Case Definition

Intermittent burning chest/epigastric painA,E,F,L,Paffected by eatingP

Peptic ulcer disease (PUD)C,G,P: Daily pain, gastrointestinal (GI) bleeding, weight lossE, or pain refractory to 4 weeks treatment with proton pump inhibitor (PPI)B

Consider possible contributing factors: dietG, obesityS, H. PyloriC,HGiardiaR, and soil transmitted helminthsR

Red Flags

Consider hospital referral for the following symptoms:

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

Management

Non-pharmacologic recommendations

1. Weight lossA,H

2. Avoid culprit foods/medications: NSAIDsAalcoholA,B, H, chocolate, citrus juice, and tomato-based productsA,H, spicy foodsB,H, consomme, large/fatty mealsA,H, and acidic instant coffeeB,H,I,

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

4. Wait 3 hours after a meal before lying downA,H, and elevate the head of the bed 8 inchesA,H

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

Pharmacologic management

Calcium/Magnesium antacid prnA,C,D,E, H or H2 blockerA,B,D,E,F,G,H,I,L,N,P,S (i.e. ranitidine 150mg po BID prn)

Reserve PPI treatmentA,B,D,E,F, G,L,P (i.e. omeprazole 20mg po QD) for suspected PUD or upper GI bleedingA

H. Pylori eradication
While expensiveN, consider H. pylori eradication if refractory to treatmentG, positive H. Pylori testB, or convincing symptoms suggestive of PUDI. Avoid antibiotics to which there has been prior exposureH.

Option 1: Amoxicillin 1g BID, and clarithromycin 500mg BID plus omeprazole for 10-14 daysB,F,G,I

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 dayH

Other options
In refractory cases, may consider albendazoleR to eradicate soil transmitted helminths, or longā€term oral vitamin B12 for chronic gastritis caused by pernicious anemiaH

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Organization A

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

Organization B

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

Organization C

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

Organization D

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

Organization E

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

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

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

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

Organization I

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

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

Organization K

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

Organization L

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

Organization M

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

Organization N

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

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

Organization P

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

Organization Q

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

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

Organization S

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

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