Dyspepsia Algorithm

1

Safety

Exclude alarm features — these patients must NOT wait

Done

Ask these questions BEFORE assuming simple dyspepsia. Alarm features mandate urgent investigation — most are upper GI suspected cancer pathway referrals.

Dysphagia Difficulty swallowing solids or liquids → Suspected cancer · upper GI (oesophageal/gastric cancer)

Progressive unintentional weight loss unexplained → urgent assessment; at ≥55 with upper abdominal pain, reflux or dyspepsia → Suspected cancer · upper GI (NG12)

Persistent vomiting Frequent or severe, not relieved by simple measures → Same-day review; at ≥55 with weight loss, reflux, dyspepsia or upper abdominal pain → consider non-urgent direct-access endoscopy (NG12)

Haematemesis Vomiting blood or coffee-grounds → 999 / A&E (upper GI bleed)

Melaena Tarry black stools → 999 / A&E (upper GI bleed)

Iron-deficiency anaemia Confirmed on FBC + ferritin without obvious cause → Urgent investigation: FIT per HTG690 (≥10 µg Hb/g → colorectal pathway) — but a low FIT does not exclude investigation; men and post-menopausal women generally need upper and lower GI assessment (BSG 2021; BSG/ACPGBI 2025)

Epigastric mass Palpable, consistent with stomach cancer → Suspected cancer · upper GI (NG12: consider a suspected cancer pathway referral)

Age ≥55 + dyspepsia, reflux or upper abdominal pain with weight loss → Suspected cancer · upper GI suspected cancer pathway referral (per NICE NG12 (updated April 2026)); treatment-resistant dyspepsia at ≥55 without weight loss → consider non-urgent direct-access endoscopy

Sudden severe epigastric pain Tearing or board-like rigidity → 999 (perforated ulcer, aortic aneurysm)

Jaundice Scleral icterus, dark urine → aged ≥40: Suspected cancer · pancreatic (pancreatic cancer, NG12); any age: urgent assessment

Upper GI cancer (oesophageal, gastric, pancreatic) frequently presents with dyspepsia-like symptoms — delay kills.
NICE NG12 (updated April 2026) mandates a suspected cancer pathway referral for dysphagia at any age, and for age ≥55 with weight loss plus any of upper abdominal pain, reflux or dyspepsia (recommendations 1.2.1 and 1.2.7).
Haematemesis needs emergency assessment — do not delay transfer for PPI, H. pylori testing or bloods; the acute team decides pre-endoscopic PPI and antithrombotic management.
Missing a perforated peptic ulcer leads to peritonitis within hours; mortality rises steeply with delay.
The ALARM acronym (Anaemia, Loss of weight, Anorexia, Recent progressive symptoms, Melaena/haematemesis) is a useful mnemonic.

2

Diagnose

Confirm dyspepsia and identify the likely cause

Done

Dyspepsia is a symptom complex — not a diagnosis. Establish which subtype applies to guide management.

Definition

Epigastric pain or discomfort, bloating, fullness, nausea, or heartburn — intermittent or persistent, ≥4 weeks. Note: heartburn-predominant = GORD; consider separately.

Key history

Site & character of pain · Relationship to meals (before vs after) · Acid taste / waterbrash · Bloating / early satiety · Nausea / vomiting · Nocturnal symptoms · Symptom duration & pattern
Ask specifically: NSAIDs, aspirin, steroids, bisphosphonates, iron supplements (all ulcerogenic) · Alcohol · Smoking · H. pylori risk (immigrant from high-prevalence country, previous infection, household contact)

Symptom pattern

Ulcer-like: Burning epigastric pain, relieved by food/antacids, wakes at night
Dysmotility-like: Bloating, nausea, early satiety, upper abdominal discomfort
GORD-predominant: Heartburn > epigastric pain, worse lying flat, acid regurgitation
Unspecified: Mixed / doesn't fit neatly

H. pylori risk

High prevalence areas: South Asia, Africa, Eastern Europe, Latin America. Prevalence is higher in people from high-prevalence regions. Always test before empirical PPI in appropriate patients (see Step 5).

