American gastroenterological association technical review on the evaluation of dyspepsia.pdf

GASTROENTEROLOGY 2005;129:1756 –1780

American Gastroenterological Association Technical Review on the Evaluation of Dyspepsia
This literature review and the recommendations therein were prepared for the American Gastroenterological Association Clinical Practice and Economics Committee. The paper was approved by the Committee on April 22, 2005, and by the AGA Governing Board on October 6,2005.

ince the publication of the initial technical review on evaluation of dyspepsia in 1998,1 test and treat for Helicobacter pylori has become very widely accepted as the approach of choice in those with chronic dyspepsia but no alarm features.2– 6 However, this choice was based predominantly on the results of decision analyses, because limited management trial evidence was available 7 yearsago. Indeed, in primary care, empirical antisecretory therapy continues to be often prescribed, but whether this is the most cost-effective and safest approach remains debated.7–9 Further, gastroenterologists often still elect to undertake prompt esophagogastroduodenoscopy (EGD) in all cases to reassure both patient and physician and treat specific disease (eg, peptic ulcer, esophagitis, Barrett’sesophagus, or malignancy) rather than rely on any kind of empirical approach.9 However, it is known that the prevalence of H pylori infection has continued to dramatically decline, as has the identification of peptic ulcer disease and gastric (but not cardia or esophageal) adenocarcinoma at EGD.9 Moreover, the prevalence of H pylori infection varies widely across the United States and is different byage and race.10 The use of cyclooxygenase-2–selective nonsteroidal anti-inflammatory drugs (NSAIDs) was common but has declined whereas prophylactic use of low-dose aspirin is increasing, also variably affecting ulcer rates.11,12 On the other hand, the prevalence of esophagitis detected at EGD may be increasing despite more rigorous and reliable classification (eg, the LA classification) for thepresence of this condition.13 Over-the-counter H2 blockers and proton pump inhibitors (PPIs) mean that many patients end up on antisecretory therapy first anyway, regardless of what physicians recommend,14 and their use may impair the ability of EGD to detect esophagitis or peptic ulceration. Our aim was to review all the available management strategies in the literature and critically evaluate them tohelp develop practice recommendations for dyspepsia and functional (nonulcer) dyspepsia. To do this, MEDLINE and Current Contents searches were performed from April 1997 (the date of completion of the previous report) to July 2004 using the Medical Subject Heading

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(MeSH) terms dyspepsia, nonulcer dyspepsia, functional dyspepsia, and H pylori. In addition, specific searches were performedwith the support of the Cochrane Upper Gastrointestinal and Pancreatic Diseases Group, and these will be highlighted in the appropriate sections. The reports that considered management of dyspepsia and functional dyspepsia were retrieved and reviewed, and their reference lists were checked for additional citations. The authors met to review the available data in order to produce currentlyapplicable recommendations for the United States.

Definitions
The definition of dyspepsia remains controversial. Guidelines from the United Kingdom16 and Canada4 use the term to mean all (or almost all) symptoms referable to the upper gastrointestinal tract, whereas the Rome II definition17 excludes patients with predominant reflux symptoms. The rationale for the Rome II definition is that when classicheartburn or regurgitation are the only or predominant symptoms or occur frequently (more than once a week), objective evidence of gastroesophageal reflux disease (GERD) can often be identified. The problem is that there is no gold standard for diagnosing GERD; patients often find it difficult to describe a predominant symptom, and even when this is possible, the predominant symptom may change over...