GastroenterologyTier 1Approach to a presentation

Indigestion

Red flags

ALARM features - mandate urgent endoscopy regardless of age: Anaemia (iron deficiency), Loss of weight (unintentional), Anorexia, Recent onset progressive symptoms, Melaena/haematemesis, Swallowing difficulty (dysphagia)
New dyspepsia age >=60 (or lower per local threshold, e.g. >=50 in some populations) - endoscopy to exclude malignancy, even without ALARM features
Odynophagia, persistent vomiting, epigastric mass on examination
Family history of upper GI malignancy in a patient with new symptoms

Organic

Peptic ulcer disease - H. pylori or NSAID-related, epigastric pain, may relate to meals
GORD - reflux/heartburn-predominant, worse lying flat/post-meal
Gastric/oesophageal malignancy - ALARM features, progressive course
Biliary disease, chronic pancreatitis - can mimic dyspepsia, RUQ/epigastric overlap

Functional (most common overall)

Functional dyspepsia - symptoms without structural explanation on endoscopy; subtypes: epigastric pain syndrome and postprandial distress syndrome

Extra-GI mimics

Cardiac ischaemia - always consider in at-risk patients presenting with epigastric "indigestion"
Medication-induced (NSAIDs, bisphosphonates, iron, potassium supplements)

Symptom pattern - relation to meals, positional (reflux worse lying flat), nocturnal symptoms
ALARM feature screen at every presentation, not only the first
NSAID/aspirin/anticoagulant use, alcohol, smoking
Cardiac risk factors if epigastric pain has any atypical features
Prior H. pylori testing/treatment, prior endoscopy findings

Epigastric tenderness (non-specific), signs of chronic liver disease, epigastric mass or lymphadenopathy (Virchow's node - gastric malignancy)
Signs of anaemia (pallor, glossitis) - prompts urgent work-up
Cardiovascular examination if any atypical/exertional component to the pain

Test-and-treat vs endoscopy pathway

No ALARM features, age below local endoscopy threshold: H. pylori test-and-treat (urea breath test or stool antigen - first-line, non-invasive) - treat if positive, empirical PPI trial if negative
Any ALARM feature, or age above threshold: upper GI endoscopy first, regardless of H. pylori status
Testing technique matters: 2-week PPI washout and 4-week antibiotic avoidance before urea breath/stool antigen testing to avoid false negatives
ECG +/- troponin if any atypical/cardiac-sounding features

A. Empirical/first-line

Full-dose PPI trial for 4-8 weeks alongside/after H. pylori management
Lifestyle: weight loss, reduce alcohol/caffeine, avoid late meals, stop NSAIDs where possible

B. H. pylori eradication

Rising clarithromycin and levofloxacin resistance has shifted first-line choice: bismuth quadruple therapy (PPI + bismuth + tetracycline + metronidazole) now preferred first-line over standard clarithromycin-based triple therapy in areas of significant resistance
Confirm eradication (urea breath/stool antigen, off PPI 2 weeks) where clinically indicated - e.g. after peptic ulcer, MALT lymphoma, or persistent symptoms

C. Functional dyspepsia (endoscopy-negative, H. pylori negative/treated)

PPI trial first-line; tricyclic antidepressant (low-dose) or prokinetic for refractory symptoms
Reassurance and symptom-directed management - a chronic relapsing-remitting condition, not curable but manageable

D. Endoscopy-detected pathology

Peptic ulcer - PPI + H. pylori eradication if positive, repeat endoscopy for gastric ulcers to confirm healing/exclude malignancy
Malignancy - refer to the relevant oncology/surgical pathway

Treating epigastric pain as "indigestion" without an ECG in a patient with cardiac risk factors
Testing for H. pylori without the required PPI/antibiotic washout, producing a false negative
Persisting with clarithromycin triple therapy as default first-line in a population/region with known high resistance rates
Reassuring based on symptom response to a PPI alone in an older patient with ALARM features - symptomatic improvement does not exclude malignancy, endoscopy is still required

1. ALARM features change the pathway, not just the urgency

"If any ALARM feature is present, I go straight to endoscopy - I don't test-and-treat first and see how they go."

2. Resistance has changed my first H. pylori regimen

"I don't reach for clarithromycin triple therapy by default anymore - resistance rates mean bismuth quadruple therapy is often the better first shot."

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