Medication review

Check prescriptions AND OTC: NSAIDs, low-dose aspirin, clopidogrel, SSRIs, bisphosphonates, calcium antagonists (may worsen reflux), iron. Stop or review causative medications before escalating.

Identifying the symptom subtype matters because it directs whether to test-and-treat for H. pylori, use empirical PPIs, or refer.
NSAIDs are a common, reversible cause — stopping or substituting them may resolve symptoms.
H. pylori eradication heals most H. pylori-associated ulcers and reduces gastric cancer risk — identifying this at the outset saves unnecessary long-term PPI use.

3

Diagnose

Classify by subtype — drives the treatment pathway

Done

Functional dyspepsia (Rome IV criteria) vs organic cause — this distinction affects prognosis, treatment goals, and patient expectations.

Functional dyspepsia Rome IV

In primary care (BSG 2022): bothersome epigastric pain/burning, early satiation or postprandial fullness for >8 weeks without alarm features, after appropriate initial assessment — routine endoscopy is not needed to make the label. Formal Rome IV (≥3 months, onset ≥6 months) is for specialist care or research.
Subtypes: PDS (postprandial distress: meal-triggered) | EPS (epigastric pain syndrome: localised pain/burning)

Peptic ulcer disease

H. pylori-associated or NSAID-induced. Confirmed on OGD. Ulcer-like symptom pattern. More likely with known H. pylori, NSAID use, or prior ulcer.

GORD

Heartburn dominant, acid regurgitation, relief with antacids, worse post-prandially and lying flat. Can co-exist with dyspepsia. Manage with full-dose PPI 4–8 weeks.

H. pylori-associated

Positive test-and-treat. Eradication may cure symptoms in PUD and modestly improves functional dyspepsia.

Medication-induced

Clear temporal link to new drug. Symptoms resolve on stopping/switching. Most common: NSAIDs, aspirin, bisphosphonates, iron.

Other / secondary

Coeliac disease (serological testing if suspected), biliary disease, chronic pancreatitis, gastroparesis (diabetes), IBS overlap. Consider if atypical features.

Functional dyspepsia is not dangerous but can be chronic and affect quality of life; it requires patient education — setting expectations prevents repeated unnecessary investigations and reassurance-seeking.
Rome IV criteria provide a positive diagnostic framework so functional dyspepsia is diagnosed actively, not just by exclusion.
H. pylori eradication gives a modest but worthwhile long-term benefit in functional dyspepsia.
Distinguish reflux-predominant symptoms from dyspepsia because treatment and referral differ; Barrett's surveillance applies only to diagnosed Barrett's or local criteria, not to a symptom subtype.

4

Diagnose

Targeted examination — exclude surgical and serious pathology

Done

Examination is often normal in uncomplicated dyspepsia — but abnormal findings mandate urgent action.

General inspection

Pallor (anaemia — bleed or malignancy) · Jaundice (biliary/pancreatic) · Cachexia/weight loss · Distress level

Vital signs

Tachycardia + hypotension → haemodynamic compromise from GI bleed → 999. Temperature → consider infection / cholangitis.

Abdominal palpation

Epigastric tenderness: Common in PUD and GORD — not diagnostic but correlates with pathology
Epigastric mass: Hard, irregular → Suspected cancer · upper GI
Hepatomegaly: May indicate metastatic disease
Succussion splash: Gastric outlet obstruction (pyloric stenosis)
Peritonism / guarding / rebound: → 999 (perforation, ischaemia)

BMI

Obesity drives GORD and dyspepsia. Record BMI — relevant to lifestyle advice and drug dosing. BMI >30 → address weight as core treatment.

Lymphadenopathy

Left supraclavicular (Virchow's node) → Suspected cancer · upper GI (gastric cancer metastasis — Troisier's sign)

Oropharynx

Dental erosions → chronic GORD. Visible peristalsis → gastric outlet obstruction (rare but important).

