Chapter 039. Nausea, Vomiting, and Indigestion (Part 9) Helicobacter pylori Eradication H. pylori eradication is clearly indicated only for peptic ulcer and mucosa- associated lymphoid tissue gastric lymphoma. The utility of eradication therapy in functional dyspepsia is less well established, but <15% of cases relate to this infection. Meta-analysis of 13 controlled trials calculated a risk ratio of 0.91, with a 95% confidence interval of 0.87–0.96, favoring H. pylori eradication therapy over placebo. Several drug combinations show efficacy in eliminating the infection (Chap. 287); most include 10–14 days of a proton pump inhibitor or bismuth subsalicylate in concert with two antibiotics. H. pylori infection is associated with reduced prevalence of GERD, especially in the elderly. However, eradication of the infection does not worsen GERD symptoms. To date, no consensus recommendations regarding H. pylori eradication in GERD patients have been offered. Gastrointestinal Motor Stimulants Motor stimulants (also known as prokinetics) such as metoclopramide, erythromycin, domperidone, and tegaserod have limited utility in GERD. The γ- aminobutyric acid B (GABA-B) agonist baclofen reduces esophageal acid exposure by inhibiting transient LES relaxations; the clinical benefits of this drug are yet to be defined in large trials. Several studies have evaluated the effectiveness of motor-stimulating drugs in functional dyspepsia; however, convincing evidence of their benefits has not been found. Some clinicians suggest that patients with symptoms resembling postprandial distress may respond preferentially to prokinetic drugs. Other Options Antireflux surgery (fundoplication) is offered to GERD patients who are young and may require lifelong therapy, have typical heartburn and regurgitation, and are responsive to proton pump inhibitors. Individuals who may respond less well to operative therapy include those with atypical symptoms, those with poor response to proton pump inhibitors, and those who have esophageal motor disturbances. Fundoplications are performed laparoscopically when possible and include the Nissen and Toupet procedures in which the proximal stomach is partly or completely wrapped around the distal esophagus to increase LES pressure. Dysphagia, gas-bloat syndrome, and gastroparesis may be long-term complications of these procedures. Endoscopic therapies for increasing the barrier function of the gastroesophageal junction, including radiofrequency energy delivery, suturing, biopolymer implantation, and gastroplication, have been investigated in patients with refractory GERD with variable results and some adverse consequences. Some patients with functional heartburn and functional dyspepsia refractory to standard therapies may respond to low-dose tricyclic antidepressants. Their mechanism of action is unknown but may involve blunting of visceral pain processing in the brain. Gas and bloating are among the most troubling symptoms in some patients with indigestion and can be difficult to treat. Dietary exclusion of gas-producing foods such as legumes and use of simethicone or activated charcoal provide symptom benefits in some patients. Therapies that modify gut flora, including antibiotics and probiotic preparations containing active bacterial cultures, are useful for cases of bacterial overgrowth and functional lower gastrointestinal disorders, but their utility in functional dyspepsia is unproven. Psychological treatments may be offered for refractory functional dyspepsia, but no convincing data suggest their efficacy. Further Readings Abell TL et al: Treatment of gastroparesis: A multidisciplinary clinical review. Neurogastroenterol Motil 18:263, 2006 [PMID: 16553582] DeVault KR, Castell DO: American College of Gastroenterology. Updated guidelines for the diagnosi s and treatment of gastroesophageal reflux disease. Am J Gastroenterol 100:190, 2005 [PMID: 15654800] Galmiche JP et al: Functional esophageal disorders. Gastroenterology 130:1459, 2006 [PMID: 16678559] Hasler WL, Chey WD: Nausea and vomiting. Gastroen terology 125:1860, 2003 [PMID: 14724837] Kahrilas PJ, Lee TJ: Pathophysiology of gastroesophageal reflux disease. Thor Surg Clin 15:323, 2005 [PMID: 16104123] Parkman HP et al: American Gastroenterological Association technical review on the diagnosis and treatment of gastroparesis. Gastroenterology 127:1592, 2004 [PMID: 15521026] Schwartzberg LS: Chemotherapy- induced nausea and vomiting: Clinician and patient perspectives. J Support Oncol 5(suppl 1):5, 2007 Tack J et al: Functional gastroduodenal d isorders. Gastroenterology 130:1466, 2006 [PMID: 16678560] Talley NJ et al: American Gastroenterological Association technical review on the evaluation of dyspepsia. Gastroenterology 129:1756, 2005 [PMID: 16285971] Talley NJ et al: Guidelines for the management of dyspepsia. Am J Gastroenterol 100:2324, 2005 [PMID: 16181387] Bibliography Quigley EM et al: American Gastroenterological Association technical review on nausea and vomiting. Gastroenterology 120:263, 2001 [PMID: 11208736] . Chapter 039. Nausea, Vomiting, and Indigestion (Part 9) Helicobacter pylori Eradication H. pylori eradication is clearly indicated only for peptic ulcer and mucosa- associated. to proton pump inhibitors, and those who have esophageal motor disturbances. Fundoplications are performed laparoscopically when possible and include the Nissen and Toupet procedures in which. implantation, and gastroplication, have been investigated in patients with refractory GERD with variable results and some adverse consequences. Some patients with functional heartburn and functional