A Canadian study: univestigated dyspepsia with predominant heartburn were as likely as those with predominant epigastric pain or discomfort to have underlying PUD.
In investigated patients without structural lesions, predominant heartburn or regurgitation can reliably identify those with NERD, whereas those with predominant epigastric pain or discomfort should be considered as having functional dyspepsia.
International guidelines recommend prompt endoscopy for patients with dyspepsia& alarm features& all older patients with new onset dyspepsia.
Patients with alarm features, as GIB, dysphagia, or weight loss, should be promptly investigated to exclude ulcer complications & malignancy, although only a minority will have structural lesions.
Older patients(45 in Asia& 55 USA) have an increased risk of malignancy&early endoscopy is recommended even in the absence of alarm features.
The advantage of above strategy is now unclear because gastric ca now not common, in UK only 0.3% > 55 with uncomplicated dyspepsia had malignancy& a Scottish study showed that routine endoscopy for older people with new onset dyspepsia may have minimal effect on mortality for UGI cancer.
UK guidelines suggest that patients>55 with uncomplicated dyspepsia should receive empirical treatment first & endoscopy is recommended only if symptoms persist after 1-2 months.
Patients with dyspepsia < 55 with no alarm features can be managed empirically,as UGI cancer is rare in these patients& when found, is often incurable.
In the UK, a retrospective study found that, of the 3293 patients with dyspepsia diagnosed with malignancy over two years in Scotland, 21 (0.6%) were < 55& without alarm features, only two (0.1%) had curative surgery.
These results suggest that, even in areas with a relatively low prevalence of H pylori, test/treat has a persistent, albeit modest, benefit over treatment with PPIs.
Taking into account the potential long term benefits of HP eradication in reducing the risk of gastric cancer & preventing future PUD, test/treat remains a valuable first line strategy.
Test /treat is not recommended for heartburn predominant dyspepsia, because these patients are thought to be most likely to have underlying GERD,but evidence now suggests that this strategy may also be beneficial for these patients.
Danish/UK trials found that test/treat also reduces symptoms in heartburn-predominant dyspepsia,suggest that a subgroup has an underlying PUD,recently reported by a Canadian study.
A recent RCT reported that a sequential strategy PPI followed by test/treat if symptoms recur, more cost effective than early OGD.
When a patient is referred for endoscopy, biopsy should be taken from the antrum &body of the stomach for the diagnosis of HP.
Endoscopy may show oesophagitis or PUD, which should be treated with PPI or H pylori eradication.
Most patients will have no structural lesions.
Patients with NERD should be treated with PPI &HP radication does not usually provide symptom relief in these patients, but it maybe considered because it does not worsen symptoms&may have other long term benefits.
HP erradication should, be the 1st line trt in patients with FD.
A Cochrane review: 10% with FD benefit from HP eradication
Although this benefit is small, eradication is the most cost effective approach for these patients as it is given once&have long term benefit.
PPI should be given to HP -ve patients&if fail to respond to HPE.
Reassurance/explanation of the benign nature of symptoms may be the best treatment for FD& may be sufficient for many
Prokinetics,antideps,spasmolytics reserved for refractory disease.