Therapeutic trial in dyspepsia: its role in the primary care setting

Owing to the vast proportions of the dyspeptic patient population, it is not practicable to initiate diagnostic investigations immediately in every single patient who presents with dyspepsia. The risks associated with postponing definite diagnosis 4-8 weeks in dyspeptic patients aged less than 45 years are exceedingly small. Therefore, empiric therapeutic trial without a firm diagnosis is an acceptable alternative in those age groups. Those who recover during the course of the trial are spared the costs and inconvenience of invasive tests. Possible adverse consequences for the patients are minimized if the therapy covers those organic diseases that may cause complications (such as peptic ulcer and esophagitis). The concept of diagnosis-free therapeutic trials presupposes, however, that a sufficiently large number of patients are cured and that their need of investigation is permanently eliminated. If not, inevitable investigations are only postponed. In those patients the costs will thereby not only be the same as if early investigation had been carried out, but the total costs may in fact increase in a longer perspective owing to suboptimal management in the period before a firm diagnosis has been established. Thus, the ideal strategy would be to treat those who have a high probability of recovering during the ensuing 6-8 weeks and to investigate those in whom a prolonged course is anticipated. An empiric therapeutic trial must be followed by a thorough evaluation within 8 weeks.