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Gisbert JP, Calvet X. Helicobacter Pylori "Test-and-Treat" Strategy for Management of Dyspepsia: A Comprehensive Review. Clin Transl Gastroenterol 2013; 4:e32. [PMID: 23535826 PMCID: PMC3616453 DOI: 10.1038/ctg.2013.3] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
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”.
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Affiliation(s)
- Javier P Gisbert
- Gastroenterology Unit, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa (IP) and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
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Rabeneck L, Souchek J, Wristers K, Menke T, Ambriz E, Huang I, Wray N. A double blind, randomized, placebo-controlled trial of proton pump inhibitor therapy in patients with uninvestigated dyspepsia. Am J Gastroenterol 2002; 97:3045-51. [PMID: 12492188 DOI: 10.1111/j.1572-0241.2002.07123.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES In patients with uninvestigated dyspepsia, a common initial management strategy in primary care is to prescribe a course of empiric antisecretory therapy and to refer those patients who do not respond for endoscopy. The objective of this research was to evaluate the effects of an empiric course of antisecretory therapy on dyspepsia-related health in patients with uninvestigated dyspepsia. METHODS We conducted a double blind, randomized, placebo-controlled trial in which patients with uninvestigated dyspepsia were randomized to a 6-wk course of omeprazole 20 mg p.o. b.id. versus placebo capsules p.o. bi.d. and followed over 1 yr. The patients were at least 18 yr old with at least a 1-wk history of dyspepsia without alarm features. Dyspepsia-related health was measured using the Severity of Dyspepsia Assessment (SODA), a valid, reliable, disease-specific outcome measure. The primary outcome was treatment failure, defined by a SODA Pain Intensity score > or = 29 (scores, 2-47) during follow-up. Patients who were treatment failures underwent endoscopy. RESULTS We enrolled 140 patients. The mean age was 51 yr, and seven (5%) were women. At 2 wk there were fewer treatment failures in the omeprazole group: 12 of 71 patients (17%) in the omeprazole group failed compared with 24 of 69 (35%) in the placebo group (p = 0.037, log rank test). Also, at 6 wk there were fewer failures in the omeprazole group: 21 of 71 patients (30%) in the omeprazole group failed compared with 31 of 69 (45%) in the placebo group in 0.067, log rank test). However, at the 1-yr follow-up, there was no significant difference in treatment failure rates in the two groups: 37 of 71 patients (52%) in the omeprazole group failed compared with 41 of 69 (59%) in the placebo group (p = 0.28, log rank test). CONCLUSIONS In patients with uninvestigated dyspepsia, as compared with a strategy that would entail prompt endoscopy for all patients, an initial 6-wk course of either placebo or omeprazole reduces the need for endoscopy over a 1-yr follow-up. Compared with placebo, an initial 6-wk course of omeprazole delays, but does not reduce, the need for endoscopy. For proton pump inhibitor therapy to reduce the need for endoscopy, it may need to be given continuously.
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Affiliation(s)
- Linda Rabeneck
- Department of Veterans Affairs Health Services Research and Development Center of Excellence and the Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
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Westbrook JI. Trends in the utilization of diagnostic upper GI endoscopy in New South Wales, Australia, 1988 to 1998. Gastrointest Endosc 2002; 55:847-53. [PMID: 12024139 DOI: 10.1067/mge.2002.124634] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Upper endoscopy is frequently performed, yet there are few published data regarding utilization trends. Such data provide an indication of changes in clinical practice over time and identify subpopulations who may be underexposed or overexposed to the procedure. METHODS Time series data were analyzed for all diagnostic upper endoscopies performed on residents of an Australia state between mid 1988 and mid 1998. Endoscopy rates by age, gender, and patient status (public vs. privately insured) were calculated. RESULTS In 1997/98 the endoscopy rate was 179 of 10,000. The majority were performed on publicly insured patients and women. Over the decade the rate increased by 128%. Rate increases were not constant across time, age, gender, or patient (insurance) status. The greatest increases occurred in the early to mid 1990s, and in patients less than 65 years of age. There was a greater increase (126%) among women 55 to 64 years of age compared with other age categories for both genders. Rates for publicly insured patients increased more than those for privately insured patients, particularly among individuals in the age range 25 to 34 years. Rates for private patients increased more for women than men (81% vs. 59%). CONCLUSIONS Rates of utilization of endoscopy increased dramatically during the period from 1988 to 1998, particularly during the earlier part of this decade. The cause(s) of the differences in subpopulation rates warrant investigation, as do their relationship to patient management and outcomes. These data provide opportunities for international comparisons.
