Authors' objectives:

This report provides guidelines on the management of dyspepsia in adults in primary care.

Authors' recommendations: The following have been identified as priorities for implementation. Referral for endoscopy - Review medications for possible causes of dyspepsia (for example, calcium antagonists, nitrates, theophyllines, bisphosphonates, corticosteroids and non-steroidal anti-inflammatory drugs [NSAIDs]). In patients requiring referral, suspend NSAID use. - Urgent specialist referral for endoscopic investigation. is indicated for patients of any age with dyspepsia when presenting with any of the following: chronic gastrointestinal bleeding, progressive unintentional weight loss, progressive difficulty swallowing, persistent vomiting, iron deficiency anaemia, epigastric mass or suspicious barium meal. - Routine endoscopic investigation of patients of any age, presenting with dyspepsia and without alarm signs, is not necessary. However, for patients over 55, consider endoscopy when symptoms persist despite Helicobacter pylori (H. pylori) testing and acid suppression therapy, and when patients have one or more of the following: previous gastric ulcer or surgery, continuing need for NSAID treatment, or raised risk of gastric cancer or anxiety about cancer. Interventions for uninvestigated dyspepsia - Initial therapeutic strategies for dyspepsia are empirical treatment with a proton pump inhibitor (PPI) or testing for and treating H. pylori. There is currently insufficient evidence to guide which should be offered first. A 2-week washout period following PPI use is necessary before testing for H. pylori with a breath test or a stool antigen test. Interventions for gastro-oesophageal reflux disease (GORD) - Offer patients who have GORD a full-dose PPI for 1 or 2 months. If symptoms recur following initial treatment, offer a PPI at the lowest dose possible to control symptoms, with a limited number of repeat prescriptions. Interventions for peptic ulcer disease - Offer H. pylori eradication therapy to H. pylori-positive patients who have peptic ulcer disease. - For patients using NSAIDs with diagnosed peptic ulcer, stop the use of NSAIDs where possible. Offer full-dose PPI or H2 receptor antagonist (H2RA) therapy for 2 months to these patients and, if H. pylori is present, subsequently offer eradication therapy. Interventions for non-ulcer dyspepsia - Management of endoscopically determined non-ulcer dyspepsia involves initial treatment for H. pylori if present, followed by symptomatic management and periodic monitoring. - Re-testing after eradication should not be offered routinely, although the information it provides may be valued by individual patients. Reviewing patient care - Offer patients requiring long-term management of dyspepsia symptoms an annual review of their condition, encouraging them to try stepping down or stopping treatment. - A return to self-treatment with antacid and/or alginate therapy (either prescribed or purchased over-the-counter and taken as required) may be appropriate. H. pylori testing and eradication - H. pylori can be initially detected using either a carbon-13 urea breath test or a stool antigen test, or laboratory-based serology where its performance has been locally validated. - Office-based serological tests for H. pylori cannot be recommended because of their inadequate performance. - For patients who test positive, provide a 7-day, twice-daily course of treatment consisting of a full-dose PPI with either metronidazole 400 mg and clarithromycin 250 mg or amoxicillin 1 g and clarithromycin 500 mg.

Authors' methods: Clinical guideline

Project Status: Completed

URL for project: http://www.nice.org.uk/page.aspx?o=218377

Year Published: 2004

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: England, United Kingdom

Organisation Name: National Institute for Clinical Excellence

Contact Address: MidCity Place, 71 High Holborn, London WC1V 6NA, UK. Tel: +44 020 7067 5800; Fax: +44 020 7067 5801

Contact Name: nice@nice.nhs.uk

Contact Email: nice@nice.nhs.uk

Copyright: National Institute for Clinical Excellence (NICE)