The management of univestigated dyspepsia in primary care

Dyspepsia is very common in western countries, where 10-40% of the population experience upper abdominal pain or discomfort over the course of one year. Mostly it is a chronic relapsing problem. Prompt endoscopy is imperative in all patients with sinister symptoms (including the first appearance of symptoms after the age of 50-55). In other patients endoscopy is unlikely to contribute to medical management. In those a ''test and treat'' strategy implying non invasive testing for Helicobacter pylori (H. pylori) and treatment of the infection if present seems to be the best approach under current conditions (H. pylori prevalence among dyspeptics 28-61% in recent studies). If the patient is H. pylori-negative and in case of persisting symptoms after successful H. pylori eradication, empirical treatment with an antisecretory drug is justified. Endoscopy is reserved for those patients in whom this approach fails. With a continuing decrease in H. pylori prevalence the accuracy of the used non-invasive H. pylori test needs to be high and urea breath tests are to be preferred, the faecal antigen test being a reasonable alternative. At a very low prevalence of H. pylori in the dyspeptic population (below 10%) non invasive testing for H. pylori loses its significance and empirical treatment with an antisecretory drug becomes a rational first step. The physician involved in the care for dyspeptic patients needs to be aware of the current H. pylori prevalence.