Evaluation of the Patient with Dyspepsia

The most recent American, Canadian, and European consensus-based guidelines all recommend that patients younger than 45 years with dyspepsia and no alarm symptoms should be tested for H pylori infection and then given eradication therapy if positive; patients older than 45 years and those with alarm symptoms should have prompt endoscopy.^37-39 H pylori–negative patients younger than 45 years and without alarm symptoms should be managed empirically for functional dyspepsia. H pylori–positive or negative patients who do not undergo endoscopy initially should do so if their symptoms persist. An algorithm depicting this approach is presented in the Figure 1. Cost-effectiveness analyses generally support this approach.^22,40,41

Direct evidence for these approaches from randomized controlled trials has recently become available.^42-45 These studies show that outcomes are similar whether patients received prompt endoscopy or follow a test and treat strategy. Note that patients older than 45 years, using NSAIDs, or with any alarm symptoms for complicated disease were either excluded from these trials or underwent prompt endoscopy.

Although the current evidence supports a test and treat strategy, the results may not be generalizable to all areas. The effectiveness of this approach depends on the prevalence of H pylori infection in patients with ulcers in the community; in some areas, this prevalence may be too low to make this approach effective.^46,47 Also, patients not undergoing prompt endoscopy may be less satisfied with their care,⁴² which is related to the observation that patients with dyspepsia are more likely than physicians to value diagnostic certainty.⁴⁸ Other data suggest, however, that patient satisfaction is more closely associated with symptom improvement than with having procedures performed.⁴⁹ With these caveats in mind, it seems most reasonable to inform your patients about the evidence regarding the advantages and disadvantages of the various approaches and allow them to share in the decision-making process.