Management of uninvestigated and functional dyspepsia: a working party report for the World Congresses of Gastroenterology 1998

Background: The management of dyspepsia is controversial. Methods: An international Working Party was convened in 1998 to review mana gement strategies for dyspepsia and functional dyspepsia, based on a review of the literature and best clinical practice. Results: Dyspepsia, defined as pain or discomfort centred in the upper abdo men, can be managed with reassurance and over-the-counter therapy if its du ration is less than 4 weeks on initial presentation. For patients with chro nic symptoms, clinical evaluation depends on alarm features including patie nt age. The age cut off selected should depend on the age specific incidenc e when gastric cancer begins to increase, but in Western nations 50 years i s generally an acceptable age threshold, In younger patients without alarm features, Helicobacter pylori test and treatment is the approach recommende d because of its value in eliminating the peptic ulcer disease diathesis. I f, after eradication of H. pylori, symptoms either are not relieved or rapi dly recur, then an empirical trial of therapy is recommended. Similarly, in H, pylori-negative patients without alarm features, an empirical trial (wi th antisecretory or prokinetic therapy depending on the predominant symptom ) for up to 8 weeks is recommended. If drugs fail, endoscopy should be cons idered because of its reassurance value although the yield will be low, In older patients or those with alarm features, prompt endoscopy is recommende d. If endoscopy is non-diagnostic, gastric biopsies are recommended to docu ment H, pylori status unless already known. While treatment of H, pylori is unlikely to relieve the symptoms of functional dyspepsia, the long-term be nefits probably outweigh the risks and treatment can be considered on a cas e-by-case basis. In H. pylori-negative patients with documented functional dyspepsia, antisecretory or prokinetic therapy, depending on the predominan t symptom, is reasonable, assuming reassurance and explanation are insuffic ient, unless patients have already failed this approach. Other treatment op tions include antidepressants, antispasmodics, visceral analgesics such as serotonin type 3 receptor antagonists, and behavioural or psychotherapy alt hough these are all of uncertain efficacy. Long-term drug treatment in func tional dyspepsia should be avoided: intermittent short courses of treatment as needed is preferred. Conclusion: The management of dyspepsia recommended is based on current bes t evidence but must be tailored to local factors such as practice setting, the background prevalence of H, pylori and structural disease, and costs.