non-ulcer dyspepsia (those that have no definite structural or biochemical explanation)
30-50% will have Helicobacter pylori infection & histological gastritis but only 1 in 15 gain symptomatic improvement above placebo with H. pylori eradication Rx, but this may be a longer term cost effectiveness over H2 antagonist & PPI Rx
5% will develop peptic ulcer disease over 12mths follow up
oesophageal spasm
gastric or oesophageal cancer (< 2%)
Investigation
The first issue is to determine if there are alarm features that mandate prompt endoscopy:
…need to get a list of alarm features
Relatively new symptoms in an older person should also be considered a reason for referral for endoscopy.
Other patients at higher risk and therefore lower threshold for endoscopy include first-degree relatives of patients with gastric cancer and those born in areas with high gastric or oesophageal cancer prevalence.
In younger adult dyspeptic patients (generally under 50 years) where there are no alarm symptoms, the test-and-treat strategy using a noninvasive diagnostic test for H. pylori has been shown to be a cost-effective way to manage dyspepsia, as it is just as or more likely to result in symptom relief compared with those sent for endoscopy or treated empirically. Testing is usually with a urea breath test because its accuracy exceeds that of serology.
Those found to be infected are offered eradication therapy with recourse to referral for endoscopy if symptoms are not relieved.
Patients with ulcer disease will only comprise a minority of these dyspeptic patients but this group derives the most immediate and durable benefit. Treatment has the added advantage of reducing long-term risks associated with H. pylori infection.