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Clinical Question:
What is the best approach to managing dyspepsia?
Bottom Line:
This evidence-based guideline (see synopsis) summarizes the best approach to
the evaluation and treatment of patients with dyspepsia, defined as chronic
or recurrent pain in the upper abdomen. (LOE = 1a)
Reference:
Talley NJ, Vakil N, for the Practice Parameters Committee of the American
College of Gastroenterology. Guidelines for the management of dyspepsia. Am
J Gastroenterol 2005; 10:2324-337.
Study Design:
Practice guideline
Synopsis:
Dyspepsia is a chronic or recurrent pain or discomfort centered in the upper
abdomen; patients with predominant or frequent (more than once a week)
heartburn or acid regurgitation, should be considered to have
gastroesophageal reflux disease (GERD) until proven otherwise. Dyspeptic
patients over 55 yr of age, or those with alarm features should undergo
prompt esophagogastroduodenoscopy (EGD). In all other patients, there are
two approximately equivalent options: (i) test and treat for Helicobacter
pylori (H. pylori) using a validated noninvasive test and a trial of acid
suppression if eradication is successful but symptoms do not resolve or (ii)
an empiric trial of acid suppression with a proton pump inhibitor (PPI) for
4-8 wk. The test-and-treat option is preferable in populations with a
moderate to high prevalence of H. pylori infection (> or =10%); empirical
PPI is an initial option in low prevalence situations. If initial acid
suppression fails after 2-4 wk, it is reasonable to consider changing drug
class or dosing. If the patient fails to respond or relapses rapidly on
stopping antisecretory therapy, then the test-and-treat strategy is best
applied before consideration of referral for EGD. Prokinetics are not
currently recommended as first-line therapy for uninvestigated dyspepsia.
EGD is not mandatory in those who remain symptomatic as the yield is low;
the decision to endoscope or not must be based on clinical judgement. In
patients who do respond to initial therapy, stop treatment after 4-8 wk; if
symptoms recur, another course of the same treatment is justified. The
management of functional dyspepsia is challenging when initial antisecretory
therapy and H. pylori eradication fails. There are very limited data to
support the use of low-dose tricyclic antidepressants or psychological
treatments in functional dyspepsia. |