REASONING GP · Clinical algorithm · Quick reference

Dyspepsia in adults — triage and diagnostic approach

Screen the ALARM features for urgent OGD, stop the culprit drugs, then test and treat H. pylori before any empirical PPI — and stop the PPI 2 weeks before testing, or the result is falsely negative.
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AdultsUninvestigatedDiagnosis firstv1.0 · Sep 2026
Core rule. Four steps, in order. 1. ALARM features — dysphagia at any age, 55 or over with weight loss, an upper abdominal mass, iron-deficiency anaemia or persistent vomiting → urgent OGD; haematemesis or melaena → admission. 2. Stop the culprit drugs — NSAIDs, aspirin, bisphosphonates, steroids, iron — which alone resolves many cases. 3. Test and treat H. pylori before an empirical PPI, having stopped the PPI 2 weeks and antibiotics 4 weeks beforehand. 4. Then the PPI, at the lowest effective dose with a planned step-down. Never leave someone on a PPI indefinitely because nobody reviewed it.
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On presentation: is this an emergency now? Stop the consultation and arrange emergency admission
Haematemesis or melaena — a significant acute upper GI bleed, with about 10% mortality · sudden severe epigastric pain, tearing or with board-like rigidity — perforated ulcer or ruptured aortic aneurysm · shock: systolic BP below 90, pulse above 120, pallor or syncope · coffee-ground vomiting with instability, or any bleed on an anticoagulant · epigastric pain with sweating or breathlessness over 40 — inferior myocardial infarction presents as indigestion, so do an ECG before any PPI · jaundice with fever and right upper quadrant pain. Nil by mouth, observations with postural BP, and hand over the drug list including NSAIDs and anticoagulants.
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Define the dyspepsia in four lines The subtype directs the treatment; the drug chart often is the diagnosis

Symptom subtype

Ulcer-like: epigastric pain, worse when hungry or at night, eased by food or antacid. Dysmotility-like: bloating, nausea, early satiety. GORD-predominant: heartburn exceeding epigastric pain, regurgitation, worse lying flat or after meals. Unspecified: mixed. The subtype decides whether you test for H. pylori, treat reflux, or address dysmotility.

Drugs — ask specifically

NSAIDs and aspirin account for up to 25% of peptic ulcer disease · also bisphosphonates, steroids, iron, potassium, calcium antagonists, nitrates, SSRIs. Ask about over-the-counter ibuprofen, which patients do not report as medication. Stopping or switching the drug alone may resolve the symptoms.

H. pylori risk

Higher in people born in South Asia, Africa, Eastern Europe or Latin America, in previously treated infection, and with a family history of gastric cancer. UK prevalence is about 30–40%. It drives roughly 80% of duodenal and 60% of gastric ulcers, so testing is not optional in an uninvestigated patient.

