Synopsis
Distinguish uncomplicated dyspepsia from cardiac, biliary, pancreatic, ulcer and malignant disease, use Helicobacter pylori testing correctly, and sequence treatment, endoscopy and review safely.
- Dyspepsia includes epigastric pain or burning, postprandial fullness and early satiation; retrosternal heartburn and regurgitation can overlap but point more towards reflux.
- Ask about exertion, breathlessness, diaphoresis and cardiovascular risk because inferior cardiac ischaemia can present as epigastric discomfort, especially in older adults and people with diabetes.
- Dysphagia, weight loss, anaemia, haematemesis, persistent vomiting, an upper abdominal mass and age-linked new symptoms trigger the current endoscopy or suspected-cancer pathway.
- Review NSAIDs, aspirin, corticosteroid combinations, bisphosphonates, iron, potassium and medicines affecting gastric emptying before assuming primary acid disease.
- For non-invasive Helicobacter pylori testing, arrange a two-week proton-pump inhibitor washout and avoid testing too soon after antibiotics, following the selected assay and local laboratory instructions.
- NICE supports H pylori test-and-treat and a time-limited full-dose PPI trial for uninvestigated dyspepsia without alarm features; sequence and local access should be explicit.
- Do not use symptom response to a PPI as proof of benign disease. Reassess adherence, indication, warning features and alternative biliary, pancreatic or cardiac causes when symptoms persist.
- Functional dyspepsia is a positive disorder of gut-brain interaction after appropriate assessment; explain meal-related sensitivity and offer layered dietary, acid-suppressing and neuromodulatory options.
- After control, step down acid suppression to the lowest effective strategy and review long-term indication rather than renewing treatment indefinitely without ownership.
Key red flags
Progressive dysphagia, unexplained weight loss with upper abdominal symptoms, iron-deficiency anaemia, persistent vomiting, haematemesis or an epigastric mass moves assessment to the current urgent endoscopy or suspected-cancer pathway.
Melaena, haematemesis, syncope or anaemia suggests bleeding; sudden severe generalised pain with rigidity suggests perforation. NSAIDs, aspirin, H pylori and previous ulcer disease raise probability.
Pressure, exertional association, breathlessness, sweating, radiation or cardiovascular risk should prompt ECG and acute coronary assessment. Reproducible meal association and antacid response cannot safely exclude myocardial ischaemia.
Investigation priorities
Exclude acute coronary syndrome when epigastric discomfort has exertional, autonomic or cardiovascular-risk features.
Management branches
A patient presents with new or worsening epigastric pain or dyspepsia.
- Check haemodynamics and look for bleeding, peritonism, cardiac ischaemia, jaundice with sepsis and severe dehydration, sending unstable patients to acute care.
- Elicit dysphagia, weight loss, anaemia, persistent vomiting, mass, family history and age-linked onset, then apply the current NG12 and endoscopy pathway.
- Review ulcerogenic and motility-altering medicines and identify biliary, pancreatic and cardiac features before assigning uncomplicated dyspepsia.
- Document the chosen pathway, expected response and named trigger for earlier reassessment.
Stable uninvestigated dyspepsia has no urgent endoscopy indication.
- Choose H pylori test-and-treat or a four-week full-dose PPI trial according to NICE and local sequence, explaining that each is a time-limited diagnostic-management step.
- If testing, arrange appropriate PPI and antibiotic washout, use a validated breath or stool assay and establish who will act on the result.
- Treat confirmed infection using the current local eradication regimen, then review symptom response and whether post-treatment confirmation is indicated.