Dyspepsia management in primary care

Background: Dyspepsia is common in western society. Prompt endoscopy is imperative in all patients with sinister symptoms or if symptoms first appear after the age of 50-55 years, but the optimal management of younger patients with uncomplicated dyspepsia is still open to debate. Methods: The literature on the management of uncomplicated dyspepsia is reviewed and a personal view is presented. Results: Strategies based on non-invasive detection of Helicobacter pylori are probably the most cost-effective. Currently (H. pylori prevalence 30%-40%), a 'test and treat' approach using a non-invasive test to detect H. pylori is likely to be the most efficient first step. If the patient is H. pylori-negative or if symptoms persist after successful H. pylori eradication, empirical treatment with an anti-secretory drug is justified. Endoscopy is reserved for those patients in whom this approach fails. If the prevalence of H. pylori decreases, the positive predictive value of any non-invasive H. pylori test will become too low. A 'test and scope' approach in which a positive test can be confirmed by two or more biopsy-based tests is then more appropriate. At a very low prevalence of H. Pylori in the dyspeptic population, non-invasive testing for H. pylori loses its significance and empirical treatment with an antisecretory drug becomes a rational first step. Conclusions: The optimal approach to management of uncomplicated dyspepsia is dependent on the prevalence of H. pylori among the dyspeptic population. At the current prevalence rate, 'test and treat', followed by acid suppressive treatment in the case of persisting symptoms, is the most appropriate strategy.