The most common diagnoses among patients with dyspepsia are functional dyspepsia, gastroesophageal reflux disease, peptic ulcer, and gastric or esophageal cancer. Helicobacter pylori infection is present in many patients with dyspepsia and is etiologic in some conditions. The evaluation of dyspepsia divides patients into 3 categories: 1) for patients taking nonsteroidal anti-inflammatory drugs (NSAIDs), NSAIDs should be discontinued; if symptoms resolve after discontinuation, no further evaluation is needed; 2) for patients with reflux symptoms, proton pump inhibitors (PPIs) should be prescribed without endoscopy unless alarm symptoms are present; and 3) for patients with no NSAID use or reflux symptoms, evaluation depends on risk. Patients older than 55 years or with alarm symptoms are at high risk and should undergo endoscopy. Those 55 years or younger with no alarm symptoms are at low risk. Those patients should be tested for H pylori and treated if results are positive. If symptoms persist after eradication treatment, PPIs should be prescribed for 4 to 6 weeks; if symptoms persist after treatment, endoscopy should be obtained. If H pylori test results are negative, PPIs should be prescribed for 4 to 6 weeks. Endoscopy should be obtained if symptoms persist. There are several regimens for eradication of H pylori. The most effective is sequential therapy with a PPI and amoxicillin for 5 days followed by a PPI, clarithromycin, and tinidazole for another 5 days.
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