Diagnostic approach to dyspepsia

The optimal diagnostic approach to the dyspeptic patient in primary care is still debated. Early endoscopy continues to be the diagnostic gold standard but competing non-invasive strategies challenge this. The most important approaches are empiric antisecretory treatment reserving encloscopy for unresponsive patients and patients with an early symptomatic relapse and helicobacter-based strategies reserving encloscopy for infected patients (test-and -scope) or for failures after eradication therapy (test-and-treat). Early encloscopy is recommended in patients with alarm features and should be considered in patients with new onset dyspepsia after age 50. In the remaining patients, early investigation can only be recommended in areas providing encloscopy at a low cost and with a short waiting list. The test-and-scope strategy may lead to a rise in the referral rates for encloscopy and cannot be recommended. The test-and-treat strategy is well documented in clinical trials as a safe and cost-effective approach. Helicobacter-based strategies are challenged by a decreasing prevalence of peptic ulcer disease and of the infection. In the near future, the empirical acid inhibition strategy will probably be cost-effective as gastro-oesophageal reflux becomes the predominant disorder in dyspeptic patients.