Dyspepsia is a common problem in the out-patient setting. Typically, patients with dyspepsia do not have ulcers; in fact, a structural explanation for their symptoms cannot be found in the majority. Patients who fit this description are said to have nonulcer dyspepsia. The large number of treatment options for nonulcer dyspepsia reflects the unknown cause of this problem. There is no consensus as to the best approach in managing patients with this disorder. Locke provides a concise review of the potential causes of nonulcer dyspepsia, the therapeutic choices and the management approaches.

Key points in this discussion include the following: (1) Definition. Dyspepsia is a complex of symptoms. It is defined as persistent or recurrent abdominal pain or abdominal discomfort centered in the upper abdomen. This discomfort may include symptoms of nausea, vomiting, early satiety, postprandial fullness and abdominal bloating. Symptoms are usually meal-related. There appears to be no effect on bowel habits. Heartburn and gastrointestinal reflux symptoms may be reported; however, if they are the main symptoms, the patient should be considered to have reflux disease rather than nonulcer dyspepsia. The symptoms should have been present for three or more months without an anatomic or biochemical abnormality. (2) Etiology. Unanswered questions in determining the cause of nonulcer dyspepsia include the following: whether nonulcer dyspepsia is caused by gastritis or infection with Helicobacter pylori? Whether nonulcer dyspepsia is an acid problem? Whether it represents occult gastroesophageal reflux disease? Whether it is a motility disorder? Whether it is a functional disorder? Whether it is a psychiatric disorder?

Regarding evaluation and therapy and given the controversy regarding etiology, the author makes the following specific recommendations: Patients should undergo a diagnostic evaluation with upper gastrointestinal tract radiography or endoscopy, to exclude peptic ulcer disease or malignancy. A trial of acid inhibition or testing for H. pylori infection should be done. The most difficult decision is whether to perform further diagnostic testing or proceed with empiric treatment trials. Therapeutic trials include those with proton pump inhibitors, prokinetic agents, mucosal protectants (e.g., sucralfate), anticholinergics and low-dose antidepressants. Despite all measures to investigate or treat nonulcer dyspepsia, one third to one half of patients have spontaneous resolution of their symptoms.