WITHDRAWN: Initial management strategies for dyspepsia

Comparison of intravenous pantoprazole and ranitidine in patients with dyspepsia presented to the emergency department: a randomized, double blind, controlled trial

BACKGROUND

This study aimed to compare pantoprazole, a proton-pomp inhibitors (PPIs), and ranitidine, a H2 receptor antagonists (H2RA), in ceasing dyspeptic symptoms in the emergency department (ED).

METHODS

This randomized, double-blinded study compared the effectiveness of 50 mg ranitidine (Ulcuran(®)) and 40 mg pantoprazole (Pantpas(®)), given in a 100 mL saline solution by an intravenous rapid infusion within 2-4 minutes in patients with dyspepsia presented to the ED. Pain intensity was measured at baseline, 30 and 60 minutes after the drug administration.

RESULTS

A total of 72 patients were eligible for the study. Of these patients, 2 were excluded from the study because the initial visual analogue scale (VAS) scores were under 20 mm and 4 were excluded from the statistical analysis because of being diagnosed as having other causes of epigastric pain despite being allocated to one of the study groups. Thirty-three patients in the pantoprazole group and 33 patients in the ranitidine group were analyzed ultimately. The mean age of the patients was 36.6±15 years, and 26 (39.4%) patients were male. Both of the groups reduced pain effectively at 30 [27.6±28 (18 to 37) vs. 28.3±23 (20 to 37), respectively] and 60 minutes [39.6±39 (26 to 53) vs. 42.3±25 (33 to 51), respectively]. There were 13 (39.4%) patients in the pantoprazole group and 8 (24.2%) patients in the ranitidine group who required additional drug at the end of the study (P=0.186).

CONCLUSION

Intravenous pantoprazole and ranitidine are not superior to each other in ceasing dyspeptic symptoms at 30 and 60 minutes in the ED.

Helicobacter Pylori "Test-and-Treat" Strategy for Management of Dyspepsia: A Comprehensive Review

OBJECTIVES:

Deciding on whether the Helicobacter pylori test-and-treat strategy is an appropriate diagnostic–therapeutic approach for patients with dyspepsia invites a series of questions. The aim present article addresses the test-and-treat strategy and attempts to provide practical conclusions for the clinician who diagnoses and treats patients with dyspepsia.

METHODS:

Bibliographical searches were performed in MEDLINE using the keywords Helicobacter pylori, test-and-treat, and dyspepsia. We focused mainly on data from randomized controlled trials (RCTs), systematic reviews, meta-analyses, cost-effectiveness analyses, and decision analyses.

RESULTS:

Several prospective studies and decision analyses support the use of the test-and-treat strategy, although we must be cautious when extrapolating the results from one geographical area to another. Many factors determine whether this strategy is appropriate in each particular area. The test-and-treat strategy will cure most cases of underlying peptic ulcer disease, prevent most potential cases of gastroduodenal disease, and yield symptomatic benefit in a minority of patients with functional dyspepsia. Future studies should be able to stratify dyspeptic patients according to their likelihood of improving after treatment of infection by H. pylori.

CONCLUSIONS:

The test-and-treat strategy will cure most cases of underlying peptic ulcer disease and prevent most potential cases of gastroduodenal disease. In addition, a minority of infected patients with functional dyspepsia will gain symptomatic benefit. Several prospective studies and decision analyses support the use of the test-and-treat strategy. The test-and-treat strategy is being reinforced by the accumulating data that support the increasingly accepted idea that “the only good H. pylori is a dead H. pylori”.

Current management strategies and emerging treatments for functional dyspepsia

Functional dyspepsia refers to painful and nonpainful symptoms that are perceived to arise in the upper digestive tract but are not secondary to organic, systemic or metabolic diseases. The symptoms of this syndrome often overlap with those of GERD and IBS, making its management far from simple. If Helicobacter pylori infection is diagnosed in patients with functional dyspepsia, it should be treated. In patients with mild or intermittent symptoms, reassurance and lifestyle advice might be sufficient; in patients not responding to these measures, or in those with more severe symptoms, drug therapy should be considered. Both PPIs and prokinetics can be used in initial empirical pharmacotherapy based on symptom patterns--a PPI is more likely to be effective in the presence of retrosternal or epigastric burning or epigastric pain, whereas a prokinetic is more effective in dyspepsia with early satiation or postprandial fullness. Although combinations of PPIs and prokinetics might have additive symptomatic effects, single-drug therapy is initially preferable. Antidepressants or referral to a psychiatrist or psychotherapist can be considered in nonresponders and in those whose symptoms have a marked effect on daily functioning. Despite extensive research, functional dyspepsia treatment often remains unsatisfactory. Better characterization of dyspeptic subgroups and understanding of underlying mechanisms will enable treatment advances to be made in the future.