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Review Article
Dig Dis 2008;26:225230
DOI: 10.1159/000121351
Current Guidelines for Dyspepsia
Management
Alexander C. Ford
a
Paul Moayyedi
b


a
Department of Academic Medicine, St. Jamess University Hospital, Leeds , UK;

b
Gastroenterology Division, McMaster University, Health Sciences Center, Hamilton, Ont. , Canada
mandatory endoscopy in those whose symptoms failed to
settle after this approach. Conclusions: Despite varying
composition of guideline development groups and the dif-
ferent geographical regions, the recommendation of all the
guidelines were remarkably similar, reflecting the quality of
research conducted by the GI community as a whole.
Copyright 2008 S. Karger AG, Basel
Introduction
Dyspepsia is a complex of symptoms referable to the
upper gastrointestinal (GI) tract. Surveys have shown
that dyspepsia is a global problem with 1540% of popu-
lations from Asia to North America complaining of up-
per GI symptoms [17] . The variation in prevalence esti-
mates depends more on the definition of dyspepsia used
than the country studied [8, 9] . The prevalence of dyspep-
sia remains relatively stable, even during prolonged peri-
ods of follow-up, as the resolution of symptoms in some
individuals is matched by the spontaneous development
of symptoms in others [7, 10, 11] .
The presence of symptoms of dyspepsia may lead an
individual to consult a physician. This probably occurs as
a result of a combination of fear of serious illness, patient
demographics, or the frequency or severity of the symp-
toms themselves [2, 3, 1214] . It is estimated that between
25 and 40% of individuals with dyspepsia will consult a
Key Words
Dyspepsia Helicobacter pylori Endoscopy Management
guidelines
Abstract
Background: Dyspepsia is a global problem and the man-
agement of the condition remains a considerable burden on
health care resources. Many countries have adopted evi-
dence-based guidelines for the management of the condi-
tion, in an attempt to reduce health care expenditure. This
article compares and contrasts dyspepsia management
guidelines from several geographical regions. Methods: We
obtained current guidelines from five regions and examined
composition of guideline development groups, methodol-
ogy involved, definition of dyspepsia utilized, and recom-
mendations in terms of first-line approach, age cutoff for
prompt upper gastrointestinal (GI) endoscopy, and subse-
quent role of endoscopy. Results: All guidelines carried out
extensive reviews of the literature to inform their recom-
mendations. The majority used a definition of dyspepsia in
line with the Rome criteria. All agreed that alarm symptoms
at any age warranted prompt endoscopy, and most recom-
mended an age cutoff of between 50 and 55 years for endos-
copy as an initial management strategy. In young patients
without alarm symptoms, either test and treat or empirical
acid suppression were the initial management strategies of
choice in all cases, with only one guideline recommending
Dr. Alex Ford
Department of Academic Medicine, Clinical Sciences Building
St. Jamess University Hospital, Room 7.23
Leeds LS9 7TF (UK)
Tel. +44 113 269 7975, Fax +44 113 242 9722, E-Mail alexf12399@yahoo.com
2008 S. Karger AG, Basel
02572753/08/02630225$24.50/0
Accessible online at:
www.karger.com/ddi
Ford /Moayyedi

Dig Dis 2008;26:225230 226
primary care physician as a result of their symptoms [2,
3, 12] . This presents the clinician with a problem, as the
underlying pathology may vary from the life-threatening
to the benign. The four major etiologies include gastric
and esophageal malignancy, peptic ulcer disease, gastro-
esophageal reflux disease (GERD), and functional dys-
pepsia, the latter occurring when epigastric-predominant
symptoms are present in the absence of a definite struc-
tural cause at upper GI endoscopy. In studies that have
reported findings at upper GI endoscopy in those with
dyspepsia, 40 to 60% of individuals have a normal exam-
ination, whilst gastro-esophageal malignancy is typically
present in less than 1% in Western populations [1517] .
The approach to these statistics will depend upon how
risk averse both the patient and the clinician are to un-
certainty. There are four widely accepted management
strategies, and all have been compared in randomized
controlled trials (RCTs) [1827] .
