NICE Guidelines for the Management of Dyspepsia.

A 35-year-old man who is usually fit and well presents to his GP with a 2 month history of indigestion. His weight is stable and there is no history of dysphagia. Examination of the abdomen is unremarkable. Of the following options, what is the most suitable initial management?
A. Urea breath testing and non-urgent referral for endoscopy
B. H pylori eradication therapy and full-dose proton pump inhibitor for three months
C. Full-dose Proton pump inhibitor and immediate referral for endoscopy
D. Three month course of a standard-dose proton pump inhibitor
E. One month course of a full-dose proton pump inhibitor

Answer:
E. One month course of a full-dose proton pump inhibitor

This question highlights the NICE guidelines for the management of dyspepsia. There is no evidence currently to suggest whether a one month course of a PPI or 'test and treat' strategy should be adopted first line. Many clinicians prefer to test for H pylori first as this cannot be done within 2 weeks of acid-suppression therapy, as false-negative results may occur Given the options available, only the answer is in line with current NICE guidelines

Discussion On Dyspepsia Management:

In 2014 NICE updated their guidelines for the management of dyspepsia. These take into account the age of the patient (whether younger or older than 55 years) and the presence or absence of 'alarm signs': 
 chronic gastrointestinal bleeding
 progressive unintentional weight loss
 progressive difficulty swallowing
 persistent vomiting
 iron deficiency anaemia
 epigastric mass
 suspicious barium meal.

Deciding whether urgent referral for endoscopy is needed
Urgent referral (within 2 weeks) is indicated for patients with any alarm signs irrespective of age
Routine endoscopic investigation of patients of any age, presenting with dyspepsia and without
alarm signs is not necessary, however
Patients aged 55 years and over should be referred urgently for endoscopy if dyspepsia symptoms
are:
 recent in onset rather than recurrent and
 unexplained (e.g. New symptoms which cannot be explained by precipitants such as NSAIDs) and
 persistent: continuing beyond a period that would normally be associated with self-limiting problems (e.g. Up to four to six weeks, depending on the severity of signs and symptoms)

Managing patients who do not meet referral criteria ('undiagnosed dyspepsia')
This can be summarised at a step-wise approach
 1. Review medications for possible causes of dyspepsia
 2. Lifestyle advice
 3. Trial of full-dose PPI for one month*
 4. 'Test and treat' using carbon-13 urea breath test

*it is unclear from studies whether a trial of a PPI or a 'test and treat' should be used first