Examination changes management: a palpable epigastric mass upgrades a routine consultation to a suspected cancer pathway referral.
Haemodynamic instability (tachycardia, hypotension) in a patient with epigastric pain is a GI bleed until proven otherwise — do not send home.
A left supraclavicular (Virchow's) node raises concern for metastatic GI or other malignancy.

5

Diagnose

Investigations — what to order and what to avoid

Done

In uncomplicated dyspepsia in patients <55 without alarm features, the key investigation is H. pylori testing — not a battery of bloods.

H. pylori test First-line

Carbon-13 urea breath test (UBT) — preferred. Stop PPI 2 weeks before, antibiotics 4 weeks before (NICE QS96).
Laboratory stool antigen (HpSA) — alternative. Same PPI/antibiotic stop rules.
Serology — no office-based tests; laboratory serology only if locally validated (may not distinguish current from past infection).
Endoscopy-based CLO test — if referred for OGD only.

FBC Bloods

If anaemia suspected (pallor, alarm features, heavy menstrual loss). Microcytic anaemia + low ferritin = iron deficiency → investigate cause. Not routine in straightforward dyspepsia.

LFTs / Amylase

If biliary/pancreatic pathology suspected (RUQ pain, jaundice, alcohol history). Not routine.

Coeliac serology If indicated

Anti-TTG IgA + total IgA if IBS-type overlap, bloating, diarrhoea, or iron deficiency. Must be eating gluten at time of test.

Fasting glucose / HbA1c

If gastroparesis suspected (diabetes + dysmotility symptoms: early satiety, vomiting, bloating). Not routine.

OGD Via referral

Indicated only via the suspected cancer pathway (alarm features) or non-urgent direct access where NICE NG12 allows or if symptoms persist despite 2 full treatment courses. NOT a first-line investigation in primary care.

Do NOT order

Office-based H. pylori serology (laboratory serology only if locally validated) · Abdominal USS routinely · Gastric emptying studies in primary care · H. pylori breath test while on PPI/antibiotics (false negatives)

NICE CG184 offers either H. pylori "test-and-treat" or a 4-week full-dose PPI first in uninvestigated dyspepsia, then the other if symptoms persist — testing first avoids the PPI washout and can remove the need for long-term PPI.
PPIs must be stopped 2 weeks before UBT/HpSA — failure to stop leads to false negative results, perpetuating untreated infection.
Routine OGD for all dyspepsia would overwhelm endoscopy services — NICE CG184 and NICE NG12 restrict this appropriately to alarm features or treatment failure.
Coeliac disease is commonly missed — test when there is diarrhoea, IBS-type bloating, malabsorption or iron deficiency, while the patient eats gluten.

6

Refer

Referral criteria — who needs specialist input?

Done

Most dyspepsia is managed entirely in primary care. Refer when alarm features are present, or when primary care management has failed.

999 / A&E

Haematemesis · Melaena · Peritonism / guarding (perforation) · Haemodynamic instability (tachycardia, hypotension)

Same-day assessment

Severe persistent vomiting with inability to keep fluids down (dehydration risk) · Acute severe epigastric pain with no clear cause — rule out perforation, AAA · Epigastric discomfort suggesting ACS at any age (sweating, breathlessness, radiation): ECG immediately but do not delay emergency transfer; aspirin 300 mg if no allergy and no active significant GI bleeding

Suspected cancer pathway

Suspected cancer pathway referral (recommendations 1.2.1 and 1.2.7): dysphagia at any age · age ≥55 with weight loss plus any of upper abdominal pain, reflux or dyspepsia
Consider a suspected cancer pathway referral: an upper abdominal mass consistent with stomach cancer
Consider non-urgent direct-access endoscopy: haematemesis once bleeding has stopped · age ≥55 with any of: treatment-resistant dyspepsia, upper abdominal pain with a low haemoglobin, a raised platelet count with nausea, vomiting, weight loss, reflux, dyspepsia or upper abdominal pain, or nausea or vomiting with weight loss, reflux, dyspepsia or upper abdominal pain
Also needs prompt investigation: confirmed iron-deficiency anaemia without clear cause · suspicious lymphadenopathy
(Per NICE NG12 (updated April 2026); the 2025 amendment replaced urgent direct-access endoscopy with a suspected cancer pathway referral)