Those that wish to eliminate all possible risk in man-
aging dyspepsia advocate prompt upper GI endoscopy for
all patients presenting with symptoms, in an attempt to
exclude gastro-esophageal malignancy which, if present,
may be detected at a stage where it is more amenable to
surgical cure. Since dyspepsia is such a prevalent condi-
tion in the general population, and a large proportion of
patients will have normal endoscopic findings, it is not
feasible to recommend prompt endoscopy for all individ-
uals who consult with dyspepsia. There are two practical
reasons for this. Firstly, endoscopy remains a relatively
expensive investigative procedure [28] . Secondly, upper
GI endoscopy is invasive, and carries the risk of potential
complications that, although rare, may have grave conse-
quences. Indeed, in younger patients, in whom serious
disease is less likely, these complications may exceed the
perceived benefits. Attempts have therefore been made in
the West to rationalize the use of endoscopy by restrict-
ing its use to those above a certain age, as younger pa-
tients have a much lower incidence of upper GI malig-
nancy [2934] , or to those who present with alarm symp-
toms, which are thought to be predictive of underlying
malignant disease, though in reality the positive predic-
tive value of such symptoms is poor [31, 35, 36] .
Testing for Helicobacter pylori and endoscopy for only
those who test positive (a so-called test and scope ap-
proach) has been proposed as an alternative, in an at-
tempt to reduce endoscopy workload. Testing for H. py-
lori followed by treatment with eradication therapy for
positive individuals (test and treat) is another option,
and the efficacy of this approach is thought to arise from
a combination of successful treatment of latent peptic ul-
cer disease [37] , as well as a modest effect on the symp-
toms of functional dyspepsia [38] . The final strategy is
one of empirical acid suppression therapy with either a
proton pump inhibitor (PPI) or an H
2
-receptor antago-
nist (H
2
RA).
As dyspepsia is prevalent worldwide, many developed
countries have adopted guidelines for the management of
dyspepsia, primarily in an attempt to use an evidence-
based approach to the management of the condition in
order to reduce dyspepsia-related health care expendi-
ture. These serve as a useful way of summarizing the cur-
rent available evidence and distilling it in such a way that
clinical practice becomes standardized. The remainder
of this article compares and contrasts dyspepsia manage-
ment guidelines from various countries or regions.
Dyspepsia Guidelines
The guidelines reviewed in this article have been pro-
duced by the Canadian Dyspepsia (CanDys) Working
Group [39] , the England and Wales National Institute of
Clinical Excellence (NICE) [40] , the Scottish Intercolle-
giate Guidelines Network (SIGN) [41] , the American Col-
lege of Gastroenterology (ACG) [42] , the American Gas-
troenterological Association (AGA) [43] , and the Asia-
Pacific Working Party [44] .
Composition of the Guideline Development Groups
The NICE guidelines and CanDys Working Group
were developed from a primary care perspective. The
NICE group consisted predominantly of primary care
physicians but with gastroenterology and pharmacy in-
put, whilst the CanDys group consisted of a more equal
mix of gastroenterologists and primary care physicians.
The SIGN guidelines were developed from a general
health service perspective and the development panel
consisted of gastroenterologists, primary care physicians,
general surgeons, radiologists, pharmacists and dieti-
cians. The SIGN and NICE guidelines were the only
guidelines to include specific methodology experts and
patient representatives. The remaining guidelines were
all developed from a gastroenterology perspective and
the group mainly consisted of gastroenterologists. The
ACG and AGA guidelines were written by two or three
gastroenterologists in conjunction with the ACG Practice
Parameters Committee and the AGA Clinical Practice
and Economics Committee respectively. Two out of the
three authors of the ACG and AGA guidelines were the
same and the guidelines were written within 12 months
Current Guidelines for Dyspepsia
Management
Dig Dis 2008;26:225230 227
of each other, so these guidelines would be expected to
show the greatest similarity.
Guideline Development Methodology
All the guidelines reviewed in this article were in-
formed by extensive reviews of the literature to obtain
contemporaneous available scientific evidence. In most
cases this evidence was graded according to quality.
