Dyspepsia, reflux, and Helicobacter pylori

Also known as Indigestion · GORD · GERD · H. pylori infection · Peptic ulcer disease

GP-fellowship guide to dyspepsia, reflux and Helicobacter pylori: the alarm features that demand endoscopy, the test-and-treat strategy with its PPI washout trap, eradication regimens chosen by local resistance (triple versus bismuth quadruple, with Hp-EuReg effectiveness data), the GORD ladder from full-dose PPI to step-down and surgery referral criteria, functional dyspepsia after a negative work-up, honest lifestyle counselling, and safety-netting.

high19 referencesUpdated 22 Aug 202610 min readVerification in progress

Practise this topic

Key points^[6]^[7]^[9]

Dyspepsia is epigastric pain or burning, postprandial fullness or early satiation; reflux disease is heartburn and acid regurgitation — but up to 30% of adults have heartburn and the syndromes overlap heavily.
Any alarm feature (dysphagia, bleeding, anaemia, weight loss, vomiting, mass, or new dyspepsia at older age) means endoscopy; everyone else under about 60 gets non-invasive testing.
Test-and-treat H. pylori in the under-60s without alarm features: urea breath test or stool antigen (both highly accurate), never serology alone — and stop PPIs two weeks before testing or the test lies.
Successful eradication cuts duodenal ulcer recurrence from roughly 64% to 13%; eradication also modestly helps functional dyspepsia (NNT 14) and reduces gastric cancer incidence (RR 0.66).

Overview

Dyspepsia describes epigastric pain or burning, postprandial fullness and early satiation; gastro-oesophageal reflux disease (GORD) describes heartburn and regurgitation, with or without extra-oesophageal symptoms. About a quarter of adults regularly experience heartburn, and most are treated empirically without endoscopy.^[5]

Endoscopy in uninvestigated dyspepsia is reassuringly boring: more than 85% of scans are completely normal, erosive oesophagitis is the most common abnormality (pooled prevalence 11.0%), peptic ulcer follows (4.4%), and gastro-oesophageal cancer is rare (below 0.4%) and equally prevalent with and without dyspepsia.^[9] This evidence supports managing dyspepsia non-invasively in the community, reserving endoscopy for those at genuine risk of malignancy.^[9]

Three organisms and mechanisms dominate the differential of the burning upper abdomen: Helicobacter pylori, acid, and the brain–gut axis when both come back negative. Peptic ulcer disease causes only about 10% of dyspepsia, but 95% of duodenal and 70% of gastric ulcers associate with H. pylori — which makes finding and eradicating it one of general practice's highest-yield interventions.^[6]

References19Show

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