Symptoms Persist >4 Weeks?

• Although ulcer healing may take 8 weeks or more, the majority of patients with a gastric or duodenal ulcer have improvement in symptoms at 4 weeks [1].
• The yield of esophagogastroduodenoscopy is improved by limiting evaluation to those with persistent symptoms persisting despite a short course of therapy [1].
Management of Symptomatic Relapse
Dyspepsia often comes and goes. Some patients will experience recurrent symptoms despite symptom resolution with the initial management
• If previous dyspepsia symptoms recur 1 to 6 months after cessation of treatment, reevaluate person for alarm signals, taking into account timing of relapse and severity of symptoms [14].
• If previous dyspepsia symptoms recur after 6 months with no alarm signals, repeat empiric therapy [14]
• If the patient had an H. pylori infection previously then testing for eradication with either a stool antigen test or a breath test would be reasonable.
• If persistent H. pylori infection is identified, then retreatment with a regimen different from the regimen used earlier would be appropriate.
• If the patient was H. pylori negative either at time of initial management or at the time of the testing of eradication then another trial of acid suppression could be considered
• If symptoms resolve, no further care is necessary.
• If symptoms persist then an endoscopy should be considered.
Functional Dyspepsia
• When no structural or biochemical abnormalities are identified to explain symptoms, patients may be given a diagnosis of functional or non-ulcer dyspepsia.
• Such patients require reassurance, and further diagnostic testing should be kept to a minimum. No medical treatment is clearly of proven benefit [19].
• The goal is to help patients accept, diminish, and cope with symptoms rather then eliminate them [19].
• At present, no firm recommendations can be made regarding the management of non-ulcer dyspepsia.
• Further care for functional dyspepsia should be done on a case by case basis.
• Elimination of certain foods (e.g., caffeine, alcohol, fat, etc.) may help.
• Elimination of certain medications (e.g., NSAIDs) may help.
• Consider drug therapy in the following order [23]:
1. Prokinetics (domperidone, Itopride)
2. H2RAs
3. Proton pump inhibitors

• Eradication of H. pylori (if not already done but benefits only minority of patients), or low-dose tricyclic antidepressant, and exploration of the contribution of psychologic distress may prove beneficial.
• There is no significant benefit from antacids or sucralfate
• Visceral analgesics, such as the serotonin receptor antagonists, the somatostatin analogue octreotide, and the kappa receptor opioid agonist fedotozine, are undergoing evaluation in the management of functional digestive disorders such as functional dyspepsia [19].