• Dyspepsia is upper abdominal discomfort or pain which may be described as a burning sensation, a heaviness, or an ache. It is often related to eating and may be accompanied by other symptoms such as nausea, fullness in the upper abdomen, or belching.
• People without alarm features should not have any of the following:
• Chronic gastrointestinal bleeding.
• Progressive unintentional weight loss.
• Progressive difficulty swallowing.
• Persistent vomiting.
• Iron deficiency anaemia.
• Epigastric mass.
• Suspicion of gastric cancer after investigation with a barium meal.
• Age 55 years or more, presenting with unexplained and persistent recent-onset dyspepsia.

• For people with dyspepsia and significant acute gastrointestinal bleeding, arrange immediate admission to hospital.
• For people with nonsteroidal anti-inflammatory drug (NSAID)-induced dyspepsia without alarm features:
• Do a full blood count if there are any features of anaemia.
• Prescribe, or advise the use of, an antacid or alginate for immediate relief of dyspepsia as required.
• Review and manage lifestyle factors known to exacerbate dyspepsia.
• Review and manage drugs (other than NSAIDs) known to increase the risk of gastrointestinal bleeds or exacerbate dyspepsia.
• Stop the NSAID if possible, and prescribe a proton pump inhibitor (PPI) for 1 month. Test and treat for Helicobacter pylori infection if symptoms recur.
• Offer alternative analgesia (paracetamol and/or opioids).
• When it is not acceptable to stop the NSAID:
• Prescribe a full-dose PPI for 1 month, and maintain treatment at a dose appropriate to the risk of gastrointestinal bleeding.
• Test for H. pylori and treat if present.
• If possible, reduce the risk from NSAID use by reducing the frequency or dose of the NSAID, or substituting it for one less likely to cause gastrointestinal symptoms.
• Refer those people whose symptoms persist despite treatment.

In depth

• Advise people with dyspepsia that symptoms may improve if they lose weight (if they are overweight), stop or reduce smoking (if they are a smoker), stop or reduce alcohol consumption, and reduce intake of any food or drink associated with worsening symptoms.
• Advise people with reflux symptoms when lying down to avoid having meals within 3–4 hours of going to bed, and to raise the height of the head of the bed by a few inches.

In depth

• For people who have not previously been diagnosed with Helicobacter pylori infection, test with:
• Urea breath test (unless they have received a proton pump inhibitor [PPI] in the past 14 days or an antibiotic in the past 28 days), or
• Stool antigen test (unless they have received a PPI in the past 14 days or an antibiotic in the past 28 days), or
• Laboratory serology testing (where the performance of the test has been locally validated).
• For people who have been previously diagnosed with H. pylori infection and treated with eradication therapy, re-test (if indicated) at least four weeks after treatment. Urea breath test is preferred. However, stool antigen test could be used if urea breath test is not available.
• Stop PPI use 14 days prior to testing. Withhold testing for 28 days after treatment with an antibiotic.

In depth

• Prescribe a 7-day, triple-therapy regimen with twice-daily dosing. Preferred regimens are:
• Amoxicillin 1 g plus clarithromycin 500 mg plus either lansoprazole 30 mg or omeprazole 20 mg (all taken twice daily), or
• Clarithromycin 250 mg plus metronidazole 400 mg plus either lansoprazole 30 mg or omeprazole 20 mg (all taken twice daily).
• Avoid amoxicillin-containing regimens for those with known or suspected penicillin allergy.

In depth