About this guideline

NICE clinical guidelines are recommendations about the treatment and care of people with specific diseases and conditions.

NICE guidelines are developed in accordance with a scope that defines what the guideline will and will not cover.

This guideline was developed by the NICE Internal Clinical Guidelines Programme. The Internal Clinical Guidelines Programme worked with a Guideline Development Group, comprising healthcare professionals (including consultants, GPs and nurses), patients and carers, and technical staff, which reviewed the evidence and drafted the recommendations. The recommendations were finalised after public consultation.

The methods and processes for developing NICE clinical guidelines are described in The guidelines manual.

NICE produces guidance, standards and information on commissioning and providing high-quality healthcare, social care, and public health services. We have agreements to provide certain NICE services to Wales, Scotland and Northern Ireland. Decisions on how NICE guidance and other products apply in those countries are made by ministers in the Welsh government, Scottish government, and Northern Ireland Executive. NICE guidance or other products may include references to organisations or people responsible for commissioning or providing care that may be relevant only to England.

Update information

November 2014: recommendation 1.7.7 has been amended to clarify the type of NSAID to be used and that a proton-pump inhibitor should also be prescribed.

This guideline updates and replaces NICE clinical guideline 17 (published in April 2004).

Recommendations are marked as [new 2014], [2014], [2004] or [2004, amended 2014]:

  • [new 2014] indicates that the evidence has been reviewed and the recommendation has been added or updated

  • [2014] indicates that the evidence has been reviewed but no change has been made to the recommended action

  • [2004] indicates that the evidence has not been reviewed since 2004

  • [2004, amended 2014] indicates that the evidence has not been reviewed since 2004, but changes have been made to the recommendation wording that change the meaning.

Recommendations from NICE clinical guideline 17 that have been amended

Recommendations are labelled [2004, amended 2014] if the evidence has not been reviewed since 2014 but changes have been made to the recommendation wording that change the meaning.

Recommendation in 2004 guideline

Recommendation in 2014 guideline

Reason for change

1.2.3 Consider the possibility of cardiac or biliary disease as part of the differential diagnosis.

1.3.3 Think about the possibility of cardiac or biliary disease as part of the differential diagnosis. [2004, amended 2014]

Changed to make recommendation active.

1.3.6 Psychological therapies, such as cognitive behavioural therapy and psychotherapy, may reduce dyspeptic symptoms in the short term in individual patients. Given the intensive and relatively costly nature of such interventions, routine provision by primary care teams is not currently recommended.

1.2.4 Recognise that psychological therapies, such as cognitive behavioural therapy and psychotherapy, may reduce dyspeptic symptoms in the short term in individual people. [2004, amended 2014]

Changed to make recommendation active and to bring in line with The guidelines manual 2012 and editorial guidance.

1.3.7 Patients requiring long-term management of dyspepsia symptoms should be encouraged to reduce their use of prescribed medication stepwise: by using the effective lowest dose, by trying as-required use when appropriate, and by returning to self-treatment with antacid and/or alginate therapy.

1.2.5 Encourage people who need long-term management of dyspepsia symptoms to reduce their use of prescribed medication stepwise: by using the effective lowest dose, by trying 'as-needed' use when appropriate, and by returning to self-treatment with antacid and/or alginate therapy (unless there is an underlying condition or comedication that needs continuing treatment). [2004, amended 2014]

Changed to make this recommendation active and for clarity as this recommendation now only applies to people without an underlying condition or comedication that needs continuing treatment.

1.4.1 Dyspepsia in unselected patients in primary care is defined broadly to include patients with recurrent epigastric pain, heartburn, or acid regurgitation, with or without bloating, nausea or vomiting.

Review common elements of care for managing dyspepsia (section 1.3).

1.4.1 Be aware that dyspepsia in unselected people in primary care is defined broadly to include people with recurrent epigastric pain, heartburn or acid regurgitation, with or without bloating, nausea or vomiting. Also see 'Common elements of care'. [2004, amended 2014]

Changed to make recommendation active and for clarity.

1.4.2 Initial therapeutic strategies for dyspepsia are empirical treatment with a PPI or testing for and treating H pylori. There is currently insufficient evidence to guide which should be offered first. A 2-week washout period following PPI use is necessary before testing for H pylori with a breath test or a stool antigen test.