Routine gastroenterology

Symptoms persisting after 2 full courses of treatment (H. pylori eradication + PPI) with no alarm features · Suspected functional dyspepsia refractory to primary care management · Coeliac disease confirmed (for dietary review and follow-up)

Manage in primary care

Age <55 · No alarm features · Uncomplicated dyspepsia / GORD · Responds to H. pylori eradication or PPI · Medication-induced dyspepsia · Functional dyspepsia with normal investigations

Dietitian referral

Confirmed coeliac disease (urgent — for gluten-free diet education) · Functional dyspepsia with dietary triggers · BMI >35 with GORD

NICE NG12 (Suspected cancer recognition) defines the suspected cancer pathway criteria — these are updated regularly; always cross-check with current guidance.
Age ≥55 is the threshold for lowered suspicion — gastric cancer incidence rises sharply after this age.
Appropriate non-referral in primary care is equally important — unnecessary OGD requests increase waiting times and patient anxiety.

7

Treat

Stepwise treatment — test-and-treat, then escalate

Done

Follow NICE CG184: always address medication causes and lifestyle first, then either H. pylori test-and-treat or a 4-week full-dose PPI (offering the other if symptoms persist), then consider specialist review.

H. pylori positive

Triple therapy eradication 1st line

Clarithromycin-based (NICE CG184):
Omeprazole 20 mg BD + Amoxicillin 1 g BD + Clarithromycin 500 mg BD — 7 days

Metronidazole-based (NICE CG184 alternative):
Omeprazole 20 mg BD + Amoxicillin 1 g BD + Metronidazole 400 mg BD — 7 days

Penicillin allergy:
Omeprazole 20 mg BD + Clarithromycin 500 mg BD + Metronidazole 400 mg BD — 7 days (SPC)

Bismuth quadruple therapy (penicillin allergy with previous clarithromycin exposure):
PPI twice daily + bismuth + tetracycline 500 mg four times daily + metronidazole 400 mg twice daily for 7 days (NICE). If using Pylera®, follow the product-specific regimen: three capsules four times daily for 10 days, with a PPI twice daily. Do not substitute the Pylera schedule for the conventional component regimen. Some areas reserve bismuth-containing regimens because of supply issues — check local guidance.

NICE gives the clarithromycin- and metronidazole-based regimens as equal options: choose the one with the least previous antibiotic exposure

Retesting is not routine for uncomplicated dyspepsia; confirm eradication after peptic ulcer (about 6–8 weeks after starting treatment), persistent symptoms, treatment failure or raised gastric-cancer risk — C13 UBT (or validated stool antigen) after antibiotics, off PPI 2 weeks

H. pylori negative or not tested

Empirical PPI 1st line

Omeprazole 20 mg OD or Lansoprazole 30 mg OD — 4 weeks, taken 30 min before food

If partial response (GORD): check timing and adherence, then double-dose PPI (omeprazole 40 mg OD or lansoprazole 30 mg BD) for a further month

Review after 4 weeks — step down to lowest effective dose or PRN

Step 1Remove causative medications Review all prescribed and OTC medicines. Stop or substitute NSAIDs where possible (if essential: lowest dose, shortest time, gastroprotection). Do not stop secondary-prevention aspirin or systemic steroids without an individual risk assessment; review bisphosphonate and iron administration, formulation and indication.

Step 2Test and treat H. pylori UBT or HpSA test. If positive → 7-day triple therapy (see above). Retest only where indicated (ulcer, persistent symptoms, failure, cancer risk).

Step 3Empirical full-dose PPI × 4 weeks If H. pylori negative or eradicated but symptoms persist. Omeprazole 20 mg OD or Lansoprazole 30 mg OD before food (full dose).

