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Dyspepsia, also commonly known as indigestion, is a frequent but ill-defined disorder primarily associated with epigastric discomfort or pain. It may be a symptom of specific diseases such as peptic ulcer disease, gastro-oesophageal reflux disease, gastric carcinoma, chronic pancreatitis, or gallstones. However, in many patients there is no identifiable systemic disease, in which case it is known as non-ulcer dyspepsia or functional dyspepsia.

A number of reviews and recommendations have addressed the subject of dyspepsia, and, in the UK, various authoritative guidelines have been issued. The initial management of non-ulcer dyspepsia usually includes advice to avoid alcohol, caffeine, smoking, and aggravating foods, and to eat small regular meals to aid digestion. Results of studies of drugs for non-ulcer dyspepsia have been variable and difficult to evaluate since the condition tends to be self-limiting, and there is often a large placebo response.

Drugs that suppress gastric acid such as antacids or antisecretory drugs are often used. Antacids may give some symptomatic relief, and are widely used for self-medication. However, long-term use is inappropriate. Similarly, H2-antagonists are often tried, especially for symptoms of reflux, and a systematic review has suggested benefit, at least in a proportion of patients. Proton pump inhibitors are also widely used, although their relative efficacy in non-ulcer dyspepsia versus H2-antagonists is unclear, and the evidence suggests that their value is limited. In the UK, NICE recommends an empirical trial for 1 month in patients with uninvestigated dyspepsia, many of whom have peptic ulcer disease or gastro-oesophageal reflux disease.

They may also be useful for on-demand therapy to manage symptoms long-term. Most authorities consider that a short course of drug therapy may be given to younger patients (under 40 to 45 years of age) lacking obvious symptoms of organic disease, before any investigation needs to be performed. However, the use of antisecretory drugs can mask the symptoms of gastric carcinoma, and in older patients who are at greater risk, early investigation may be desirable.

Alternatively, prokinetic drugs may be given, particularly if an underlying gastrointestinal motility disorder is suspected. Meta-analysis has suggested that prokinetic therapy may be more effective than an H2-antagonist in non-ulcer dyspepsia, but this may be due to publication bias. In addition, cisapride is no longer available in many countries and evidence for domperidone or metoclopramide is limited. Results with motilin agonists (derivatives of erythromycin) and 5-HT3 antagonists have been disappointing to date. Other approaches to drug therapy include the use of an insoluble bismuth salt, and the use of antispasmodics.

It is not clear whether Helicobacter pylori plays any role in the pathology of non-ulcer dyspepsia. One meta-analysis found eradication to be of no benefit in non-ulcer dyspepsia, but another, incorporating more patients, found that a small benefit existed, although it noted that most patients positive for H. pylori will continue to have symptoms after eradication. As a result there has been much debate about the appropriateness of so-called \'test and treat\' strategies, but eradication in H. pylori-positive patients has been suggested on the grounds that it will benefit patients with undiagnosed peptic ulcer disease and reduce the need for endoscopy.

In the UK, guidelines recommend testing and treating H. pylori in patients with uninvestigated dyspepsia who do not respond to an initial trial with a proton pump inhibitor; alternatively, the test and treat strategy may precede a trial of acid suppression. Eradication is also recommended in patients with endoscopically determined non-ulcer dyspepsia, despite the limited benefit.

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