Stomach Problems – Causes, Symptoms, Diagnosis, Treatment

Treatment of

The goals of managing stomach problems are to address the resolution of symptoms and prevent complications such as esophagitis, BE, and esophageal adenocarcinoma. Treatment options include lifestyle modifications, medical management with antacids and antisecretory agents, surgical therapies, and endoluminal therapies.

Lifestyle modifications

Lifestyle modifications are considered to be the cornerstone of any stomach problems therapy. Counseling should be provided about the importance of weight loss given that underlying obesity is a significant risk factor for the development of stomach problems, and studies have shown that weight gain in individuals with a normal BMI has been associated with the development of stomach problem symptoms [rx]. Individuals should also be counseled about avoiding meals at least 3 hours before bedtime and maintaining good sleep hygiene as it has been shown that minimal disturbances in sleep are associated with suppression of TLESRs, resulting in decreased reflux episodes[rx] [rx]. Studies have also shown improvement in stomach problems symptoms and pH monitoring studies with the elevation of the head end of the bed. Diet modification with the elimination of chocolate, caffeine, and spicy foods, citrus, and carbonated beverages in stomach problems is controversial and is not routinely recommended as per current ACG guidelines[rx].

Medical Therapy

Medical therapy is indicated in patients who do not respond to lifestyle modifications. Medical therapy is comprised of antacids antisecretory agents like histamine (H2) receptor antagonists (H2RAs) or PPI therapy and prokinetic agents. Currently, there are two US Food and Drug Administration (FDA) approved H2RAs (famotidine and cimetidine) available in the US and are available over-the-counter. The other commonly used H2RA known as ranitidine has been recalled as a potential health hazard or safety risk due to an unexpected impurity in the active ingredient. The less commonly known prescription-only H2RA nizatidine has also been recalled as well due to similar concerns. In the US, there are six PPIs that are currently available, of which three (omeprazole, lansoprazole, and esomeprazole) are available over-the-counter, and the remaining three (pantoprazole, dexlansoprazole, and rabeprazole) are prescription-only medications. Of the available medical options, PPI therapy is considered to be the most effective for both erosive and non-erosive stomach problems based on multiple large-scale studies. These studies have also shown improved symptom control, healing of underlying esophagitis, and decreased relapse rates compared to H2RAs [rx][rx]. ACG guidelines recommend PPI therapy to be initiated at once a day dosing before the first meal of the day[rx]. Patients with incomplete responses to once-daily dosing can be treated with twice-daily dosing or adjustment of dose timing, specifically in patients with nighttime symptoms [rx]. As needed, bedtime administration of H2RAs is recommended for individuals with nighttime symptoms not optimized with maximal PPI therapy[rx]. The role of prokinetic agents such as metoclopramide and domperidone in stomach problems is limited due to lack of data and also due to their profound adverse effects on the central nervous system and cardiovascular system.

Antibiotic therapy

Not every patient, even with a known bacterial etiology, should be given antibiotic therapy, especially with Shiga toxin-producing E. coli. Empiric antibiotic therapy with azithromycin or fluoroquinolones can be indicated in severe illness (e.g., greater than 6 stools in a day, fever, need for hospitalization), specific host factors (e.g., age greater than 70 years, immunocompromised host, having co-morbidities), and features suggesting of the invasive organisms (e.g., blood or mucus in stool) but should be discontinued if EHEC is isolated. Tetracyclines have the greatest efficacy for Vibrio. For pregnant patients with the suspicion of Listeria, ampicillin is the drug of choice. For C. difficile infection (CDI), discontinuation of the causative antibiotic and antibiotic therapy should be initiated. It should be noted that recent Centers for Disease Control and Prevention guidelines changed in March 2018 and now recommend either oral vancomycin or fidaxomicin for nonsevere over oral metronidazole for severe CDI. Combination therapy of oral vancomycin with IV metronidazole should be used for fulminant CDI.