Context

Age, and whether the dyspepsia is new or changed · weight loss, appetite, dysphagia · alcohol, smoking, obesity · previous ulcer, endoscopy or eradication · anticoagulants · family history of upper GI cancer · stress and mood · how long, and what has changed recently.
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Red-flag screen: trigger → concern → destination → what to do before handover One row is enough; do not add up reassuring features
Trigger / red flagLeading concern · destinationDo now · do not delay
Haematemesis, coffee-ground vomiting or melaena; or sudden severe epigastric pain with rigidity; or shock with systolic BP below 90, pulse above 120 or syncope — particularly on NSAIDs, steroids or anticoagulants. Upper GI bleed · perforated peptic ulcer · ruptured aortic aneurysm
Emergency admission now		 Nil by mouth, observations including postural BP. Stop NSAIDs; discuss anticoagulation with the receiving team rather than stopping it unilaterally. Do not start a PPI and review a patient who has had melaena. Send the drug list — NSAIDs, aspirin, steroids, anticoagulants — with the referral.
Epigastric pain with sweating, nausea or breathlessness in anyone over 40, or with known cardiovascular risk; pain radiating to the jaw or arm. Inferior myocardial infarction presenting as indigestion
999 if pain is ongoing Same-day if settled		 ECG before any PPI in this group — this is the classic miss. Aspirin 300 mg if an acute coronary syndrome is suspected, unless contraindicated. Do not attribute new epigastric pain with autonomic features to reflux because antacids helped: response to antacid does not exclude cardiac pain.
Dysphagia at ANY age · 55 or over with weight loss plus upper abdominal pain, reflux or dyspepsia · an upper abdominal (stomach) mass · iron-deficiency anaemia · persistent vomiting. Or: 60 or over with weight loss plus back pain, new-onset diabetes, nausea, vomiting, constipation, diarrhoea or abdominal pain · or jaundice at 40 or over. Oesophageal or gastric cancer
Urgent direct-access OGD within 2 weeks · NICE NG12
Pancreatic or hepatobiliary cancer
Urgent direct-access CT (or ultrasound if CT unavailable) within 2 weeks; urgent suspected-cancer referral for jaundice at 40+ · NICE NG12		 Dysphagia needs urgent OGD whatever the age — do not treat it as reflux first. Do not start a PPI before the endoscopy: it masks and heals mucosal lesions and can obscure a cancer. State the ALARM feature and the drug history in the request. UK 5-year oesophageal cancer survival is about 15%, and delay is the modifiable part. New-onset diabetes with weight loss in this age group is a pancreatic cancer criterion, not a metabolic coincidence. Painless jaundice at 40 or over is an urgent suspected-cancer referral, never a routine hepatobiliary letter. Send LFTs, HbA1c and the weight trend with the request.
Non-urgent direct-access OGD criteria: 55 or over with treatment-resistant dyspepsia · upper abdominal pain with a low haemoglobin · raised platelets with nausea, vomiting, weight loss, reflux, dyspepsia or upper abdominal pain · nausea or vomiting with any of those features. Upper GI malignancy at a lower threshold of suspicion
Non-urgent direct-access endoscopy (NG12)		 These sit below the 2-week threshold but still need endoscopy — they are not a reason for another PPI course. Stop the PPI 2 weeks before the OGD. Check FBC and ferritin in anyone with dyspepsia and fatigue: an unexplained iron-deficiency anaemia moves the patient up to the 2WW row above.
Persistent vomiting, dehydration or inability to keep fluids down; or suspected gastric outlet obstruction — vomiting undigested food, succussion splash, weight loss. Or: Dyspepsia in the frail, the immunosuppressed or those on chemotherapy; new dyspepsia in known cirrhosis or portal hypertension; or a first presentation of dyspepsia over 55 that is new or changed. Gastric outlet obstruction · severe peptic ulcer disease · malignancy
Same-day assessment; admission if dehydrated
Variceal disease · opportunistic or ulcerating pathology · malignancy
Same-day advice where unwell; otherwise urgent investigation		 Check U&E for a hypochloraemic alkalosis and AKI, and assess hydration face to face. Do not manage persistent vomiting with an antiemetic and a review at a distance — it is an obstruction question until answered, and it is also an NG12 criterion. New or changed dyspepsia at 55 or over is not the same clinical event as long-standing reflux in a 30-year-old, and it should not enter a routine PPI pathway without thought. In cirrhosis, an upper GI bleed is variceal until proven otherwise — admit rather than prescribe.
Safety rule. Test and treat H. pylori before an empirical PPI, and stop the PPI 2 weeks and antibiotics 4 weeks before any urea breath test, stool antigen test or OGD — otherwise the result is falsely negative and the infection goes untreated. Do not start a PPI before an endoscopy that has been requested. H. pylori serology cannot distinguish current from past infection and is not a test of active disease. And response to a PPI or antacid excludes neither cancer nor cardiac pain.
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Assessment and investigation H. pylori testing is the investigation in the uninvestigated patient — not a battery of bloods

Assess, then test

Examine: weight and trend, BMI; pallor and conjunctivae; epigastric mass, hepatomegaly, ascites; supraclavicular nodes; a succussion splash where vomiting; rectal examination where melaena is described. Test: urea breath test (93% sensitivity, 97% specificity) or stool antigen — with the PPI stopped 2 weeks and antibiotics 4 weeks beforehand · FBC and ferritin for iron-deficiency anaemia · U&E where vomiting · LFTs · coeliac serology where there is bloating or diarrhoea · HbA1c where gastroparesis is suspected · ECG over 40 with autonomic features. Do not order: H. pylori serology — it cannot distinguish current from past infection · a breath test while on a PPI or antibiotics · routine abdominal ultrasound · gastric emptying studies · OGD as a first-line primary-care test outside the NG12 routes.
Colour is semantic: red = emergency now · amber = same-day or urgent assessment · blue = define/assess · green = primary-care management · purple = uncertain / specialist route (including 2WW). Continued on page 2: investigation, classification, cause classifier, routine referral, primary-care management, endpoint.
REASONING GP · Dyspepsia in adults — triage and diagnostic approach
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Classify: three exits, not two "Dyspepsia, try omeprazole" is a prescription, not a diagnosis

Serious cause likely

Bleeding, perforation, cardiac pain, obstruction, or an NG12 criterion — an ALARM feature, dysphagia at any age, 55+ with weight loss, a mass, iron-deficiency anaemia or persistent vomiting. Output: destination with date, the feature that triggered it, drugs stopped, and whether a PPI was withheld for endoscopy.