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Affiliation(s)
- Johanna I Westbrook
- Centre for Health Informatics, University of New South Wales, Kensington, Australia
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Ofman JJ. What have we learned from recent dyspepsia trials? Curr Gastroenterol Rep 2000; 2:471-7. [PMID: 11079049 DOI: 10.1007/s11894-000-0011-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
Abstract
Dyspepsia is a common disorder and a frequent complaint of patients presenting for primary care. Understanding of the role of Helicobacter pylori has led to re-evaluation of management strategies for these patients. This article highlights results from clinical trials that have helped to clarify the role of empiric therapy, endoscopy, radiography, and H. pylori eradication in patients with nonulcer dyspepsia.
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Affiliation(s)
- J J Ofman
- Department of Medicine, Cedars-Sinai Health System, UCLA School of Medicine, Beverly Hills, CA 90212, USA.
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Sahai AV, Mishra G, Penman ID, Williams D, Wallace MB, Hadzijahic N, Pearson A, Vanvelse A, Hoffman BJ, Hawes RH. EUS to detect evidence of pancreatic disease in patients with persistent or nonspecific dyspepsia. Gastrointest Endosc 2000; 52:153-9. [PMID: 10922084 DOI: 10.1067/mge.2000.107910] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Mild chronic pancreatitis is difficult to diagnose and the diagnosis is therefore not sought routinely in patients with dyspepsia. The aim of our study was to compare the prevalence of endosonographic pancreatic abnormalities in patients with dyspepsia and control subjects. METHODS The number of endosonographic abnormalities was compared prospectively in patients with dyspepsia and control patients. Patients in whom there was any suspicion of pancreatic disease were analyzed separately. RESULTS Between November 1998 and January 1999, 156 patients with dyspepsia were compared with 27 control patients. The groups were similar except that control patients were significantly older and more likely to be men. The mean number of endosonographic abnormalities was higher in dyspeptic patients than in control patients (mean number of abnormalities 3.3: 95% CI [2.9, 3.6] vs. 1.9: 95% CI [0.3, 1.7]). The strongest independent predictors of severe endosonographic abnormalities (defined as 5 or more abnormalities) were the presence of suspected pancreatic disease (odds ratio 7.29: 95% CI [2.03, 26. 14]) and dyspepsia (odds ratio 7.21: 95% CI [1.99, 26.26]). In the dyspepsia group, no clinical variables were significant predictors of severe abnormalities. However, most patients had nonspecific-type dyspepsia or persistent symptoms after therapeutic trials of acid suppression. CONCLUSIONS Dyspepsia may be an atypical presentation of pancreatic disease in patients with persistent or nonspecific symptoms. Endosonography may be useful to screen for pancreatic disease in patients with persistent dyspepsia.
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Affiliation(s)
- A V Sahai
- Division of Gastroenterology and Hepatology/Digestive Disease Center, Medical University of South Carolina, Charleston, South Carolina, USA
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Affiliation(s)
- J P Gisbert
- Department of Gastroenterology, University Hospital of La Princesa, Madrid, Spain.
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Abstract
PURPOSE Dyspepsia is a common primary care condition, yet its optimal management is poorly defined. We reviewed the literature to answer the following questions about patients with dyspepsia: 1) Does endoscopy result in improved patient outcomes? 2) Does endoscopy result in a reduction in the use of subsequent medical resources? 3) Does endoscopy result in improved medical decision making? 4) Is endoscopy cost effective? METHODS We performed a systematic review of English-language articles in the MEDLINE, HEALTHSTAR, and EMBASE computerized bibliographic databases from January 1985 to July 1998. We included all studies, including decision analyses, with information about the effectiveness of endoscopy, as measured by its impact on patient outcomes, resource utilization, clinical decision making, or cost effectiveness. Two independent reviewers abstracted data from each study, and assessed its methodologic quality. RESULTS Twenty-one studies met the inclusion criteria. For 3 of the 4 clinical questions, the weight of evidence does not support the effectiveness of endoscopy. The largest randomized clinical trial comparing endoscopy with empiric therapy demonstrates equivalent symptoms and quality of life at 1 year, with increased patient satisfaction and lower costs for initial endoscopy. Suboptimal study design, including lack of appropriate comparison groups, limit studies measuring the impact of endoscopy on resource utilization and decision-making. Decision analyses indicate that noninvasive H pylori testing followed by anti-H pylori therapy or empiric antisecretory therapy is more cost effective than initial endoscopy. CONCLUSIONS With the exception of one randomized clinical trial, the preponderance of available data does not support the effectiveness of endoscopy in the management of dyspepsia. Prospective clinical trials that evaluate patient outcomes and resource utilization, and take H pylori status into account, are needed to determine the effectiveness of endoscopy in the management of dyspepsia.