Symptomatic therapy

Loperamide can be given carefully in patients who are afebrile and have non-bloody diarrhea.[rx]

Surgical therapy

Patients who present with either medically refractory stomach problems, noncompliance, or experience side effects with medical therapy, underlying large hiatal hernia, or individuals who desire to discontinue long-term medical treatment can be considered for surgical management[rx]. The available surgical options for stomach problems are laparoscopic Nissen fundoplication, Laparoscopic anterior 180° fundoplication (180° LAF), or bariatric surgery in obese patients[rx]. Laparoscopic Nissen fundoplication has been the gold standard surgical treatment in the management of stomach problems patients. However, given the rapid prevalence of obesity in the United States, gastric bypass surgery is becoming the most common surgical treatment for stomach problems [rx]. It should be considered in obese patients with symptoms of stomach problems who prefer surgical therapy[rx][rx][rx][rx][rx]. Current ACG guidelines recommend performing preoperative ambulatory pH monitoring in patients without erosive esophagitis and esophageal manometry to rule out achalasia or undiagnosed scleroderma-like esophagus prior to surgical therapy [rx]. Two large meta-analyses comparing medical therapy with surgical therapy reported contrary conclusions with one reporting improvement of symptoms of stomach problems after surgery compared with medical therapy and others reporting considerable uncertainty in the benefits of surgical therapy compared to medical therapy [rx][rx][rx]. However, patients undergoing fundoplication are at risk for developing postoperative adverse events that include bloating, which is seen in 15 to 20% of patients, dysphagia, and belching. The most common bariatric surgeries performed are Roux-en-Y gastric bypass (RYGB), laparoscopic adjustable gastric banded plication (LAGP), and sleeve gastrectomy[rx]. Studies have shown that the resulting weight loss from surgical management of obesity has had positive effects on stomach problems. Of all the bariatric surgeries available, RYGB has proven to be the most effective bariatric surgery for reducing stomach problems symptoms[rx]. It is recommended as the bariatric procedure of choice in patients with severe stomach problems npreoperatively[rx].

Endoluminal Therapy

In the era of minimally invasive surgery techniques, many different types of endoscopic therapies have been developed for stomach problem management. Most of them were discontinued after failing to demonstrate long-term efficacy. The current available endoluminal therapies include magnetic sphincter augmentation (MSA) and transoral incision-less fundoplication using the EsophyX (EndoGastric Solutions, Redmond, WA, United States)[rx].  A recent meta-analysis by Gerson et al. that included data from 233 patients demonstrated that subjects who underwent TIF 2.0 procedure had improved esophageal pH, decreased need for PPIs, and significant improvement in the quality of life at three years after the TIF 2.0 procedure [rx]. Another prospective study by Testoni et al. demonstrated TIF with EsophyX as an effective long-term treatment option for patients with symptomatic stomach problems with associated hiatal hernia less than 2 cm. A meta-analysis comparing Nissen fundoplication and magnetic sphincter augmentation that included data from patients who underwent MSA and the rest who were treated with Nissen fundoplication concluded that MSA was an effective therapeutic option for stomach problems as short-term outcomes with magnetic sphincter augmentation appeared to be comparable to Nissen fundoplication[rx].

Avoid the Following Foods

There are certain foods that can worsen bloating and cause gassiness. These include the following:

• Lentils and beans contain indigestible sugars which are broken down by bacteria, resulting in the generation of gas[rx]
• Fruits and vegetables like carrots, cabbage, Brussel sprouts,  prunes, and apricots also cause gassiness
• Artificial sweeteners like sorbitol are not easy to digest and hence are broken down by bacteria to produce gas.
• Patients with meteorism should avoid dairy products, as they can worsen the bloating sensation.
• Wheat contains a protein called gluten which may cause bloating[rx]. Gluten should be included in the elimination diet to rule out gluten sensitivity.
• Finally, people prone to meteorism should become physically active as this can also lead to increased peristalsis and emptying of gas from the intestine.