Uncomplicated, managed in primary care

No ALARM feature, and either H. pylori positive (treat it) or negative with a clear subtype. Output: culprit drug stopped, the H. pylori result, the eradication or PPI regimen with its duration, the retest plan, and the step-down date.

Refractory or uncertain

Symptoms persisting after two full treatment courses, eradication failure after first- and second-line, or diagnostic doubt. Output: list each course with drug, dose and duration, state the uncertainty, take the §6 route.
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Cause classifier Only once the ALARM screen is negative
The four causes, and what not to concludeDrugs — NSAIDs and aspirin cause up to 25% of peptic ulcer disease; also bisphosphonates, steroids, iron, potassium, nitrates, calcium antagonists, SSRIs. Always the first thing to remove. Peptic ulcer — H. pylori-associated or NSAID-induced, ulcer-like pain, confirmed at OGD; H. pylori drives about 80% of duodenal and 60% of gastric ulcers, and eradication cures roughly 80% of duodenal ulcers and reduces gastric cancer risk. GORD-predominant: Heartburn dominant over epigastric pain, acid regurgitation, worse lying flat and after meals, relieved by antacids — and it can coexist with dyspepsia. Treat with a full-dose PPI for 4–8 weeks. Distinguishing it matters: misclassifying GORD as functional dyspepsia means missing Barrett's surveillance criteria. Functional dyspepsia: Rome IV: bothersome postprandial fullness, early satiety, or epigastric pain or burning, for the last 3 months with onset at least 6 months ago, with no structural explanation — a positive diagnosis, not a label of exclusion. A gut–brain interaction disorder with a benign prognosis; explaining that prevents repeated investigation. Eradicating H. pylori helps about 10% above placebo (NNT ~14) — modest, but worth doing. Do not conclude: "Reflux" for dysphagia at any age · "functional" without meeting Rome IV or without stopping the culprit drug · "H. pylori negative" on a test taken while on a PPI · "negative" on serology, which cannot distinguish current from past infection · "treatment-resistant" after a PPI course the patient took after food rather than 30 minutes before it · or reflux in an over-40 with epigastric pain and sweating who has not had an ECG.
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Refer routinely from this consultation Not same-day — the cases that leave by letter; §7 is what primary care does today
Symptoms persisting after two full treatment courses, or diagnostic doubt → gastroenterology, listing each course with drug, dose and duration so it is not repeated · H. pylori failing first- and second-line eradication → gastroenterology for culture-guided therapy — do not simply cycle through regimens · 55 or over with treatment-resistant dyspepsia, or upper abdominal pain with a low haemoglobin → non-urgent direct-access OGD (NG12) · confirmed GORD with long duration, or Barrett's risk factors — male, over 50, white, obese, long-standing reflux → gastroenterology for endoscopic assessment and Barrett's surveillance · a gastric ulcer confirmed at OGD → repeat endoscopy at 6–8 weeks to confirm healing and exclude malignancy · suspected gastroparesis — diabetes with early satiety, vomiting and bloating → gastroenterology · positive coeliac serology → gastroenterology for biopsy, without starting a gluten-free diet first (NG20) · long-term PPI with no clear indication → structured deprescribing rather than an indefinite repeat.
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The only decisions that belong in this consultation Drugs off → eradicate → PPI → review, in that order
1 · Remove the culprit drugs, test, then eradicateStop NSAIDs and aspirin where it is safe to do so, along with bisphosphonates, steroids and iron; where an NSAID must continue, switch agent or add gastroprotection. Then test for H. pylori before any empirical PPI — urea breath test or stool antigen, with the PPI stopped 2 weeks and antibiotics 4 weeks beforehand. Never test by serology, and never test while the patient is still taking the PPI. If positive: 7-day triple therapy: omeprazole 20 mg twice daily + amoxicillin 1 g twice daily + clarithromycin 500 mg twice daily. If penicillin-allergic, substitute metronidazole 400 mg twice daily for the amoxicillin. The full 7 days must be completed or resistance follows. Confirm eradication with a urea breath test at 4 weeks, again with the PPI stopped 2 weeks beforehand; If first-line fails, second line is 14-day bismuth-based quadruple therapy: omeprazole 20 mg twice daily + bismuth subsalicylate 120 mg four times daily + tetracycline 500 mg four times daily + metronidazole 400 mg three times daily for 14 days — not a swapped antibiotic in the same 7-day triple. Refer to gastroenterology if second line fails.
3 · PPI, lifestyle, review and the escalation ruleOmeprazole 20 mg once daily or lansoprazole 30 mg once daily, taken 30 minutes before food, for 4 weeks — timing is the usual reason a "failed" PPI has not worked. On a partial response, increase to full dose twice daily for 4–8 weeks (GORD), then step down to the lowest effective or as-required dose. Adjuncts: an alginate or antacid as required, or an H₂ antagonist such as famotidine where a PPI is not tolerated. Lifestyle and deprescribing: Weight loss where overweight, smaller earlier evening meals, nothing for 3 hours before bed, head-of-bed elevation, less alcohol, caffeine, fat and spice; smoking cessation. Review every long-term PPI: step down or stop with a planned taper where there is no ongoing indication, since indefinite use risks hypomagnesaemia, B12 deficiency, fracture and enteric infection. Review at 4–8 weeks, recording drug, dose, timing, adherence and response before changing anything, and re-test after eradication. Write the triggers down: haematemesis, melaena, collapse or severe sudden pain → 999; new dysphagia, weight loss, persistent vomiting or a mass → same-day or the NG12 route. Do not: start a PPI before a requested endoscopy · test for H. pylori on a PPI · use serology · treat over-40 epigastric pain with autonomic features before an ECG · or leave a PPI on repeat with no indication and no review date.
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Endpoint and documentation Finish with one of four conclusions