1.4.2 Leave a 2‑week washout period after proton pump inhibitor (PPI) use before testing for Helicobacter pylori (hereafter referred to as H pylori) with a breath test or a stool antigen test. [2004, amended 2014]

Changed to make recommendation active and for clarity.

1.4.6 Offer H2RA or prokinetic therapy if there is an inadequate response to a PPI.

1.4.6 Offer H2 receptor antagonist (H2RA) therapy if there is an inadequate response to a PPI. [2004, amended 2014]

Reference to prokinetic therapy has been removed as the original guideline only reviewed the evidence for cisapride, not domperidone or metoclopramine. Cisapride has been suspended in the UK since the publication of CG17.

1.5.1 Offer people requiring long-term management of symptoms for dyspepsia an annual review of their condition, encouraging them to try stepping down or stopping treatment.

1.5.1 Offer people who need long-term management of dyspepsia symptoms an annual review of their condition, and encourage them to try stepping down or stopping treatment (unless there is an underlying condition or comedication that needs continuing treatment). [2004, amended 2014]

Changed for clarity.

1.5.2 A return to self-treatment with antacid and/or alginate therapy (either prescribed or purchased over-the-counter and taken as-required) may be appropriate.

1.5.2 Advise people that it may be appropriate for them to return to self‑treatment with antacid and/or alginate therapy (either prescribed or purchased over-the-counter and taken as needed). [2004, amended 2014]

Changed to make recommendation active.

1.6.1 Gastro-oesophageal reflux disease (GORD) refers to endoscopically determined oesophagitis or endoscopy-negative reflux disease. Patients with uninvestigated 'reflux-like' symptoms should be managed as patients with uninvestigated dyspepsia.

1.6.1 Manage uninvestigated 'reflux-like' symptoms as uninvestigated dyspepsia. [2004, amended 2014]

Changed to make recommendation active.

1.6.3 If symptoms recur following initial treatment, offer a PPI at the lowest dose possible to control symptoms, with a limited number of repeat prescriptions.

1.6.3 If symptoms recur after initial treatment, offer a PPI at the lowest dose possible to control symptoms. [2004, amended 2014]

Removed 'with a limited number of repeat prescriptions' as the GDG felt this was included due to the costs of PPI at the time of original publication. Costs have since fallen and therefore limiting repeat prescriptions due to costs is not a factor in current practice.

1.6.5 Offer H2RA or prokinetic therapy if there is an inadequate response to a PPI.

1.6.5 Offer H2RA therapy if there is an inadequate response to a PPI. [2004, amended 2014]

Reference to prokinetic therapy has been removed as the original guideline only reviewed the evidence for cisapride, not domperidone or metoclopramine. Cisapride has been suspended in the UK since the publication of CG17.

1.7.3 Patients with gastric ulcer and H pylori should receive repeat endoscopy, retesting for H pylori 6–8 weeks after beginning treatment, depending on the size of the lesion.

1.7.3 Offer people with gastric ulcer and H pylori repeat endoscopy 6 to 8 weeks after beginning treatment, depending on the size of lesion. [2004, amended 2014]

The GDG felt the original recommendation needed to be split to reflect the different actions taken in each flowchart within the Full guideline. People with gastric ulcers needed an endoscopy and retesting, however just retesting for H pylori was necessary for people with duodenal ulcers.

1.7.3 Patients with gastric ulcer and H pylori should receive repeat endoscopy, retesting for H pylori 6–8 weeks after beginning treatment, depending on the size of the lesion.

1.7.4 Offer people with peptic ulcer (gastric or duodenal) and H pylori retesting for H pylori 6 to 8 weeks after beginning treatment, depending on the size of lesion. [2004, amended 2014]

The GDG felt the original recommendation needed to be split to reflect the different actions taken in each flowchart within the Full guideline. People with gastric ulcers needed an endoscopy and retesting, however just retesting for H pylori was necessary for people with duodenal ulcers.

The GDG felt peptic ulcer was the more appropriate term to use and included gastric and duodenal for further clarification.

1.7.8 If symptoms recur following initial treatment, offer a PPI to be taken at the lowest dose possible to control symptoms, with a limited number of repeat prescriptions. Discuss using the treatment on an as-required basis with patients to manage their own symptoms.

1.7.9 If symptoms recur after initial treatment, offer a PPI to be taken at the lowest dose possible to control symptoms. Discuss using the treatment on an 'as-needed' basis with people to manage their own symptoms. [2004, amended 2014]

Removed 'with a limited number of repeat prescriptions' as the GDG felt this was included due to the costs of PPI at the time of original publication. Costs have since fallen and therefore limiting repeat prescriptions due to costs is not a factor in current practice.

