At-a-glance
• Dyspepsia: offer empirical full-dose PPI for 4 weeks.
• Offer H. pylori “test and treat” for dyspepsia; ensure appropriate testing conditions.
• If on PPI therapy, leave a 2-week washout before breath/stool antigen testing for H. pylori.
• Urgent direct access endoscopy: within 2 weeks if dysphagia or age ≥55 with weight loss.
Red flags and urgent referral
- Urgent endoscopy within 2 weeks for adults with dyspepsia/reflux symptoms who have dysphagia, or who are 55 and over with weight loss.
- Also follow local suspected cancer pathways and NICE NG12 triggers (e.g., persistent vomiting, iron deficiency anaemia, palpable mass) where applicable.
Stepwise management (NICE CG184)
1) Lifestyle + symptom framing
- Weight management where appropriate, smoking cessation, alcohol moderation, avoid late meals, consider trigger foods, and review NSAID use.
2) Empirical acid suppression
- Dyspepsia: offer full-dose PPI for 4 weeks.
- GORD: offer a full-dose PPI for 4 or 8 weeks. If symptoms recur, use the lowest dose that controls symptoms and discuss “as needed” use.
3) H. pylori testing and eradication
- Offer H. pylori test-and-treat to people with dyspepsia.
- If on PPI therapy, ensure a 2-week PPI washout before breath/stool antigen testing; avoid antibiotics for 4 weeks before testing (per QS96 definitions).
- For eradication regimens, follow local antimicrobial guidance (resistance patterns and allergy status matter), and confirm eradication where indicated.
“Full-dose PPI” — practical examples
NICE CG184 refers to “full-dose PPI” (see guideline appendix tables). In practice, common UK “full-dose” examples include:
- Omeprazole 20 mg once daily
- Lansoprazole 30 mg once daily
- Pantoprazole 40 mg once daily
- Esomeprazole 20–40 mg once daily
Choose based on interactions (e.g., clopidogrel considerations with omeprazole/esomeprazole per local policy), patient factors, and local formulary.
Frequently asked questions
How long should I try a full-dose PPI for dyspepsia?
NICE CG184 recommends empirical full-dose PPI therapy for 4 weeks for dyspepsia (and 4–8 weeks for GORD).
Why the 2-week PPI washout before H. pylori testing?
PPIs can reduce test accuracy; NICE QS96 specifies a 2-week washout before breath/stool antigen tests when the patient has been using a PPI.
Who needs urgent endoscopy within 2 weeks?
NICE QS96: dysphagia, or age ≥55 with weight loss, in the context of dyspepsia/reflux symptoms.
Transparency
This page is an educational, clinician-written summary of publicly available NICE guidance intended for trained healthcare professionals. It uses original wording (not copied text) and should be used alongside the full NICE source, local pathways, and clinical judgement. Doses provided are for general reference; always check the BNF/SPC.