1 · Emergency

Admission arranged; the feature that triggered it, observations with postural BP, ECG if done, drugs stopped and anticoagulant status.

2 · Urgent or NG12 route

Urgent OGD, CT or suspected-cancer referral sent with date; the ALARM feature stated; PPI withheld before endoscopy; FBC and ferritin sent.

3 · Uncomplicated, managed

Culprit drug stopped; H. pylori result with the PPI washout confirmed; eradication or PPI regimen with dose and duration; retest and step-down dates; review booked.

4 · Refractory or uncertain

Each course listed with drug, dose and duration; uncertainty stated; §6 referral sent with date; interim plan and review owner.
Why primary-care management is safe today, in one line: no row on the page-1 screen applies · no dysphagia at any age, no weight loss at 55 or over, no mass, no persistent vomiting, no iron-deficiency anaemia · FBC and ferritin checked · ECG done where there was epigastric pain with autonomic features over 40 · culprit drugs stopped · H. pylori tested off PPI for 2 weeks, and treated if positive · NG12 criteria applied and documented as absent · PPI dose, timing and step-down date recorded, with review booked at 4–8 weeks and a named reviewer. Safety-net wording: contact us the same day if you have difficulty swallowing, lose weight without trying, vomit repeatedly or cannot keep fluids down, or feel a lump in your stomach; call 999 for vomiting blood, black tarry stools, collapse, or sudden severe stomach pain. Take the eradication course for the full 7 days, and take the PPI 30 minutes before food. Remote assessment limitation. Convert to face-to-face where there is dysphagia, weight loss, vomiting or reported bleeding; where the epigastrium cannot be examined for a mass; in anyone over 40 with epigastric pain and sweating, nausea or breathlessness who needs an ECG; in frailty, cirrhosis or immunosuppression; or where the patient is anticoagulated. A new or changed dyspepsia at 55 or over should not be started on a PPI over the telephone without the ALARM screen and bloods.
Clinical decision support only; follow local endoscopy, antimicrobial and prescribing policies and check doses against the current BNF. Source hierarchy: NICE guidelines and CKS first, then BNF/MHRA for doses and safety, then national specialty guidance. Sources: NICE CG184 Gastro-oesophageal reflux disease and dyspepsia in adults · NG12 Suspected cancer (May 2025) · NG20 Coeliac disease · CG95 Chest pain of recent onset · NICE CKS Dyspepsia — unidentified cause, Dyspepsia — proven peptic ulcer, Dyspepsia — proven GORD, Helicobacter pylori infection · Rome IV criteria for functional dyspepsia · British Society of Gastroenterology guidance · BNF · MHRA. Review after any guidance or medicines-safety update, otherwise every 6 months. © Reasoning GP · gpreasoning.uk