Empiric Treatment of Dyspepsia in the ED
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   "If a person has undiagnosed dyspepsia, the first step is to stop NSAID use
and reassess. If symptoms persist, there are three strategies: empirical
antiulcer therapy and workup if symptoms persist; immediate encloscopy (which
is preferred if the patient has anemia, bleeding, anorexia, weight loss, or
early satiety); or noninvasive testing for H. pylori followed by antibiotics
if H. pylori is present. There is no strong evidence on which to base a choice
among these strategies."
   "Cure of H. pylori infection decreases ulcer recurrence and facilitates
healing. Infection is easy to suppress but difficult to cure, so it is
important to use a proven multidrug regimen. Each of the recommended regimens
includes a proton pump inhibitor in addition to one of the following
combinations: (1) bismuth, metronidazole, and tetracycline; (2) darithromycin
and metronidazole; or (3) clarithromycin and amoxicillin. Treatment for one
week is probably sufficient. The H. pylori cure rate is 90 percent."
   "If the ulcer is large, complicated, or refractory, use of the proton pump
inhibitor should be continued past the one week of combination therapy and a
test of H. pylori cure should be performed. In other circumstances, the test
of cure is controversial, with some experts believing that it is unnecessary."
   "The role of conventional antiulcer therapy is clear: it enhances symptom
relief and ulcer cure. In uncomplicated ulcer, any monotherapy is effective.
The guidelines also provide advice about preventing recurrence. H. pylori
eradication reduces the recurrence rate from 85 percent to 10 percent.
Patients who are H. pylori-negative or who fail curative therapy will require
maintenance therapy."
Reference:
[Soll AH: Medical treatment of peptic ulcer disease: practice guidelines.
JAMA 275:622, 1996.]
 --Harold C. Sox, Jr., M.D.
   Joseph M. Huber Professor of Medicine and Chainnan of the Department of
   Medicine at Dartmouth Medical School and an Associate Editor of Scientific
   American Medicine. [writing in SAM, XX(9), September 1997]

My take on all this is that, if you suspect peptic ulcer disease in the ED, you should
(1) check a CBC for otherwise-unexpected anemia, (2) do a rectal for blood,
and (3) ask about anorexia, early satiety or weight loss.  If any of these are
present, refer to a GI specialist for endoscopy; otherwise, start on a
proton-pump inhibitor and one of the above antibiotic regimes and refer to a
primary care physician.  --KC