Patients with dyspepsia who are younger than age 50 and without alarm features are commonly evaluated by one of three methods: noninvasive testing for Helicobacter pylori (H. pylori), with subsequent treatment if positive (the "test-and-treat" approach), a trial of acid suppression or an initial endoscopy.

In many patients with dyspepsia who have peptic ulcer disease, H. pylori infection will be present. Noninvasive testing options for this infection include a blood test, urea breath testing (UBT), and stool antigen. There is growing evidence that patients who are managed with the test-and-treat approach have similar outcomes when compared with those undergoing initial endoscopy. The test-and-treat approach is more cost effective. Results from a meta-analysis of five randomized studies of test-and-treat versus an initial endoscopy showed a negligible improvement of symptoms in the endoscopy group, but a savings of $389 per patient in the test-and-treat group.

Many investigators and societies advocate acid-suppressive therapy as the initial treatment for patients with dyspepsia. Proton pump inhibitors (PPI) are more effective than H2 blockers in this approach. Initiation of empiric acid suppression will not address underlying H. pylori in those patients with H. pylori-associated peptic ulcer disease, risking recurrent symptoms when acid suppression is withdrawn. This may prompt long-term acid suppression if no further investigation is performed.

One advantage of early endoscopy is the chance of establishing a specific diagnosis, such as peptic ulcer disease or erosive esophagitis. The risk of malignancy is quite low in young patients without alarm features. Many patients, however, with early stage malignancy do not have alarm symptoms. Another advantage of a negative endoscopy in the evaluation of patients with dyspepsia is a reduction in anxiety and an increase in patient satisfaction. However, there is little evidence to suggest significant improvement in outcomes by the initial endoscopy approach. Most studies demonstrate an increased cost with the initial endoscopic approach compared with the test-and-treat method.

In summary, it is recommended that patients with dyspepsia who are 50 years of age or older and/or those with alarm features undergo endoscopic evaluation. Those younger than 50 years of age without alarm features should undergo an initial test-and-treat approach for H. pylori. Younger patients who are H. pylori negative can undergo an initial endoscopy or a short trial of PPI acid suppression, and patients with dyspepsia who do not respond to empiric PPI therapy or have recurrent symptoms after an adequate trial should undergo endoscopy.


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