Clinical Question: What is the best approach to managing dyspepsia?

Setting: Various (guideline)

Study Design: Practice guideline

Synopsis: Patients with dyspepsia may have gastroesophageal reflux disease (GERD), peptic ulcer, functional (nonulcer) dyspepsia, or, rarely, malignancy. The authors reviewed the literature and based their recommendations on the results of the best available evidence. Patients with the onset of dyspepsia at 56 years or older, or those with alarm symptoms (e.g., bleeding, anemia, early satiety, unexplained weight loss, dysphagia or odynophagia, persistent vomiting, family history of gastrointestinal malignancy, previous documented peptic ulcer, abdominal mass, or lymphadenopathy) at any age should undergo immediate upper endoscopy. Patients with reflux-predominant symptoms should be treated as if they have GERD. If the prevalence of Helicobacter pylori infection in the community is less than 10 percent, a trial of a proton pump inhibitor is recommended. If that fails, a test for H. pylori infection, followed by eradication if positive, should be pursued. When H. pylori is more common, the test-and-treat strategy should be pursued first, followed by a trial of a proton pump inhibitor. If these strategies fail, upper endoscopy should be considered according to the physician’s judgment. However, the prevalence of ulcer or malignancy in H. pylori–negative patients is low in this group.

Bottom Line: This evidence-based guideline summarizes the best approach to the evaluation and treatment of patients with dyspepsia, defined as chronic or recurrent pain in the upper abdomen. (Level of Evidence: 1a)