Dyspepsia and Helicobacter pylori: test, treat or investigate?

The annual prevalence of dyspepsia in the UK is about 25%. Dyspepsia is one of the most common reasons for a patient to visit a primary care physician (PCP), accounting for between 3 and 4% of all PCP consultations. Antisecretory drugs prescribed by PCPs to relieve dyspepsia consume over 7% of the annual UK National Health Service drugs budget. In patients < 45 years old and in the absence of sinister symptoms (weight loss, anorexia or gastrointestinal blood loss) or treatment with non-steroidal anti-inflammatory drugs, three conditions account for the majority of cases of dyspepsia, namely functional (non-ulcer) dyspepsia (up to 60%), gastroesophageal reflux (5-15%) and peptic ulcer disease (15-25%). The discovery of Helicobacter pylori and its association with peptic ulcer disease led to a reevaluation of the management strategies used for dyspepsia. It became possible, using non-invasive testing, to determine whether a patient with dyspepsia was colonized with H. pylori and if not, it made peptic ulcer disease most unlikely. There are four main strategies for the management of patients with dyspepsia: empiric treatment, 'test and treat', 'test and investigate', or simply 'investigate'. The advantages, disadvantages and possible outcomes using each of these strategies are discussed using an evidence-based approach.