Many patients with nonulcer dyspepsia have abnormalities of gastric emptying and increased pain perception in the gastrointestinal tract, suggesting that the condition is part of the spectrum of irritable bowel syndrome (see Chapter 32). Patients with predominant epigastric pain or reflux symptoms may improve with simple antacids taken as needed. More severe symptoms may require antisecretory drugs, particularly a proton pump inhibitor, although the response rate is lower (40-50%) than in patients with documented pathology. Where the main symptom is bloating, a prokinetic agent (metoclopramide or domperidone, see below) is preferred.
Flatulent patients may benefit from carminatives, substances which are held to assist expulsion of gas from the stomach and intestines. Examples are: dimethicone, peppermint, dill, anise and other herbs which are commonly included in liqueurs and (in nonalcoholic solutions) for babies. The problem is not new. The Roman Emperor Claudius (AD 10-54) planned an edict to legitimise the breaking of wind at table, either silently or noisily, after hearing about a man who was so modest that he endangered his health by an attempt to restrain himself [Suetonius (trans) R Graves],
Bitters are substances taken before meals to improve appetite. They have not been scientifically investigated. They include gentian, nux vomica and quinine. Preparations can be found in formularies and at wine merchants (Dubonnet, Campari).
The incidence of Helicobacter pylori colonisation in patients with nonulcer dyspepsia is not significantly different from that in the general population and eradication of the organism provides, at best, only one-quarter of patients with prolonged symptomatic improvement (a proportion that is similar to the placebo response for this condition).
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