Where evidence was lacking expert consensus, either
from the literature or from the guideline development
groups, was used in some cases. In the case of the NICE
guidelines, several systematic reviews and meta-analyses
of RCTs were also undertaken as part of the development
process. The AGA guidelines used these systematic re-
views, as well as conducting others on the utility of alarm
symptoms in diagnosing upper GI malignancy. In the
NICE, SIGN, CanDys Working Group and the Asia-Pa-
cific Working Party guidelines consensus was reached by
the jury method which is an informal approach used for
a group to reach consensus. The AGA and ACG guide-
lines were written by two to three authors who informal-
ly reached agreement amongst themselves, and this was
modified by committees appointed by the relevant soci-
ety. None of the guidelines used formal consensus meth-
Table 1. Summary of guidelines for dyspepsia
Guideline Dyspepsia
definition
When to endoscope Place of H. pylori test and treat Use of PPI therapy
ACG 2005
(US)
Rome II Age >55 or alarm features
(any age)
If H. pylori eradication and/or
PPI fails in those 55 consider
H. pylori test and treat if prevalence
>10%, empirical PPI in lower
prevalence areas
Empiric PPI therapy first line in
low H. pylori prevalence areas
After H. pylori test if negative or
positive and failing treatment in
high prevalence areas
Standard doses of PPI therapy
should be used with double doses
considered if symptoms persist
AGA 2005
(US)
Rome II Age >55 or alarm features
(any age)
If H. pylori eradication and/or
PPI fails in those 55 consider
H. pylori test and treat if prevalence
>10%, empirical PPI if prevalence
<5%, if 510% strategy uncertain
Empiric PPI therapy first line in
low H. pylori prevalence areas
After H. pylori test if negative or
positive and failing treatment in
high prevalence areas
NICE 2004
(England
and Wales)
All upper GI
symptoms
Age >55 or alarm features
(any age)
If H. pylori eradication and/or
PPI fails in those 55 consider
Evidence of H. pylori test and treat
or empiric PPI therapy uncertain
so first line choice left to individual
preference
If one fails try the other
Initial therapy should be standard
dose for one month
Then patient should be managed
with on-demand PPI therapy at
the lowest dose that manage the
patients symptoms
SIGN 2003
(Scotland)
Rome II Alarm features (any age)
Consider referral to
secondary care if 55 years
and symptoms persist
First line for those with dyspepsia
and no alarm symptom at any age
Empiric PPI therapy if H. pylori
eradication fails
Dose not explicitly stated
CanDys
2005
(Canada)
All upper GI
symptoms,
except
isolated
heartburn
Age >50 or alarm features
(any age)
If H. pylori eradication and/or
PPI fails in those 50 consider
H. pylori test and treat if epigastric
pain is the dominant problem
Empiric acid suppression if heart-
burn is the predominant problem
Standard dose PPI for 48 weeks
then consider on demand PPI or
stepping down to H
2
RA
Asia-
Pacific
working
party
1998
Rome I Age 3555 (depending on risk
of gastric cancer in the region)
or alarm features (any age)
Consider H. pylori test and treat if
patient fails empiric acid suppres-
sion and/or prokinetic therapy
In areas with high prevalence of
H. pylori this strategy unlikely to
be beneficial
First-line therapy for young patients
with no alarm features
Either PPI or H
2
RA at standard dose
Ford /Moayyedi

Dig Dis 2008;26:225230 228
ods such as the modified Delphi or nominal group tech-
niques.
Recommendations of the Guidelines
Despite the varying make-up of the development
groups and the methodology used, as well as differences
in the target audiences, the guidelines provide remark-
ably similar management strategies for dyspepsia. This is
probably because the underlying evidence base in this
field is so good, and this reflects well on the GI commu-
nity as a whole. There are some differences, however, and
these are discussed below and detailed in table 1 .
Differences in the Definition of Dyspepsia Used by
the Guidelines
The majority of the guidelines used a definition of dys-
pepsia that is in line with the Rome criteria, where those
with suspected GERD are excluded. The exceptions to
this are the NICE guidelines and the CanDys clinical
management tool. The former used a broad definition of
dyspepsia that included all symptoms referable to the up-
per GI tract, whilst the latter only excluded those with
isolated heartburn. This probably reflects the fact both
were developed with a primary care audience in mind,
where physicians are often consulting with patients be-
fore the results of investigations are available, and even
when these are on hand, studies suggest that the value of
distinctions made on the grounds of symptom patterns
alone are imperfect, due to poor sensitivity and specific-
ity of individual symptoms for predicting underlying pa-
thology, as well as considerable overlap of both individu-
al symptoms and symptom subgroups [16, 45, 46] .
