The management of someone with dyspepsia is determined by their use of nonsteroidal anti-inflammatory drugs and presence of alarm features.

• Scenario: Dyspepsia with alarm features: covers the management of people with dyspepsia and alarm features.
• Scenario: Dyspepsia - no alarm features, not taking NSAIDs: covers the management of people with dyspepsia who do not have alarm features and who are not taking nonsteroidal anti-inflammatory drugs (NSAIDs).
• Scenario: Dyspepsia - no alarm features, taking NSAIDs: covers the management of people who do not have alarm features and who are taking NSAIDs.

• 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.
• Alarm features include one or more 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 all other people with dyspepsia and alarm features:
• Arrange endoscopy within 14 days and do a full blood count.
• Suspend nonsteroidal anti-inflammatory drugs while awaiting referral. Offer alternative analgesics (e.g. paracetamol and/or opioids).
• The management of other drugs will depend on clinical judgement of the benefits and risks of continued treatment. When there is uncertainty seek specialist advice. Management options include:
• Stopping the drug.
• Reducing the frequency or dose of the drug.
• Substituting the drug for one less likely to cause bleeding or dyspepsia.
• Review and manage lifestyle factors known to exacerbate dyspepsia.
• Prescribe either an alginate or an antacid to relieve dyspepsia whilst awaiting endoscopy. Ensure that proton pump inhibitors or H₂-receptor antagonists (including those obtained over-the-counter) are not used, for a minimum of 2 weeks, before endoscopy.
• Advise those people who deteriorate significantly to seek medical attention.

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

• 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 other people with dyspepsia without alarm features who are not taking a nonsteroidal anti-inflammatory drug (NSAID):
• Do a full blood count if there are any features of anaemia.
• Review and manage drugs known to increase the risk of gastrointestinal bleeding or exacerbate dyspepsia.
• Review and manage lifestyle factors known to exacerbate dyspepsia.
• Prescribe, or advise the use of, an antacid or alginate as required for immediate relief of dyspepsia. Prescribe an alginate if symptoms of gastro-oesophageal reflux are present.
• Prescribe additional drug treatment to settle persistent symptoms:
• Step 1: treat with either a proton pump inhibitor (PPI) at full dose for 1 month, or test and treat for Helicobacter pylori.
• Step 2: for people who have not responded to a PPI, test and treat for H. pylori. For people who have not responded to treatment for H. pylori, treat with a PPI for 1 month.
• Step 3: for people responding to neither a PPI nor treatment for H. pylori, prescribe either a prokinetic (metoclopramide, domperidone) or an H₂-receptor antagonist for 1 month.
• Refer those people not responding to all three treatment steps to secondary care for further management.
• For people with recurrent dyspepsia following successful treatment with either an acid suppressing drug or a prokinetic, restart and maintain the treatment but:
• Prescribe the lowest dose that controls symptoms.
• Advise using the treatment on an as required basis when possible.
• Review maintenance treatment at least annually.

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

• 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