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Affiliation(s)
- J J Ofman
- Department of Medicine and Health Services Research, Cedars Sinai Medical Center, University of California, Los Angeles, School of Medicine, USA
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Abstract
OBJECTIVE The conceptual revolution concerning the role of Helicobacter pylori in the pathogenesis of peptic ulcer disease has raised the larger question of how to integrate this new information into the management of patients with dyspepsia. The aim of this research was to critically evaluate current knowledge about dyspepsia and its management. METHODS Relevant articles on dyspepsia were identified from MEDLINE searches and from the bibliographies of identified articles. Studies that contained information on the prevalence of dyspepsia, endoscopic findings, and evaluations of alternative management strategies were reviewed. RESULTS By coupling H. pylori serological testing with clinical factors such as age and nonsteroidal antiinflammatory drug use, strategies have been developed that identify patients with organic disease. Although the use of these strategies can reduce the volume of endoscopies, their effects on dyspepsia symptoms are unknown. Computerized decision analysis models have been used to evaluate the cost-effectiveness of alternative strategies. The indirect evidence obtained from these models suggests that empiric therapy, guided by H. pylori testing, may be the preferred approach. However, the models have been hampered by the lack of information concerning dyspepsia symptoms, the primary health outcome of the majority of patients seen in primary practice settings. CONCLUSIONS Currently, the knowledge needed to integrate H. pylori tests and antimicrobial therapies into the management of patients with dyspepsia in primary practice settings has not been developed. A pressing need exists for a randomized controlled trial to evaluate alternative management strategies. In conducting such a trial, valid, reliable instruments for measuring dyspepsia will be needed.
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Affiliation(s)
- L Rabeneck
- Department of Veterans Affairs Medical Center, Houston, Texas 77030, USA
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Tosetti C, Stanghellini V. Management of dyspepsia in general practice. A critical assessment. PHARMACOECONOMICS 1998; 14 Suppl 2:57-66. [PMID: 10344924 DOI: 10.2165/00019053-199814002-00006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The International Gastro Primary Care Group (IGPCG) Upper Gastrointestinal Disease Management Plan is mainly characterised by the proposal that management of patients with upper gastrointestinal syndromes be based on the predominant symptom, rather than on symptom clusters. Although no study has directly tested this hypothesis in general practice, some data indirectly support the proposal. Classification based on the relevance of specific symptoms could identify distinct subgroups of patients with functional dyspepsia with at least partially different features. Data obtained from the literature are discussed and evaluated in relation to the suggested algorithm. Overall, this management plan for patients with dyspepsia seems to be both safe and effective. However, there is a need for prospective studies evaluating its actual validity.
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Affiliation(s)
- C Tosetti
- National Health System, Bologna, Italy
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Adang RP, Vismans JF, Talmon JL, Hasman A, Ambergen AW, Stockbrügger RW. Appropriateness of indications for diagnostic upper gastrointestinal endoscopy: association with relevant endoscopic disease. Gastrointest Endosc 1995; 42:390-7. [PMID: 8566625 DOI: 10.1016/s0016-5107(95)70037-4] [Citation(s) in RCA: 56] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Since the institution of open access endoscopy units there has been a considerable increase of referrals for UGI examinations. Therefore, guidelines for the appropriate use of UGI endoscopy are needed. METHODS The outcome of first diagnostic UGI endoscopy was prospectively assessed for several referral indications in a consecutive series of 2900 patients. Indications were judged "appropriate" when significantly (p < 0.01) associated with clinically "relevant" endoscopic findings. RESULTS The proportion of relevant disease for various indications was as follows: signs of UGI bleeding (42.2%); history of peptic ulcer (40.5%); dysphagia (31.9%), short-term (24.4%), and without therapy (20.9%). Relevant endoscopic findings were observed in 21.0% of dyspeptic patients aged 45 years or less, and in 25.3% of those older than 45 years of age. CONCLUSIONS The generally approved alarm symptoms should be a reason to perform endoscopy without hesitation. Dyspeptic symptoms, despite adequate empiric treatment, as well as first dyspeptic symptoms in patients older than 45 years should also be a reason for endoscopic investigation. Our results support the strategy to treat patients younger than 45 years who have isolated dyspepsia by a limited course of antipeptic agents, provided that they are seen for re-evaluation within 4 to 6 weeks.
