Diagnosis and management of dyspepsia--clinical guideline, 1999. Dyspepsia Working Group, South African Medical Association, South African Gastroenterology Society Working Group.

OBJECTIVE: To outline an approach for the effective, practical and safe diagnosis and management of uninvestigated dyspepsia at a primary level of care appropriate to South Africa. The target group for guideline use included general practitioners and other primary health care providers in the public and private sectors. The guideline includes referral points to higher levels of care.

OPTIONS: Two main treatment options for the management of patients with uninvestigated dyspepsia were considered to be relevant to South Africa: Empiric medical therapy (often based on the dominant symptom or symptom complex) with further investigation reserved for 'empiric treatment failures'. Immediate diagnostic evaluation (endoscopy/radiology) of all cases and targeting of therapy based on results.

EVIDENCE: Literature review of relevant studies. However, there are insufficient South African data to make fully evidence-based recommendations.

VALUES: The working group considered that immediate investigation (by endoscopy/radiology) was not a practical option in the South African setting, owing to a lack of resources. The group stressed the importance of adequate initial evaluation to identify the 'high-risk' patient.

RECOMMENDATIONS: Early identification of 'high-risk' patients needing immediate referral to a higher level of care and for further investigation. The remaining 'low-risk' patients should be offered acceptable symptomatic management of dyspepsia. As there is no single ideal first choice drug, selection is often empiric after considering the following: level of contact and care, dominant dyspepsia symptom, availability and cost of medicines, individual preferences. Drug treatment should continue for a finite period (2-4 weeks) and response should be monitored. If treatment fails after a trial of a second drug, then further investigation should be considered as for the 'at-risk' patient. All patients should be given advice on lifestyle changes. A diagnosis of non-ulcer dyspepsia should only be considered when further investigation has not shown specific pathology. When indicated, endoscopy is the preferred method of investigation, but if not available then a barium meal is recommended. The role of Helicobacter pylori in dyspepsia is poorly understood. Empiric H. pylori eradication therapy is not recommended.

VALIDATION: Endorsement by the South African Gastroenterology Society, SAMA and other groups that sent representatives to a multidisciplinary consensus meeting to consider the draft guideline and its later modifications. FINANCIAL SPONSOR: Development supported by an unrestricted educational grant by Janssen-Cilag to SAMA.