An evidence-based approach to the management of uninvestigated dyspepsia in the era of Helicobacter pylori

Objectives: To provide Canadian primary care physicians with an evidence-ba sed clinical management tool, including diagnostic and treatment recommenda tions, for patients who present with uninvestigated dyspepsia. Recommendations: The management tool has 5 key decision steps addressing th e following: (1) evidence that symptoms originate in the upper gastrointest inal tract, (2) presence of alarm features, (3) use of nonsteroidal anti-in flammmatory drugs (NSAIDs), (4) dominant reflux symptoms and (5) evidence o f Helicobacter pylori infection. All patients over 50 years of age who pres ent with new-onset dyspepsia and patients who present with alarm features s hould receive prompt investigation, preferably by endoscopy. The management options for patients with uninvestigated dyspepsia who use NSAIDs regularl y are: (1) to stop NSAID therapy and assess symptomatic response, (2) to tr eat with NSAID prophylaxis ii NSAID therapy cannot be stopped or (3) to ref er for investigation. Gastroesophageal reflux disease can be diagnosed clin ically if the patient's dominant symptoms are heartburn or acid regurgitati on, or both; these patients should be treated with acid suppressive therapy . The remaining patients should be tested for H. pylori infection, and thos e with a positive result should be treated with H. pylori-eradication thera py. Those with a negative result should have their symptoms treated with op timal antisecretory therapy or a prokinetic agent. Validation and evidence: Evidence for resolution of the dyspepsia symptoms was the main outcome measure. Supporting evidence for the 5 steps in the ma nagement tool and the recommendations for treatment were graded according t o the strength of the evidence and were endorsed by consensus of committee members. If no randomized controlled clinical trials were available, the re commendations were based on the best available evidence. Literature review: Evidence was obtained from MEDLINE searches for pertinen t articles published from 1966 to October 1999. The searches focused on dys pepsia, diagnosis and treatment Additional articles were retrieved through a manual search of bibliographies and abstracts from international gastroen terology conferences. Sponsors: Supported by unrestricted educational grants from AstraZeneca Can ada Inc., Isotechnika Inc. and Integrated Healthcare Communications Inc.