Brooks D. Cash, MD, FACP, FACG

Disclosures

December 12, 2002

In This Article

Therapeutic Approach to Dyspepsia

The most recent American Gastroenterological Association recommendations for the approach to dyspepsia are shown in the Figure. Known as the "test-and-treat" approach, it calls for a careful history to be taken to exclude alternative conditions (gastroesophageal reflux disease, gallbladder disease, IBS, etc.) and to identify alarm features. Alarm features in patients presenting with dyspepsia include age older than 45 years, recurrent vomiting, weight loss, dysphagia, evidence of bleeding, or anemia.[2] Prompt upper endoscopy is recommended for patients with alarm features. According to the test-and-treat approach, patients with dyspepsia without alarm features should be tested for HP infection and treated with an appropriate antibiotic regimen if infection is detected. Patients who have not been infected with HP should receive empiric therapy with antisecretory agents, but not antibiotics. Failure to respond to antisecretory or HP therapy (when indicated) should be followed by upper endoscopy. Most patients will fall into this latter category and eventually be classified as having functional dyspepsia.

Test-and-treat approach to dyspepsia.



Recently, the effectiveness of the test-and-treat approach has received careful scrutiny based on findings from several prospective trials that showed that the strategy applies to the minority of patients with dyspepsia and, perhaps more important, fails to significantly alter the impaired quality of life of affected individuals.[15,16,17] Moreover, it appears that treating HP infection in patients with functional dyspepsia results in only modest symptom improvement.[8,18] Recently, a decision-analysis of competing strategies determined that, compared with the test-and-treat approach, an initial empiric trial of antisecretory therapy with proton-pump inhibitors (PPIs) may offer substantially improved clinical outcomes at a lower cost.[19]

In contrast to studies that focused on initial empiric therapy (antibiotic treatment against HP or treatment with antisecretory agents), several trials have examined the therapeutic response to early endoscopic-directed therapy.

Bytzer and colleagues[20] randomized patients with dyspepsia to initial endoscopy vs empiric histamine-2 receptor antagonist (H2RA) therapy. They found that patients in both groups had similar symptom relief at 1 year and that the majority of patients in the empiric-therapy group eventually underwent endoscopy during that time. Additionally, patients treated empirically were less satisfied with their care, and 40% of peptic ulcers were missed in this group.

A nonrandomized trial conducted by Hungin and colleagues[21] found that healthcare-seeking behavior and drug therapy were reduced in patients without endoscopic abnormalities 1 year after endoscopy, suggesting a therapeutic benefit to a normal diagnostic evaluation and its reassurance. Similar results were observed in a randomized, controlled trial comparing 13C-urea breath testing and HP eradication with endoscopy.[22] At 1 month, patients in the endoscopy group had greater symptom relief and satisfaction with their care than did patients in the breath-test group.

Based on the data presented above, the optimal initial therapeutic approach to dyspepsia remains to be determined. Clearly, patients with alarm features should initially undergo endoscopic evaluation with subsequent treatment based on the results of that investigation. Medications known to be potential causes of dyspepsia should be identified and discontinued. It appears reasonable to administer a trial of potent antisecretory treatment as a first-line empiric therapy to treat gastroesophageal reflux disease or underlying peptic ulcer disease that may present as dyspepsia, but it is unclear whether this approach will result in less healthcare-seeking behavior or associated costs.

Testing and treating for HP may also offer some benefit for those patients with HP-mediated pathology, but is less likely to benefit patients with functional dyspepsia. Initial endoscopic evaluation may offer therapeutic benefit if study findings are normal (as will be the case in the majority of patients with dyspepsia), and is an attractive option, but is an impractical initial approach due to the inherent increased costs and burden on endoscopic resources. After initial evaluation and empiric therapy, most patients will be diagnosed with functional dyspepsia.

The remainder of this report addresses the therapeutic approach to this group of patients.

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