1.8.4 If H pylori has been excluded or treated and symptoms persist, offer either a low-dose PPI or an H2RA for 1 month.

1.8.4 If H pylori has been excluded and symptoms persist, offer either a low-dose PPI (see table 1 in appendix A) or an H2RA for 4 weeks. [2004, amended 2014]

Treatment has been removed from this recommendation and this is now covered by recommendations on H pylori eradication.

1.8.5 If symptoms continue or recur following initial treatment offer a PPI or H2RA to be taken at the lowest dose possible to control symptoms, with a limited number of repeat prescriptions.

1.8.5 If symptoms continue or recur after initial treatment offer a PPI or H2RA to be taken at the lowest dose possible to control symptoms. [2004, amended 2014]

Removed 'with a limited number of repeat prescriptions' as the GDG felt this was included due to the costs of PPI at the time of original publication. Costs have since fallen and therefore limiting repeat prescriptions due to costs is not a factor in current practice.

1.8.7 Long-term, frequent dose, continuous prescription of antacid therapy is inappropriate and only relieves symptoms in the short term rather than preventing them.

1.8.7 Avoid long-term, frequent dose, continuous antacid therapy (it only relieves symptoms in the short term rather than preventing them). [2004, amended 2014]

Changed to make recommendation active and for clarity

1.9.1 H pylori can be initially detected using a carbon‑13 urea breath test or a stool antigen test, or laboratory-based serology where its performance has been locally validated.

1.9.1 Test forH pylori using a carbon‑13 urea breath test or a stool antigen test, or laboratory-based serology where its performance has been locally validated. [2004, amended 2014]

Changed to make recommendation active.

1.9.3 Office-based serological tests for H pylori cannot be recommended because of their inadequate performance.

1.9.3 Do not use office-based serological tests for H pylori because of their inadequate performance. [2004, amended 2014]

Changed to make recommendation active.

Strength of recommendations

Some recommendations can be made with more certainty than others. The Guideline Development Group makes a recommendation based on the trade-off between the benefits and harms of an intervention, taking into account the quality of the underpinning evidence. For some interventions, the Guideline Development Group is confident that, given the information it has looked at, most patients would choose the intervention. The wording used in the recommendations in this guideline denotes the certainty with which the recommendation is made (the strength of the recommendation).

For all recommendations, NICE expects that there is discussion with the patient about the risks and benefits of the interventions, and their values and preferences. This discussion aims to help them to reach a fully informed decision (see also patient-centred care).

Interventions that must (or must not) be used

We usually use 'must' or 'must not' only if there is a legal duty to apply the recommendation. Occasionally we use 'must' (or 'must not') if the consequences of not following the recommendation could be extremely serious or potentially life threatening.

Interventions that should (or should not) be used – a 'strong' recommendation

We use 'offer' (and similar words such as 'refer' or 'advise') when we are confident that, for the vast majority of patients, an intervention will do more good than harm, and be cost effective. We use similar forms of words (for example, 'Do not offer…') when we are confident that an intervention will not be of benefit for most patients.

Interventions that could be used

We use 'consider' when we are confident that an intervention will do more good than harm for most patients, and be cost effective, but other options may be similarly cost effective. The choice of intervention, and whether or not to have the intervention at all, is more likely to depend on the patient's values and preferences than for a strong recommendation, and so the healthcare professional should spend more time considering and discussing the options with the patient.

Recommendation wording in guideline updates

NICE began using this approach to denote the strength of recommendations in guidelines that started development after publication of the 2009 version of The guidelines manual (January 2009). This does not apply to any recommendations ending [2004] (see update information above for details about how recommendations are labelled). In particular, for recommendations labelled [2004] the word 'consider' may not necessarily be used to denote the strength of the recommendation.

Other versions of this guideline

The full guideline, dyspepsia and gastro-oesophageal reflux disease, contains details of the methods and evidence used to develop the guideline. It is published by the Internal Clinical Guidelines Programme.

The recommendations from this guideline have been incorporated into a NICE Pathway.

We have produced information for the public about this guideline.

Implementation

Implementation tools and resources to help you put the guideline into practice are also available.

ISBN: 978-1-4731-0717-5

  • National Institute for Health and Care Excellence (NICE)