Investigating dyspepsia

doi:10.1136/bmj.a1400

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Rocco Maurizio Zagari, assistant professor of gastroenterology ,
Lorenzo Fuccio, research fellow in gastroenterology,
Franco Bazzoli, professor of gastroenterology

¹Department of Internal Medicine and Gastroenterology, University of Bologna, 40138, Bologna, Italy

Correspondence to: F Bazzoli franco.bazzoli{at}unibo.it

Summary points

Around 25-40% of adults have chronic and recurrent dyspeptic symptoms
Most patients have no structural lesions and malignancy is rare, especially in Western populations
Two empirical strategies show results—a non-invasive test for H pylori and treatment of H pylori positive patients with eradication therapy (test and treat), and empirical treatment with proton pump inhibitors
The ¹³C-urea breath test and stool antigen test are the recommended non-invasive tests for H pylori infection. Patients should stop proton pump inhibitors two weeks before and antibiotics four weeks before performing either of these tests

Dyspepsia is a complex condition comprising chronic and recurrent symptoms related to the upper gastrointestinal tract. The cardinal symptoms are epigastric pain and discomfort, including postprandial fullness and early satiety, which may overlap with heartburn and regurgitation. Box 1 shows the various definitions of dyspepsia. Around 25-40% of adults in the general population have dyspepsia,1 2 and dyspepsia accounts for 2-5% of all consultations in primary care.3 Although several guidelines have been published,1 2 4 5 6 7 the management of patients with uninvestigated dyspepsia is still controversial. One outstanding dilemma is the choice of the most appropriate empirical strategy8; the benefit of early endoscopy in older patients without alarm symptoms is also widely debated.9 Dyspepsia has a substantial economic impact, and appropriate management is essential to reduce costs.2

This review examines strategies for managing patients with uninvestigated dyspepsia in primary care. We provide an overview of current guidelines and recommendations and report recent evidence from systematic reviews and clinical trials.

Box 1 Definitions of dyspepsia

Symptoms relating to the upper gastrointestinal tract

Epigastric pain, postprandial fullness, early satiety, heartburn, and regurgitation

UK (National Institute for Health and Clinical Excellence)

Dyspepsia—any chronic and recurrent symptoms referable to the upper gastrointestinal tract

US (American Gastroenterological Association, American College of Gastroenterology)

Dyspepsia—chronic and recurrent pain or discomfort centred in the upper abdomen (epigastrium). Discomfort is a subjective feeling that is not painful …