Acid-related disorders include not only reflux esophagitis and peptic
ulcer, but also a subset of patients with endoscopy-negative dyspepsia
. The management strategy differs between these diseases and therefore
a precise diagnosis is important. The unaided clinical diagnosis is o
f limited value in patients with pain or discomfort in the upper abdom
en, and endoscopy is therefore an important and cost-effective diagnos
tic tool. Duodenal ulcer is caused by an interplay between gastric aci
d and Helicobacter pylori. The treatment is aimed at rapid symptom rel
ief and healing and at the same time eradication of H. pylori. At pres
ent the best choice is the combination of a proton pump inhibitor and
two effective antimicrobial drugs, e.g., clarithromycin and metronidaz
ole. The proton pump inhibitor has dual effect in this combination it
provides optimal symptom relief and healing, and it increases the anti
-ti. pylori-effect of the antimicrobial drugs. The risk of reinfection
varies geographically; in Europe it is around 1 percent per year, and
cure of the infection provides long-term, maybe life-long, cure of th
e ulcer disease. Some gastric ulcers are not H. pylori related and the
treatment strategy therefore includes a diagnostic test for this infe
ction. If positive, treatment is similar to that in duodenal ulcer, wh
ile H. pylori-negative gastric ulcer patients are treated with antisec
retory drugs alone. Reflux esophagitis correlates with the degree of a
cid exposure to the esophagus, and intensive acid inhibition is the mo
st effective non-surgical therapy. In most cases the disease is chroni
c and needs continuous long-term therapy to prevent relapse. A staged
reduction in dosage of the acid inhibitory drug may be attempted when
the esophagitis is healed and the patient has become symptom free, but
full dose therapy is often needed. Patients with endoscopy-negative d
yspepsia are a heterogenous group and a more precise identification of
the cause of the symptoms is a prerequisite for rational treatment. E
mpiric treatment can be tried in patients without alarm symptoms like
bleeding or a palpable abdominal mass, and often an acid inhibitory dr
ug is used. A more precise identification of those patients who have a
cid-related symptoms is possible using placebo controlled single-subje
ct trials with an effective acid inhibitory drug, but in daily routine
these drugs are simply given for a short period of time, and in case
symptomatic relief is observed, the symptoms may be regarded as being
acid-related and treated accordingly.