Case Definition

Intermittent burning chest/epigastric pain1,5,6,12,16affected by eating16

Peptic ulcer disease (PUD)3,7,16: Daily pain, gastrointestinal (GI) bleeding, weight loss5, or pain refractory to 4 weeks treatment with proton pump inhibitor (PPI)2

Consider possible contributing factors: diet7, obesity19, H. Pylori3,8Giardia18, and soil transmitted helminths18

Red Flags

Consider hospital referral for the following symptoms:

1. Large volume hematemesis3
2. Typical cardiac chest pain/pressure radiating to shoulders, neck, jaw, or arms 3
3. Dyspnea or dizziness3

Management

Non-pharmacologic recommendations

1. Weight loss1,8

2. Avoid culprit foods/medications: NSAIDs1alcohol1,2, 8, chocolate, citrus juice, and tomato-based products1,8, spicy foods2,8, consomme, large/fatty meals1,8, and acidic instant coffee2,8,9,

3. Avoid factors that increase abdominal pressure and relax the lower esophageal sphincter: smoking, mint, anticholinergics, calcium channel blockers (CCBs), smooth muscle relaxants 8

4. Wait 3 hours after a meal before lying down1,8, and elevate the head of the bed 8 inches1,8

5. Traditional approaches: Women may loosen their faja/belt (which may push up on the esophageal sphincter)2; some may try ginger5

Pharmacologic management

Calcium/Magnesium antacid prn1,3,4,5, 8 or H2 blocker1,2,4,5,6,7,8,9,12,14,16,19 (i.e. ranitidine 150mg po BID prn)

Reserve PPI treatment1,2,4,5,6, 7,12,16 (i.e. omeprazole 20mg po QD) for suspected PUD or upper GI bleeding1

H. Pylori eradication
While expensive14, consider H. pylori eradication if refractory to treatment7, positive H. Pylori test2, or convincing symptoms suggestive of PUD9. Avoid antibiotics to which there has been prior exposure8.

Option 1: Amoxicillin 1g BID, and clarithromycin 500mg BID plus omeprazole for 10-14 days2,6,7,9

Option 2 (one-day protocol due to concerns of compliance and follow-up): Lansoprazole 60 mg QD x1 day, bismuth subsalicylate 524 mg QID x1 day, amoxicillin 2g QID x1 day, metronidazole 500 mg QID x1 day8

Other options
In refractory cases, may consider albendazole18 to eradicate soil transmitted helminths, or long‐term oral vitamin B12 for chronic gastritis caused by pernicious anemia8

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1. Organization A

Locations: Nicaragua
Trips per year: 4
Format of trips: Mobile medical clinics and standing clinics
Setting: Rural
Type of Organization: Secular

2. Organization B

Locations: Guatemala
Trips per year: Variable
Format of trips: Clinics
Setting: Rural
Type of Organization: Secular

3. Organization C

Locations: Haiti
Trips per year: Variable
Format of trips: Clinic
Setting: Urban
Type of Organization: Faith-based

4. Organization D

Locations: Dominican Republic
Trips per year: 3
Format of trips: Clinic
Setting: Rural
Type of Organization: Secular

5. Organization E

Locations: Haiti
Trips per year: 7
Format of trips: Not mentioned
Setting: Rural
Type of Organization: Secular

6. Organization F

Locations: Honduras, Ecuador, Belize, Guyana, Guatemala
Trips per year: 5
Format of trips: Mobile brigades
Setting: Rural and Urban
Type of Organization: Faith-based

7. Organization G

Locations: Ecuador, Guatemala, Dominican Republic
Trips per year: 100 (spread over 6 sites)
Format of trips: Mobile brigades
Setting: Rural and Urban
Type of Organization: Secular

8. Organization H

Locations: Ecuador
Trips per year: 3
Format of trips: Mobile brigades in schools/Clinics in health centers
Setting: Rural
Type of Organization: Secular

9. Organization I

Locations: Honduras
Trips per year: 1
Format of trips: Mobile brigades in 20 villages
Setting: Rural
Type of Organization: Faith-based

10. Organization J

Locations: Jamaica, Haiti
Trips per year: 4
Format of trips: Mobile brigades, Permanent clinics/hospital medicine
Setting: Rural and urban
Type of Organization: Secular

11. Organization K

Locations: Haiti
Trips per year: 4
Format of trips: Clinic
Setting: Rural
Type of Organization: Secular

12. Organization L

Locations: Guatemala, Nicaragua
Trips per year: 3
Format of trips: Mobile clinics
Setting: Rural
Type of Organization: Faith-based

13. Organization M

Locations: Nicaragua, Honduras
Trips per year: 51
Format of trips: Mobile brigades, Hospital-based
Setting: Rural
Type of Organization: Faith-based

14. Organization N

Locations: Guatemala
Trips per year: 12
Format of trips: Hospital
Setting: Rural
Type of Organization: Secular

15. Organization O

Locations: Honduras
Trips per year: Up to 50
Format of trips: Mobile brigades in school and churches
Setting: Rural
Type of Organization: Faith-based

16. Organization P

Locations: Haiti
Trips per year: Variable
Format of trips: Mobile brigades and clinics
Setting: Rural and urban
Type of Organization: Secular

17. Organization Q

Locations: Dominican Republic, Haiti
Trips per year: 12 to 15
Format of trips: Mobile brigades
Setting: Rural
Type of Organization: Secular

18. Organization R

Locations: Honduras, Nicaragua, Panama
Trips per year: Hundreds
Format of trips: Mobile brigades in community centre or school
Setting: Rural
Type of Organization: Secular

19. Organization S

Locations: Honduras
Trips per year: 4
Format of trips: Mobile brigades, Specialty hospital services
Setting: Rural
Type of Organization: Secular

20. Organization T

Locations: Haiti
Trips per year: Approximately 40
Format of trips: Mobile clinics in 14 villages and Standing clinic
Setting: Rural
Type of Organization: Faith-based