Management of the dyspeptic patient: anything goes?

Guidelines on the initial management of dyspeptic patients are remarkably conflicting or ambiguous and recommend a variety of initial approaches and no single strategy has been successfully implemented in primary care. In this issue of the American Journal of Gastroenterology, Jarbol and colleagues report the results of a large Danish trial comparing a test-and-treat strategy, an empiric PPI strategy, and a combined strategy with Helicobacter testing if symptoms improved after the PPI. Patient-related outcomes at 1 yr did not differ, but the use of endoscopy was highest in the PPI strategy. From the patient's perspective it seems that anything goes as long as the clinician sticks to a well-defined and proven strategy. Helicobacter pylori testing is still recommendable owing to the long-term benefits, but the rapidly decreasing Helicobacter prevalence will soon make the test-and-treat strategy cost-ineffective as the initial step.