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Affiliation(s)
- R P Adang
- Department of Gastroenterology and Hepatology, University Hospital, Maastricht, The Netherlands
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Stichele RHV, Petri H. Utilization patterns of subsidized and nonsubsidized reimbursable peptic ulcer medication in Belgium. Pharmacoepidemiol Drug Saf 1995. [DOI: 10.1002/pds.2630040404] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Affiliation(s)
- J F Morrissey
- Department of Medicine, University of Wisconsin Medical School, Madison 53792
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Goulston KJ, Dent OF, Mant A, Logan J, Ngu M. Use of H2-receptor antagonists in patients with dyspepsia and heartburn: a cost comparison. Med J Aust 1991; 155:20-6. [PMID: 1676825 DOI: 10.5694/j.1326-5377.1991.tb116372.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Under the Pharmaceutical Benefits Scheme, the use of H2-receptor antagonists (H2A) in the treatment of dyspepsia and heartburn is only subsidised when there is a proven diagnosis of ulcer. This study compared the costs of this Australian practice with a simulation of British practice, which allows unrestricted prescribing of subsidised H2A. DESIGN Patients with heartburn and/or dyspepsia were prospectively randomised to either a "British" group treated freely at the discretion of their general practitioner without necessarily being investigated or an "Australian" group where use of H2A was allowed only after gastroscopy or a barium meal had demonstrated a peptic ulcer or ulcerative oesophagitis. The patients were followed up for six months and all direct and indirect costs were recorded. SETTING Forty-nine Sydney general practitioners recruited primary care patients for the study. PATIENTS Any patient with heartburn or dyspepsia was considered for recruitment; 139 patients entered the study and 137 completed it. MAIN OUTCOME MEASURES The outcome measures were the costs of general practitioner consultations, specialist consultations, radiology and gastroscopy, other tests, H2A, other medications, personal costs, and total cost per patient. RESULTS The cumulative total cost per patient at the end of the study was equivalent in the "Australian" ($392) and "British" ($406) groups. A higher initial cost per patient of H2A in the "British" group was offset by a rapid decrease in the proportion that continued to use H2A and by the cost of specialist consultations and investigations in the "Australian" group. CONCLUSION Over a six-month period the cost of early investigation of heartburn and dyspepsia was equivalent to the cost of a therapeutic trial of H2A.
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Affiliation(s)
- K J Goulston
- Gastroenterology Unit, Repatriation General Hospital, Concord, NSW
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Hunt RH. Acid suppression. West J Med 1990. [DOI: 10.1136/bmj.301.6764.1330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Johannessen T, Petersen H, Kleveland PM, Dybdahl JH, Sandvik AK, Brenna E, Waldum H. The predictive value of history in dyspepsia. Scand J Gastroenterol 1990; 25:689-97. [PMID: 2396082 DOI: 10.3109/00365529008997594] [Citation(s) in RCA: 81] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Symptomatic patients referred to an open-access upper gastrointestinal endoscopy completed a detailed, self-administered questionnaire aimed at assessing the predictive value of history in dyspepsia. Nine hundred and thirty patients were suitable for analysis. Of these, 29% were found to have organic dyspepsia. A substantial overlap of symptoms and demographic data was found among the various endoscopic diagnoses. Discriminating variables were identified by stepwise logistic regression analysis and included in predictive score models. Pain relieved by antacids, age above 40 years, previous peptic ulcer disease, male sex, symptoms provoked by berries, and night pain relieved by antacids and food were found to predict organic dyspepsia with a sensitivity and specificity of approximately 70%, when applied on the observed material. Similar probabilities were found for score models of peptic ulcer and esophagitis. In general, the low prevalence of organic diseases resulted in low positive and high negative predictive values. Accordingly, the main impact of the predictive models may be to reduce the number of negative endoscopies rather than to predict a precise diagnosis. Independent of disease category and age, 41% of the subjects expressed a fear of malignancy, emphasizing the value of reassurance from a negative endoscopy.
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Affiliation(s)
- T Johannessen
- Dept. of Medicine, Trondheim Regional Hospital, Norway
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Kahn KL. A systematic approach to the initial evaluation of dyspepsia. J Gen Intern Med 1989; 4:461-2. [PMID: 2795269 DOI: 10.1007/bf02599702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Zell SC, Budhraja M. An approach to dyspepsia in the ambulatory care setting: evaluation based on risk stratification. J Gen Intern Med 1989; 4:144-50. [PMID: 2651600 DOI: 10.1007/bf02602357] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- S C Zell
- Department of Internal Medicine, University of Nevada School of Medicine, Reno
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Crump WJ. Reflux Esophagitis. Prim Care 1988. [DOI: 10.1016/s0095-4543(21)01055-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Petersen H. Over the counter sales of histamine-2 receptor antagonists. SCANDINAVIAN JOURNAL OF GASTROENTEROLOGY. SUPPLEMENT 1988; 155:20-2. [PMID: 2907682 DOI: 10.3109/00365528809096276] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Self treatment with H2 antagonists may have a positive impact on quality of life and costs. It may, however, also lead to incomplete peptic ulcer healing with frequent relapse and complications, inadequate long term treatment, neglectance of the life style type treatment for gastroesophageal reflux disease and a delay in the diagnosis of gastric malignancy. More research needs to be focused on the consequences of a more unrestricted and symptom guided use of H2 antagonists.
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Affiliation(s)
- H Petersen
- Department of Medicine, Trondheim Regional Hospital, Norway
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