Dyspepsia
H. pylori test-and-treat, PPI therapy and stepwise management per NICE CG184
Dyspepsia encompasses a range of upper GI symptoms — epigastric pain, bloating, early satiety, and nausea — arising from the stomach and duodenum. NICE CG184 recommends H. pylori test-and-treat as the first-line strategy in patients under 55 without alarm features, followed by empirical PPI therapy if H. pylori negative.
Assessment and Red Flags
Dyspepsia affects up to 40% of the population at some point. Before prescribing, it is essential to exclude alarm features that require urgent endoscopy: dysphagia, progressive unintentional weight loss, persistent vomiting, haematemesis, iron-deficiency anaemia, epigastric mass, and new-onset dyspepsia in patients over 55. These warrant an urgent 2-week wait upper GI endoscopy referral per NICE NG12. All medications should be reviewed — NSAIDs, aspirin, bisphosphonates, calcium channel blockers, and nitrates can all cause or worsen dyspepsia.
H. pylori Test and Treat
NICE CG184 recommends offering H. pylori testing (urea breath test or stool antigen test) to all patients with uncomplicated dyspepsia under 55, before endoscopy. If positive, eradication therapy is offered: a PPI plus two antibiotics for 7–14 days (14 days preferred in current UK practice — see H. pylori & PUD care plan). Eradication must be confirmed by UBT or stool antigen test at least 4 weeks after completing antibiotics and at least 2 weeks after stopping PPI. If H. pylori negative, an empirical 4-week course of standard-dose PPI is offered.
PPI Therapy and Long-Term Management
Omeprazole 20 mg once daily (or equivalent) for 4 weeks is the standard empirical treatment. If symptoms respond, step-down to the lowest effective dose — using on-demand or intermittent therapy for mild intermittent dyspepsia. Long-term PPI prescriptions should be reviewed annually — risks of prolonged use include hypomagnesaemia, B12 deficiency, and increased C. difficile susceptibility. Antacids and alginate preparations (Gaviscon) provide symptomatic relief for breakthrough symptoms. Prokinetics (metoclopramide 10 mg TDS — maximum 5 days per MHRA guidance; or domperidone 10 mg TDS) are used short-term for nausea-predominant dyspepsia.