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Case definition

Intermittent burning chest/epigastric pain affected by eating

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

Consider possible contributing factors: diet, obesity, H. Pylori, Giardia, and soil transmitted helminths.

Consider hospital referral for the following symptoms:

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

Clinical management

1. Weight loss

2. Avoid culprit foods/medications: NSAIDs, alcohol, chocolate, citrus juice, and tomato-based products, spicy foods, consomme, large/fatty meals, and acidic instant coffee

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

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

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

Pharmacologic management

Calcium/Magnesium antacid prn or H2 blocker (i.e. ranitidine 150mg po BID prn)

Reserve PPI treatment (i.e. omeprazole 20mg po QD) for suspected PUD or upper GI bleeding

H. Pylori eradication
While expensive, consider H. pylori eradication if refractory to treatment, positive H. Pylori test, or convincing symptoms suggestive of PUD. Avoid antibiotics to which there has been prior exposure.

Option 1: Amoxicillin 1g BID, and clarithromycin 500mg BID plus omeprazole for 10-14 days

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 day

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

Adapted from:
Dainton, C., and Chu, C. 2017. A review of gastrointestinal protocols for primary care medical service trips (MSTs) in Latin America and the Caribbean. International Health.