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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