Step 4Antacids / alginates PRN For breakthrough symptoms. Gaviscon Advance 10 mL after meals + at bedtime (alginate barrier). Suitable alongside PPI or as sole treatment for mild/intermittent symptoms.

Step 5H2 receptor antagonist If PPI poorly tolerated or patient preference. Famotidine 20 mg BD. Less effective than PPIs but useful as add-on nocturnal acid suppression in GORD.

Step 6No routine prokinetics Domperidone and metoclopramide are not treatments for dyspepsia or presumed dysmotility (MHRA: domperidone nausea/vomiting only, usually ≤7 days, cardiac contraindications; metoclopramide ≤5 days, neurological effects). If nausea and vomiting need treatment, choose by cause; suspected gastroparesis → investigate and refer.

Step 7Low-dose tricyclic antidepressant For refractory functional dyspepsia (EPS type). Second line (BSG 2022), after H. pylori management and a 4-week PPI or H2RA trial: amitriptyline 10 mg nocte (off-label), titrate cautiously if tolerated. Review sedation, constipation, urinary retention, QT and overdose risk, falls. Explain this is for gut-nerve sensitivity, not depression.

Step 8Specialist options Mirtazapine and other agents for refractory postprandial distress are specialist-led — refer if severe, atypical or refractory.

Failed 2nd courseRefer routine gastroenterology For OGD + specialist review if symptoms persist after two treatment courses with no alarm features.

PPI long-term use

Caution Review indication at least annually; lowest effective dose, step-down or intermittent use where appropriate, with a deprescribing plan (warn about rebound acid). Continue where clearly indicated (severe oesophagitis, Barrett's where advised, recurrent ulcer, high-risk NSAID/antiplatelet gastroprotection). Check magnesium selectively (prolonged use, digoxin, diuretics, renal disease, symptoms — MHRA); B12 or iron only if clinically indicated.

H. pylori 2nd-line eradication

If 1st-line fails (confirmed on UBT/HpSA): NICE CG184 second line — 7-day PPI + amoxicillin + whichever of clarithromycin or metronidazole was not used first; if both already used, PPI + amoxicillin + tetracycline or levofloxacin (penicillin-allergic regimens and doses per CG184 and the local formulary; quinolones carry MHRA warnings — use with local microbiology input). Do not cycle antibiotics empirically: refer to gastroenterology if 2nd line fails.

NSAID gastroprotection

Any patient requiring ongoing NSAID: gastroprotection per local guidance (e.g. omeprazole 20 mg OD). Higher-risk patients (age >65, PUD history, corticosteroids, anticoagulants): consider misoprostol or COX-2 selective NSAID.

Next steps: see GORD and acid reflux · PPI prescribing · Coeliac disease · Iron deficiency anaemia

Test-and-treat H. pylori before empirical PPI avoids the PPI washout and can reduce long-term PPI use; NICE CG184 allows either strategy first, with the other offered if symptoms persist.
H. pylori eradication is the key treatment for H. pylori-associated ulcer disease.
PPIs help GORD more reliably than functional dyspepsia.
Domperidone and metoclopramide are restricted by the MHRA (cardiac and neurological risks) and are not dyspepsia treatments.
Low-dose TCAs work via central visceral hypersensitivity modulation — the mechanism is well-established in functional GI disorders (Rome Foundation 2021).
NICE CG184 recommends an annual review for people on long-term treatment for dyspepsia, aiming for the lowest effective dose or stopping — patients on long-term PPIs should have a documented reason.

8

Lifestyle

Non-pharmacological interventions — first-line, not afterthought

Done

Offer individualised lifestyle advice (NICE CG184) — not a universal exclusion diet.

Dietary modification Eat smaller, regular meals. Avoid foods the patient identifies as reproducible triggers. Don't eat within 3 hours of bedtime.

Posture & timing Stay upright 2–3 hours post-meals. Elevate head of bed 15–20 cm (use bed blocks — not extra pillows). Reduces nocturnal GORD by reducing acid exposure.

Weight loss Weight reduction where overweight helps reflux symptoms; refer per local weight-management criteria.

