Review article: the continuing dilemma of dyspepsia

Dyspepsia drains a substantial proportion of healthcare resources in indust rialized countries and an appropriate management strategy is needed. An aet iological role for Helicobacter pylori infection has been demonstrated in a number of pathological conditions associated with dyspepsia, such as pepti c ulcer and gastric malignancies, but not in functional dyspepsia. Endoscop y and diagnosis-based treatment, H. pylori testing and eradication therapy, history taking and empirical therapy, are the main tools that are currentl y available for managing patients with upper gastrointestinal symptoms. End oscopy identifies malignancies and organic diseases of the proximal gut and therefore provides reassurance to both doctors and patients. It should be recommended in older patients with suspicious symptoms and it has proven to be more cost-effective than empirical H-2-receptor antagonists in patients with ulcer-like symptoms, Empirical eradication in all dyspeptics without suspicious symptoms is a cost-effective approach that cures the majority of peptic ulcers. Nevertheless, it does not control symptoms in the majority of patients, it may exacerbate gastrooesophageal reflux disease, and it enc ourages antibiotic resistance. The realities of current clinical practice r equire empirical therapy in most, if not all, the dyspeptics seen by genera l practitioners. A detailed history taking can help to diagnose gastro-oeso phageal reflux disease and to identify suspicious symptoms. Furthermore, id entification of dyspepsia subgroups may provide guidance for empirical ther apy. Nevertheless, even analysis of individual symptoms does not provide a sufficient diagnostic yield to differentiate functional from organic dyspep sia and appropriate investigations are needed in patients with poor respons e to short-term therapy or frequent relapses.