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

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