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Clinical Practice: Diagnosis and Evaluation of Dyspepsia

Graham, David Yates MD*; Rugge, Massimo MD* † ‡

Journal of Clinical Gastroenterology: March 2010 - Volume 44 - Issue 3 - p 167-172
doi: 10.1097/MCG.0b013e3181c64c69
ALIMENTARY TRACT: Clinical Reviews

The main issue regarding the approach to the patient with uninvestigated dyspepsia is whether the symptoms are the result of an important clinical illness, which then determines the appropriate management strategy for the treatment of the symptoms. An initial trial of empiric antisecretory drugs is recommended for those without Helicobacter pylori infection and no alarm symptoms, whereas H. pylori eradication is recommended for those with an active H. pylori infection. Treatment expectations for H. pylori infections should theoretically be similar to other common infectious diseases. In most regions, clarithromycin resistance has undermined traditional triple therapy so that it is no longer a suitable choice as an empiric therapy. Four drug therapies, such as sequential, concomitant, and bismuth-quadruple therapy are generally still acceptable choices as empiric therapies. Posteradication testing is highly recommended to provide early identification of otherwise unrecognized increasing antimicrobial resistance. However, despite the ability to successfully cure H. pylori infections, a symptomatic response can be expected in only a minority of those with dyspepsia not associated with ulcers (so called nonulcer dyspepsia). Overall, from the patients stand point, symptomatic relief is often difficult to achieve and physicians must rely on reassurance along with empiric and individualized care.

*Department of Medicine, Veterans Affairs Medical Center and Baylor College of Medicine Houston, Texas, USA

Department of Diagnostic Sciences & Special Therapies-Pathology Unit, University of Padova

Veneto Institute of Oncology IOV-IRCCS Padova, Pathology Unit, Italy

This material is based upon the work supported in part by the Office of Research and Development Medical Research Service, Department of Veterans Affairs. Dr Graham is supported in part by Public Health Service grant DK56338 that funds the Texas Medical Center, the Digestive Diseases Center, and the R01 CA116845. The contents are solely the responsibility of the authors and do not necessarily represent the official views of the VA or the NIH. In the last 3 years, Dr Graham has received small amounts of grant support and/or free drugs or urea breath tests from Meretek and BioHit for investigator initiated and completely investigator-controlled research. Dr Graham is a consultant for Novartis in relation to vaccine development for the treatment or prevention of the H. pylori infection. Dr Graham is also a paid consultant for Otsuka Pharmaceuticals and until July 2007 was a member of the Board of Directors of Meretek, Diagnostics, the manufacturer of the 13C-urea breath test. Until October 2009, Dr Graham received royalties on the Baylor College of Medicine patent covering materials related to 13C-urea breath test.

Reprints: David Yates Graham, MD, Michael E. DeBakey Veterans Affairs Medical Center, Rm 3A-320 (111D), 2002 Holcombe Boulevard, Houston, USA-TX 77030 (e-mail:

© 2010 Lippincott Williams & Wilkins, Inc.