Differences in the Age Cutoff for Prompt Endoscopy
In terms of when to offer prompt endoscopy, all the
guidelines are in agreement that individuals of any age
with alarm symptoms warrant this, though it is accepted
that the predictive value of these symptoms is poor, and
the yield of endoscopy in this setting is low [15, 17] . The
age cutoff recommended by the various guidelines for
when to offer prompt endoscopy in uncomplicated dys-
pepsia varies from 50 to 55 years of age, the age at which
incidence of upper GI malignancy is said to significantly
increase, with the exception of the Asia-Pacific Working
Party and the SIGN guidelines. The former did not set a
specific cutoff, as a number of countries were represented
with varying risks of upper GI malignancy and different
health care budgets, though they suggested an age from
35 years in very-high-risk developed countries such as
Japan and made no recommendation for endoscopy at all
in low-risk developing countries. The SIGN guidelines do
not recommend prompt endoscopy as the management
of choice at any upper age limit, because it is felt that there
is no evidence that potentially curable gastric cancer
found at endoscopy for uncomplicated dyspepsia is any-
thing other than a chance finding. Some of these differ-
ences may have arisen due to differences in the way health
service provision is funded between the UK and the US.
The publicly funded UK system may be expected to rec-
ommend a reduction in the use of endoscopy, if this is
unlikely to adversely affect patient care, in order to min-
imize costs.
Differences in First-Line Approach to Young Patients
with Uncomplicated Dyspepsia
SIGN and the CanDys clinical management tool rec-
ommend a first-line strategy of test and treat with erad-
ication therapy for positives and a trial of empirical acid
suppression for negative individuals. Both the ACG and
AGA state that if the prevalence of H. pylori in the local
population is ten percent or more, then test and treat
with empirical acid suppression for negatives should be
first-line management, with empirical acid suppression
as first-line in areas of lower prevalence. NICE state that
there is no current available evidence as to which of these
two strategies is superior, and therefore either should be
offered.
Differences in When to Offer Endoscopy
Subsequently
In young patients with uncomplicated dyspepsia, ei-
ther H. pylori test and treat with PPI for those testing
negative, or empirical acid suppression therapy are rec-
ommended as first-line management strategies by all the
guidelines, depending on the prevalence of H. pylori in
the local population. For those whose symptoms persist
or recur following either, or both, of these approaches,
only the CanDys clinical management tool advocates en-
doscopy to confirm or refute the presence of underlying
pathology. The ACG and AGA guidelines state that some
patients, particularly those who are anxious, may require
the reassurance afforded by endoscopy, but that it should
not be routinely offered. The NICE guidelines state that
endoscopy should be considered only if medical therapy
has failed. Finally, the SIGN guidelines do not recom-
mend endoscopy at all in this setting, but state that for
those aged 55 years and over, referral to a specialist in
secondary care should be considered.
Current Guidelines for Dyspepsia
Management
Dig Dis 2008;26:225230 229
Conclusions
Dyspepsia is a common complaint, and the manage-
ment of the condition represents a considerable financial
burden for the health service. The development of guide-
lines standardizes treatment and reduces costs, whilst
maintaining patient safety. Despite the excellent evidence
base already in existence that has been used to inform
much of the recommendations contained in the various
guidelines, gaps in current knowledge still exist. We still
do not know the lower limit of H. pylori prevalence at
which a test and treat strategy remains cost-effective.
Nor do we have any clear evidence for the use of an upper
age limit for referral for prompt endoscopy, and if so, at
what age that should be set. Finally, though we now have
strong evidence that test and treat is a more cost-effec-
tive management strategy than prompt endoscopy for the
initial management of uncomplicated dyspepsia [47] , it is
still not clear whether it is more cost-effective than em-
pirical acid suppression therapy, though one large trial in
the UK has recently been completed that may answer this
question [48] .
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