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Canadian Journal of Gastroenterology
Volume 19, Issue 5, Pages 285-303
http://dx.doi.org/10.1155/2005/674607
Special Article

Evidence-Based Recommendations for Short- and Long-Term Management of Uninvestigated Dyspepsia in Primary Care: An Update of the Canadian Dyspepsia Working Group (CanDys) Clinical Management Tool

Sander JO Veldhuyzen van Zanten,1 Marc Bradette,2 Naoki Chiba,3 David Armstrong,4 Alan Barkun,5 Nigel Flook,6 Alan Thomson,7 and Ford Bursey8

1Department of Medicine, Queen Elizabeth II Health Sciences Centre, Dalhousie University, Halifax, Nova Scotia, Canada
2Department of Medicine, Université Laval, and the Department of Gastroenterology, Centre hospitalier universitaire de Québec, Pavillon Hôtel-Dieu de Québec, Quebec, Quebec, Canada
3Division of Gastroenterology, McMaster University, Hamilton, and the Surrey Gl Clinic∕Research, Guelph, Ontario, Canada
4Department of Medicine, McMaster University, and the Division of Gastroenterology, Hamilton Health Sciences Corporation, McMaster Site, Hamilton, Ontario, Canada
5Department of Medicine, McGill University, and the Division of Gastroenterology, McGill University Health Centre, Montreal, Quebec, Canada
6Department of Family Medicine, University of Alberta, and the Misericordia Community Health Centre, Canada
7Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
8Health Sciences Centre, Department of Medicine, Memorial University of Newfoundland, St John’s, Newfoundland, Canada

Received 9 September 2004; Accepted 2 February 2005

Copyright © 2005 Canadian Association of Gastroenterology. This open-access article is distributed under the terms of the Creative Commons Attribution Non-Commercial License (CC BY-NC) (http://creativecommons.org/licenses/by-nc/4.0/), which permits reuse, distribution, and reproduction of the article, provided that the original work is properly cited and the reuse is restricted to noncommercial purposes.

Abstract

The present paper is an update to and extension of the previous systematic review on the primary care management of patients with uninvestigated dyspepsia (UD). The original publication of the clinical management tool focused on the initial four- to eight-week assessment of UD. This update is based on new data from systematic reviews and clinical trials relevant to UD. There is now direct clinical evidence supporting a test-and-treat approach in patients with nondominant heartburn dyspepsia symptoms, and head-to-head comparisons show that use of a proton pump inhibitor is superior to the use of H2-receptor antagonists (H2RAs) in the initial treatment of Helicobacter pylori-negative dyspepsia patients. Cisapride is no longer available as a treatment option and evidence for other prokinetic agents is lacking. In patients with long-standing heartburn-dominant (ie, gastroesophageal reflux disease) and nonheartburn-dominant dyspepsia, a once-in-a-lifetime endoscopy is recommended. Endoscopy should also be considered in patients with new-onset dyspepsia that develops after the age of 50 years. Conventional nonsteroidal anti-inflammatory drugs, acetylsalicylic acid and cyclooxygenase-2-selective inhibitors can all cause dyspepsia. If their use cannot be discontinued, cotherapy with either a proton pump inhibitor, misoprostol or high-dose H2RAs is recommended, although the evidence is based on ulcer data and not dyspepsia data. In patients with nonheartburn-dominant dyspepsia, noninvasive testing for H pylori should be performed and treatment given if positive. When starting nonsteroidal anti-inflammatory drugs for a prolonged course, testing and treatment with H2RAs are advised if patients have a history of previous ulcers or ulcer bleeding.