Reasoning GP · Algorithm · 1-page summary
Dyspepsia in adults
For: adults with new, changed or uninvestigated dyspepsia, in person or remote. Not for: children; ongoing GORD or long-term PPI care (full algorithm, Steps tab).
Core rule: four steps, in order — screen ALARM features, review the culprit drugs, test and treat H. pylori (off PPI 2 weeks, antibiotics 4 weeks), then the PPI. A response to a PPI or antacid excludes neither cancer nor cardiac pain.
0Stop — call 999 now — before any history
- Haematemesis, coffee-ground vomiting or melaena; any bleed on an anticoagulant; shock (systolic BP <90, pulse >120, pallor or syncope) → 999. In cirrhosis, assume variceal.
- Sudden severe epigastric pain, tearing or with rigidity (perforation, ruptured aneurysm) → 999. Jaundice, fever and RUQ pain → Emergency admission
- Epigastric pain with sweating, nausea or breathlessness, any age (inferior MI) → ongoing 999, settled Same-day; ECG without delaying transfer.
- While waiting: nil by mouth, postural BP; stop NSAIDs; discuss (don't stop) anticoagulation with the receiving team; aspirin 300 mg for suspected ACS unless allergic, contraindicated or actively GI bleeding; send the drug list. Do not delay transfer for a PPI, H. pylori test or bloods.
1Triage — ALARM features (NICE NG12)
| Finding | Action |
|---|---|
| Dysphagia | At any age; or ≥55 + weight loss with upper abdominal pain, reflux or dyspepsia → Suspected cancer pathway |
| Abdominal mass | Upper abdominal → consider Suspected cancer pathway |
| Jaundice ≥40 | Suspected cancer pathway. ≥60, weight loss + back pain, new diabetes or GI symptoms → CT ≤2 weeks |
| ≥55, other | Treatment-resistant; upper abdominal pain + low Hb; raised platelets, or nausea/vomiting, with weight loss, reflux, dyspepsia or upper abdominal pain → consider Non-urgent OGD |
Dysphagia is never "reflux first". No PPI trial before referral; tell endoscopy of any PPI (masks lesions).
2Screen — one row is enough
- Persistent vomiting or outlet obstruction (succussion splash) → Same-day, U&E; admit if dehydrated. Never antiemetic + remote review.
- Severe epigastric pain, no clear cause → Same-day
- Unexplained iron-deficiency anaemia → Urgent FIT (≥10 µg Hb/g → colorectal); OGD + colonoscopy if male or postmenopausal.
- Frail, immunosuppressed, chemo, cirrhosis → Same-day if unwell, else Urgent
- New or changed at ≥55 → seek these features; NG12, not age alone.
3Assess — once blocks 0–2 are answered
☐ Drugs, OTC ibuprofen too: NSAIDs, aspirin, steroids, bisphosphonates, iron, potassium, calcium antagonists, nitrates, SSRIs ☐ Weight trend, pallor, mass, liver, Virchow's node; PR if melaena ☐ Urea breath test or lab stool antigen, off PPI 2 weeks, antibiotics 4 weeks ☐ FBC, ferritin, LFTs; U&E if vomiting; coeliac serology (on gluten) if bloating or diarrhoea; HbA1c if gastroparesis
Not: office serology, routine ultrasound, gastric emptying, first-line OGD.
4Classify — only if the screen is negative
- Drug-induced — linked to a new drug → stop or switch.
- Ulcer-like / H. pylori — worse hungry or at night, eased by food → test and treat.
- GORD-predominant — heartburn > epigastric pain, regurgitation → full-dose PPI 4–8 weeks.
- Functional — fullness, early satiety or pain >8 weeks, alarm-free, drugs reviewed → positive diagnosis.
- Other — coeliac, biliary, pancreatic, gastroparesis.
- Refractory or uncertain — say so; after two full courses → block 6.
5Treat today — in this order
- Drugs: stop or substitute NSAIDs (if essential: lowest dose, shortest time, gastroprotection). Risk-assess before stopping secondary-prevention aspirin or steroids.
- H. pylori positive — 7 full days: omeprazole 20 mg BD + amoxicillin 1 g BD + clarithromycin 500 mg BD (or metronidazole 400 mg BD). Penicillin allergy: PPI + clarithromycin 500 mg BD + metronidazole 400 mg BD; prior clarithromycin → bismuth quadruple, 7 days (Pylera®: own 10-day regimen). Least prior antibiotic use decides.
- Negative: omeprazole 20 mg OD or lansoprazole 30 mg OD, 30 min before food, 4 weeks; partial (GORD) → double-dose PPI for a further month, then step down. Alginate PRN; famotidine if PPI not tolerated. No domperidone or metoclopramide for dyspepsia.
- Lifestyle: weight loss, smaller earlier meals, nothing 3 h before bed, less alcohol, stop smoking. Doses: SPC and local formulary.
6Refer routinely — review at 4–8 weeks
- Two full courses failed, or doubt → gastroenterology; list each course.
- Eradication fails → 7-day PPI + amoxicillin + the antibiotic not used first (penicillin allergy: CG184/local); fails again → gastroenterology.
- Positive coeliac serology (gluten not stopped first), suspected gastroparesis → gastroenterology.
- Retest only after ulcer, persisting symptoms, failure or cancer risk (≥4 weeks after antibiotics, off PPI 2 weeks). Long-term PPI: review yearly.
7Never reassure by
- Relief with a PPI or antacid — excludes neither cancer nor cardiac pain.
- Young age when there is dysphagia.
- A negative H. pylori test on a PPI or antibiotics, or office serology.
- A low FIT when iron-deficiency anaemia is unexplained.
- "Treatment-resistant" after a PPI taken after food, not 30 min before.
- "Reflux" for epigastric pain with sweating, without an ECG.
8Safety-net — say it, then document it
999 “Call 999 if you vomit blood, pass black tarry stools, collapse, or get sudden severe stomach pain.” Same day: “Contact us today for difficulty swallowing, weight loss without trying, repeated vomiting or a lump in your stomach.” Full 7-day eradication course; PPI 30 min before food.
Remote or OOH: face-to-face for dysphagia, weight loss, vomiting, bleeding, an unexamined epigastrium, pain needing an ECG, frailty, cirrhosis, immunosuppression or anticoagulation. No phone PPI for new dyspepsia at ≥55 without the ALARM screen and bloods. A new alarm feature later → refer at once.
✓Safe to leave primary care only if — all five, documented
No block 0–2 row applies; NG12 criteria documented absent
FBC and ferritin checked; ECG if autonomic features
Culprit drugs stopped; H. pylori tested off PPI 2 weeks, treated if positive
PPI dose, timing and step-down date; review at 4–8 weeks, named reviewer
Safety-net given and documented
Summary of the full Reasoning GP dyspepsia algorithm, which holds the detail and evidence. Sources: NICE CG184, NG12 (April 2026), HTG690, NG20, CG95; BSG 2021, 2022; BSG/ACPGBI 2025; local formulary; MHRA. Clinical reference — follow local endoscopy, antimicrobial and prescribing policies and check doses in the SPC and your local formulary.