What is the recommended workup and treatment for an adult with dyspepsia, including assessment of alarm symptoms, age‑based H. pylori testing, and appropriate pharmacologic therapy?

Management of Dyspepsia in Adults

For patients under 55 years without alarm symptoms, use non-invasive H. pylori testing ("test and treat") followed by PPI therapy if negative or symptoms persist; for patients ≥55 years or any age with alarm features, proceed directly to endoscopy. 1

Initial Risk Stratification by Age and Alarm Features

Patients ≥55 Years with New-Onset Dyspepsia

• Proceed directly to esophagogastroduodenoscopy (EGD) regardless of alarm symptoms because upper gastrointestinal malignancy incidence increases substantially after age 55, making direct visualization and tissue sampling essential rather than optional. 1, 2
• The age cutoff is critical: approximately 70% of early gastric cancers present with uncomplicated dyspepsia without alarm features like anemia, dysphagia, or weight loss. 2
• Endoscopy should be preferred over upper gastrointestinal radiography because it has greater diagnostic accuracy and allows biopsy specimens for H. pylori testing. 1, 3

Urgent Endoscopy (Within 2 Weeks) Required For:

• Age ≥55 years with dyspepsia plus weight loss 1
• Age >40 years from high gastric cancer risk areas or with family history of gastro-esophageal cancer 1
• Any age with alarm features: progressive dysphagia, recurrent vomiting, evidence of gastrointestinal bleeding, palpable abdominal mass 1

Non-Urgent Endoscopy Considered For:

• Age ≥55 years with treatment-resistant dyspepsia 1
• Age ≥55 years with raised platelet count or nausea/vomiting 1

Patients <55 Years Without Alarm Features

• Use the "test and treat" approach for H. pylori as it is equally effective and more cost-efficient than prompt endoscopy. 4
• This recommendation is cost-effective and includes patients with uncomplicated duodenal ulcer disease. 1

H. Pylori Testing Strategy

Optimal Non-Invasive Tests (Choose One):

• 13C-urea breath test (preferred) 1, 4
• Stool antigen test (alternative) 1, 4
• Do NOT use IgG or IgM antibody serology as primary diagnostic method due to lower specificity and cost-effectiveness. 4

If H. Pylori Positive:

• Provide eradication therapy using triple therapy: PPI + amoxicillin + clarithromycin for 14 days. 4
• Eradication provides modest but significant benefit in dyspepsia, leads to long-term symptom improvement, and reduces risk of peptic ulcer disease, atrophic gastritis, and gastric cancer. 4
• Confirmation testing after eradication is only needed in patients with increased risk of gastric cancer (family history, high-risk ethnicity), not routinely in low-risk patients. 1, 4

If H. Pylori Negative or Symptoms Persist After Eradication:

• Offer empirical acid suppression with PPI for 4-8 weeks. 1, 4
• PPIs are the drug class of choice for acid suppression with strong evidence in dyspepsia. 1
• Use the lowest effective PPI dose, taken 30-60 minutes before meals. 4

Baseline Laboratory Investigations

• Full blood count mandatory in patients aged ≥55 years 1
• Coeliac serology in all patients with overlapping IBS-type symptoms 1
• Urgent abdominal CT scan for patients ≥60 years with abdominal pain and weight loss to exclude pancreatic cancer. 1

Endoscopy Technique Requirements (When Performed)

• Obtain biopsy specimens for H. pylori at time of endoscopy using rapid urease test and/or culture/sensitivity/histology. 1
• For gastric lesions, obtain at least 6 samples using standard biopsy forceps to achieve diagnostic accuracy approaching 100%. 2
• Stop PPIs before first endoscopy as they can mask endoscopic findings, delay diagnosis, or result in misdiagnosis by "healing" malignant ulcers. 2

Management After Failed Empirical Therapy

If Symptoms Persist Despite H. Pylori Eradication and PPI Trial:

• Consider endoscopy in younger patients (<55 years) but recognize this should be evaluated in the wider context of reassessing symptoms and diagnosis. 1
• Endoscopy may reassure some young patients but evidence suggests this is not the case in those who are most anxious. 1
• The yield of endoscopy is low in young patients without alarm features who have failed empirical therapy. 1

Alternative Therapies if PPI Ineffective:

• Tricyclic antidepressants or prokinetic therapies can be tried. 5
• Regular aerobic exercise is recommended for all patients with functional dyspepsia. 1

Critical Pitfalls to Avoid

• Do NOT dismiss symptoms as functional dyspepsia without proper investigation in patients ≥55 years with new-onset symptoms, as this age cutoff exists specifically because malignancy risk increases substantially. 2
• Do NOT rely on absence of alarm symptoms to defer endoscopy in elderly patients, as this approach causes localized disease to be overlooked. 2
• Do NOT use CT imaging as substitute for endoscopy in initial evaluation, as CT may miss gastric masses due to gastric underdistension. 2, 3
• The value of alarm symptoms in younger patients is controversial and not very useful in diagnosing upper gastrointestinal malignancy, but they remain important in older patients. 1

Patient Education and Follow-Up

• Establish an effective and empathic doctor-patient relationship as this may reduce healthcare utilization and improve quality of life. 1
• Explain FD as a disorder of gut-brain interaction, including how the gut-brain axis is impacted by diet, stress, cognitive, behavioral and emotional responses to symptoms, and postinfective changes. 1
• Screen for potential aetiological triggers including previous acute enteric infection (present in ~10% of patients). 1