Management Recommendations
Patients 55 years of age or younger without alarm features should receive Helicobacter pylori test and treat followed by acid suppression if symptoms remain (see Figure 2 in the original guideline document). H. pylori testing is optimally performed by a 13C-urea breath test or stool antigen test. Proton pump inhibitors (PPIs) are the drug class of choice for acid suppression. Those who are H. pylori negative should be prescribed an empirical trial of acid suppression with a PPI for 4 to 8 weeks. Empirical PPI therapy is the most cost-effective approach in populations with a low prevalence of H. pylori (10% or less). The recommendation to test and treat is based on randomized controlled trials and the possible impact of eradication in preventing future gastric adenocarcinoma.
Patients who respond to H. pylori test and treat or PPI therapy can be managed without further investigation. Endoscopy usually adds little in young patients who continue to have upper gastrointestinal symptoms without alarm features despite H. pylori test and treat and PPI therapy. There is a very low probability of finding relevant organic disease in this group of patients. Endoscopy may reassure some young patients with continued symptoms, but evidence suggests this is not the case in those who are most anxious and that many H pylori test-and-treat patients can be managed in the long term without further investigation. Endoscopy may be appropriate for some young patients who continue to have dyspepsia, but this should be considered in the wider context of reevaluating the symptoms and the diagnosis. Endoscopy appears not to be a cost-effective use of resources compared with alternatives such as screening for colorectal cancer (see Figure 3 in the original guideline document).
The value of alarm symptoms in younger patients is controversial. A systematic review of alarm symptoms suggests that these are not very useful in diagnosing upper gastrointestinal malignancy. However, although the yield of endoscopy is low, it is recommended for patients older than 55 years of age and for younger patients with alarm features (e. g., weight loss, progressive dysphagia, recurrent vomiting, evidence of gastrointestinal bleeding, or family history of cancer) presenting with new-onset dyspepsia. Upper gastrointestinal malignancy becomes more common after age 55 years. Biopsy specimens should be obtained for H. pylori at the time of endoscopy, and eradication therapy offered to those who are infected because this may reduce the risk of subsequent peptic ulcer disease and gastric malignancy. Endoscopy should be preferred over upper gastrointestinal radiography because it has greater diagnostic accuracy and biopsy specimens can be taken for H pylori infection. After endoscopy, and H. pylori eradication therapy if positive, treatment should be targeted at the underlying diagnosis. Most patients will have functional dyspepsia and can be offered acid suppression therapy.
Patients of any age who continue to have symptoms despite appropriate investigations, therapy, and reassurance are a difficult group to manage (see Figure 4 in the original guideline document). Symptoms should be reassessed and prokinetic agents, antidepressant therapy, or psychological treatments considered, although the benefits of these approaches are not established.