Alcohol Reduces lower oesophageal sphincter (LOS) tone. Advise ≤14 units/week with alcohol-free days. Reduce where alcohol is a trigger.

Smoking cessation Smoking reduces LOS pressure and delays gastric emptying — directly worsens dyspepsia and GORD. Refer to NHS Stop Smoking Service. Offer support to stop.

Stress management Strong brain-gut axis evidence in functional dyspepsia. Psychological therapy (via NHS Talking Therapies) may help persistent functional dyspepsia.

Clothing & posture Avoid tight-fitting clothing around abdomen (increases intra-abdominal pressure). Avoid bending and heavy lifting post-meals.

Caffeine reduction Reduce coffee or tea if the patient notices a relationship. Carbonated drinks worsen bloating — switch to still water.

Medication timing Take bisphosphonates and iron with a full glass of water, remain upright for 30 minutes. Never take NSAID on an empty stomach. Review all medication timing to minimise GI irritation.

Weight loss helps reflux in people who are overweight.
Head-of-bed elevation (bed blocks or a wedge) is a free option for nocturnal GORD.
Psychological therapy can help functional GI disorders — NICE CG61 recommends psychological interventions (CBT, hypnotherapy) for IBS that has not responded to drug treatment after 12 months — an approach extrapolated to refractory functional dyspepsia.
Patients who make sustained lifestyle changes have lower long-term PPI dependency, fewer GP visits, and better quality of life.

9

Safety

Follow-up, monitoring & safety-netting

Done

Always safety-net. Dyspepsia can evolve — new alarm features at any point mandate urgent re-assessment.

After H. pylori treatment

Not routine for uncomplicated dyspepsia. Confirm eradication after peptic ulcer (about 6–8 weeks after starting treatment), persistent symptoms, treatment failure or raised gastric-cancer risk: C13 UBT (or validated stool antigen) at least 4 weeks after antibiotics, off PPI for 2 weeks. If negative → eradication successful. If positive → CG184 second-line therapy.

After PPI course

4 weeks: Review symptom response. If resolved → step down to lowest effective dose or stop (PRN only). If partial (GORD) → check timing and adherence, then double-dose PPI for a further month. If no response → reassess diagnosis, consider H. pylori testing if not done.

Long-term PPI review

Annually: Review indication; step down where appropriate with a deprescribing plan; continue where clearly indicated. Magnesium selectively (prolonged use, digoxin, diuretics, renal disease); B12/iron only if indicated. Document the reason if continuing.

Functional dyspepsia

6–8 weeks: Review response to low-dose TCA / psychological therapy. Reassurance and explanation of the brain-gut axis at each visit. If no improvement after 2 treatment trials → routine gastroenterology referral.

Coeliac disease

Positive serology → local coeliac pathway; no gluten-free diet before diagnostic assessment. Ongoing monitoring sits in the coeliac guideline (NICE NG20)

Safety-net 999

New haematemesis · Melaena · Collapse / syncope · Severe acute abdominal pain with rigidity

Safety-net same-day

New dysphagia · Rapidly progressive symptoms · Inability to swallow fluids · New unintentional weight loss · Persistent vomiting >24 hours

Safety-net · suspected cancer

Any new alarm feature developing during follow-up in a patient previously managed conservatively → make the upper GI suspected cancer pathway referral immediately

Patient information

Provide written information: NHS Choices Dyspepsia leaflet · Guts UK patient information · Explain that dyspepsia can recur — knowing when to re-consult is key to patient safety

Where there was an ulcer, confirming eradication matters — untreated persistent infection continues to drive ulcer disease and increases gastric cancer risk.
Many patients on long-term PPIs have no clear ongoing indication on review — annual step-down attempts can safely reduce unnecessary prescribing (STOPP/START criteria, international).
Alarm features can develop de novo in a patient previously diagnosed with functional dyspepsia — a safety-netting "red-flag return" plan is essential and should be documented in the notes.
Detailed coeliac follow-up sits in the coeliac guideline rather than here.