What is the recommended management for epigastric pain presumed dyspepsia in a patient without alarm features, including when to test for Helicobacter pylori and use of proton‑pump inhibitors?

Management of Epigastric Pain (Presumed Dyspepsia)

Initial Risk Stratification and When to Refer for Endoscopy

For patients without alarm features and age <55 years, proceed directly to H. pylori testing and empirical PPI therapy without endoscopy. 1, 2

Urgent endoscopy is required for:

• Patients ≥55 years with dyspepsia AND weight loss 1, 2
• Patients >40 years from high gastric cancer risk areas or with family history of gastro-oesophageal cancer 1, 2
• Any age with dysphagia 1, 2
• Patients ≥60 years with abdominal pain and weight loss require urgent CT scan to exclude pancreatic cancer 1, 2

Non-urgent endoscopy is considered for:

• Patients ≥55 years with treatment-resistant dyspepsia 1, 2
• Patients ≥55 years with dyspepsia plus raised platelet count, nausea, or vomiting 1, 2

Initial Laboratory Testing

Obtain a full blood count in all patients ≥55 years with dyspepsia. 1, 2

Obtain coeliac serology in all patients with overlapping IBS-type symptoms (bloating, altered bowel habits). 1, 2

H. Pylori Testing Strategy

Test all patients with dyspepsia for H. pylori using either 13C-urea breath test (preferred) or stool antigen test—both have >90% sensitivity and specificity. 1, 3, 2

Critical testing considerations:

• Avoid whole blood serological tests as they lack adequate sensitivity and specificity 1
• The urea breath test has 88-95% sensitivity and 95-100% specificity 4
• The stool antigen test has 94% sensitivity and 92% specificity 4
• Testing during acute bleeding may yield false-negatives, requiring repeat testing if initially negative 4

If H. pylori positive:

Provide eradication therapy immediately with standard triple therapy: PPI twice daily + amoxicillin 1000mg twice daily + clarithromycin 500mg twice daily for 14 days. 3, 4

This eliminates peptic ulcer mortality risk and prevents gastric adenocarcinoma, though it may not resolve all dyspeptic symptoms. 1, 3, 2

Confirmation of successful eradication is only necessary in patients at increased risk of gastric cancer. 1

Proton Pump Inhibitor Therapy

For H. pylori-negative patients or persistent symptoms after eradication:

Start standard-dose PPI (omeprazole 20mg or equivalent) once daily, taken 30-60 minutes before a meal, for 4-8 weeks. 1, 3, 2, 5

All commercially available PPIs have similar efficacy for symptom control, and PPIs are superior to H2-receptor antagonists, which are superior to placebo. 3

If symptoms persist after 4-8 weeks of once-daily PPI:

Increase to twice-daily dosing (morning and evening) before meals, and continue for an additional 4-8 weeks. 3

Symptom-based approach:

• For ulcer-like dyspepsia (epigastric pain predominant): Full-dose PPI is first choice, with response confirming acid-related nature 1, 3
• For dysmotility-like symptoms (bloating, fullness, early satiety): Add a prokinetic agent, though availability and side effects limit use 3

Critical PPI prescribing details:

• PPIs must be taken 30-60 minutes before meals for optimal effect 3
• H2-receptor antagonists develop tolerance within 6 weeks, limiting long-term effectiveness 3
• If symptoms persist despite optimized PPI therapy (twice daily for 8 weeks), endoscopy is indicated 3

Long-Term Management

After initial symptom resolution, attempt treatment withdrawal to assess if ongoing therapy is needed. 2

If symptoms recur, restart the successful medication and consider on-demand therapy (taking PPI only when symptoms occur) to minimize long-term exposure. 2, 5

Taper to the lowest effective dose rather than continuing full-dose indefinitely. 2

When to Refer to Gastroenterology

Refer when diagnostic doubt exists, symptoms are severe or refractory to first-line treatments (H. pylori eradication and 8 weeks of optimized PPI therapy), or the patient requests specialist opinion. 1, 2

Ideally, patients should be managed in a specialist clinic with access to dietetic support and gut-brain behavioral therapies. 1

Lifestyle Modifications

Advise all patients to take regular aerobic exercise. 1, 2

There is insufficient evidence to recommend specific dietary therapies, including low-FODMAP diets, for functional dyspepsia. 1, 2

Common Pitfalls to Avoid

• Do not use whole blood H. pylori tests—they lack adequate sensitivity and specificity for reliable test-and-treat strategies 1
• Do not use H2-receptor antagonists as first-line therapy—they are significantly less effective than PPIs and develop tolerance within 6 weeks 3, 4
• Do not forget to take PPIs 30-60 minutes before meals—timing is critical for optimal acid suppression 3
• Do not continue NSAIDs in patients with peptic ulcer disease—they significantly increase recurrence and complication risk 4
• Do not assume H. pylori eradication will resolve all symptoms—many patients require subsequent acid suppression therapy 1, 3