Dyspepsia has most recently been defined as predominant epigastric pain present for at least four weeks, with or without heartburn.1 By implication gastro-oesophageal reflux disease (GORD) refers to predominant heartburn. These definitions work reasonably well when peptic ulcer has been excluded by endoscopy, but they fail to be sufficiently predictive in uninvestigated patients.2 Thus the guideline on dyspepsia produced by the National Institute for Health and Clinical Excellence (NICE) in 2004 recommended a common pathway for investigating and treating previously uninvestigated patients who had both heartburn and epigastric pain.3 Patients who have had endoscopy can be categorised according to the cause found—peptic ulcer, oesophagitis, or no obvious cause (functional dyspepsia or functional heartburn).

Eradication of Helicobacter pylori is most effective in preventing the recurrence of duodenal ulcer: the number needed to treat (NNT) for preventing one recurrence of ulceration at one year is 2.4 It now seems naive to have expected such effectiveness of eradication in other conditions related to dyspepsia, but undue optimism has led to several underpowered randomised controlled trials, particularly on functional …