Guidelines for the management of dyspepsia

Dyspepsia is a common problem necessitating strategies for investigation and management because of the scarcity of available resources for investigation, i.e. endoscopy, and the need to focus on those at risk of serious disease. It is agreed that those in the older age group, with the presence of alarm symptoms or non-steroidal anti-inflammatory drug use require prompt endoscopy, but there remains a significant proportion of patients in whom the underlying diagnosis is unclear, presenting a management problem. Unfortunately, no universally applicable approach to investigation and management is available. Each major community needs to modify its guidelines for the management of dyspepsia based upon such factors as the local incidence of organic disease, prevalence of Helicobacter pylori infection and lifestyle. Endoscopy off acid suppressive therapy remains the only way of making a certain diagnosis. A diagnosis of gastrooesophageal reflux disease can now be made confidently by endoscopy, with selective use of 24 h pH study of the lower oesophagus. The same cannot be said for other groups with dyspepsia where symptoms alone are a poor guide to diagnosis. Evidence is beginning to emerge, however, that further stratification of dyspeptics on the basis of symptoms and other risk factors, e.g. H. pylori status, may help in management. In addition, there is a clinical need for accurate, inexpensive tests of foregut motility. Integrating clinical data with specific investigation in dyspepsia is required in order for the practising clinician to better define the dyspeptic so that patients can be managed effectively and simply.