offered H. pylori testing via stool antigen test or urea breath test. 1 This is critical because:

• If positive, eradication therapy may resolve symptoms entirely 1
• Testing should occur before initiating PPI therapy when possible, as PPIs can cause false-negative results

H. pylori Eradication Regimens (if positive)

Triple therapy: Omeprazole 20 mg + amoxicillin 1000 mg + clarithromycin 500 mg, all taken twice daily for 10 days. 2 If an ulcer is present at initiation, continue omeprazole 20 mg once daily for an additional 18 days. 2

Alternative dual therapy: Omeprazole 40 mg once daily + clarithromycin 500 mg three times daily for 14 days, with an additional 14 days of omeprazole 20 mg once daily if ulcer present. 2

Second-Line: Empiric PPI Therapy

If H. pylori testing is negative, or if symptoms persist after successful eradication, provide a 4-8 week trial of single-dose PPI therapy. 1, 3

• Omeprazole 20 mg once daily taken before meals is the standard starting dose 2
• This approach is safe and appropriate for patients with typical reflux symptoms (heartburn, regurgitation, epigastric pain) without alarm symptoms 1
• Antacids may be used concomitantly for breakthrough symptoms 2

PPI Dosing Adjustments

• If symptoms persist after 4 weeks on once-daily dosing, escalate to twice-daily dosing before switching agents 1
• For symptomatic GERD in this age group, treatment duration is up to 4 weeks 2
• If symptoms resolve, titrate to the lowest effective dose or on-demand therapy 1, 4

Lifestyle and Dietary Modifications

Provide education on GERD mechanisms and lifestyle modifications as foundational therapy alongside pharmacotherapy. 1 Key recommendations include:

• Weight management if overweight 1
• Avoiding large meals, especially before bedtime 1
• Reducing intake of trigger foods (caffeine, alcohol, fatty foods, chocolate, mint) 1
• Elevating the head of the bed if nocturnal symptoms present 1
• Regular aerobic exercise has positive effects on GI symptoms 5

However, there is no evidence for specialized restrictive diets in functional dyspepsia, and excessive dietary restriction risks malnutrition or disordered eating. 1

When Symptoms Persist Despite Initial Therapy

If symptoms remain uncontrolled after optimizing PPI therapy and lifestyle modifications:

1. Consider neuromodulator therapy: Low-dose tricyclic antidepressants (TCAs) are effective for functional dyspepsia and visceral pain 1
2. Evaluate for psychological comorbidity: Stress, anxiety, and depression commonly coexist with functional GI disorders 1
3. Consider brain-gut behavioral therapies: Cognitive behavioral therapy or gut-directed hypnotherapy can be beneficial 1

Critical Pitfalls to Avoid

• Do not perform exhaustive investigations in young patients without alarm features - this delays treatment initiation and increases patient anxiety 1
• Emphasize PPI safety - address patient concerns about long-term use, as media reports have created unwarranted fear 1, 3
• Avoid opioid analgesics for dyspeptic pain, as they worsen GI motility and outcomes 5
• Do not overlook H. pylori testing - this is a potentially curative intervention that should not be skipped 1
• Avoid premature discontinuation of effective therapy once symptoms are controlled 4

Long-Term Management

Once symptoms are controlled, use on-demand therapy with the successful agent as an appropriate long-term strategy. 4 For patients who achieve symptom control:

• Wean to the lowest effective PPI dose 1, 4
• Consider switching to H2-receptor antagonists or antacids for maintenance if symptoms remain mild 1
• Regular follow-up every 3-6 months initially, then less frequently as symptoms stabilize 4