Diagnosis and management of dyspepsia - Clinical guideline, 1999

Objective. To outline an approach for the effective, practical and safe dia gnosis and management of uninvestigated dyspepsia at a primary level of car e appropriate to South Africa. The target group for guideline use included general practitioners and other primary health care providers in the public and private sectors. The guideline includes referral points to higher leve ls of care. Options. Two main treatment options for the management of patients with uni nvestigated dyspepsia were considered to be relevant to South Africa: Empiric medical therapy (often based on the dominant symptom or symptom com plex) with further investigation reserved for 'empiric treatment failures'. Immediate diagnostic evaluation (endoscopy/radiology) of all cases and targ eting of therapy based on results. Evidence. Literature review of relevant studies. However, there are insuffi cient South African data to make fully evidence-based recommendations. Values. The working group considered that immediate investigation (by endos copy/radiology) was not a practical option in the South African setting, ow ing to a lack of resources. The group stressed the importance of adequate i nitial evaluation to identify the 'high-risk' patient. Recommendations. Early identification of 'high-risk' patients needing immediate referral to a higher level of care and for further investigation. The remaining 'low-risk' patients should be offered acceptable symptomatic management of dyspepsia. As there is no single ideal first choice drug, selection is often empiric a fter considering the following: level of contact and care, dominant dyspeps ia symptom, availability and cost of medicines, individual preferences. Dru g treatment should continue for a finite period (2 - 4 weeks) and response should be monitored. If treatment fails after a trial of a second drug, the n further investigation should be considered as for the 'at-risk' patient. All patients should be given advice on lifestyle changes. A diagnosis of non-ulcer dyspepsia should only be considered when further i nvestigation has not shown specific pathology. When indicated, endoscopy is the preferred method of investigation, but if not available then a barium meal is recommended. The role of Helicobacter pylori in dyspepsia is poorly understood. Empiric H. pylori eradication therapy is not recommended.