Dyspepsia Management

• Specialist investigation is necessary for patients with alarm symptoms, patients ≥60 years (younger in areas with high prevalence of gastric cancer), patients who did not respond to empiric therapy and have persistent symptoms, and for further evaluation of an alternate diagnosis  

Endoscopy

• Upper GI endoscopy is the investigation of choice when further evaluation is warranted
• Endoscopy allows a clinician to view the GIT and, if necessary, perform diagnostic and therapeutic procedures, eg biopsy
• Routine endoscopic investigation of patients <60 years old, presenting with dyspepsia and with or without alarm signs, is not necessary; consideration for endoscopy should be on a case-by-case basis per physician’s clinical judgment  
• Should be reserved for patients who have little or no response to therapy after 7-10 days or for patients whose symptoms have not resolved after 4-8 weeks
  • If upper GI endoscopy is unremarkable, patients with persistent symptoms or alarm features should be evaluated further for other diagnosis
• Depending on local protocol: For patients ≥60 years (younger in areas with high prevalence of gastric cancer), consider endoscopy when symptoms persist despite H pylori testing/treatment and acid suppression therapy, and when patient has one or more of:
  • Previous gastric ulcer or surgery
  • Continuing need for NSAID treatment
  • Raised risk of gastric cancer
  • Anxiety about cancer

• Offer low-dose PPI or H₂RA treatment with limited number of prescriptions or stopping treatment
  
  • Dyspepsia is a remitting and relapsing disease and continuous medication is not necessary after eradication of symptoms unless there is an underlying condition requiring treatment
• May consider treatment with antacids when necessary
• Continue to avoid known precipitants of dyspepsia including smoking, alcohol, coffee, chocolate, fatty foods and being overweight, and to adhere to lifestyle modifications
• Monitor for appearance of alarm signs and symptoms