NICE CG184 (2019 update): GORD and dyspepsia in adults

Who it applies to

Adults (18 years and over) presenting with symptoms of dyspepsia or reflux in primary, community, or secondary care settings, excluding those with alarm features requiring urgent referral.

Key recommendations

• Patients presenting with dyspepsia should first be assessed for alarm features (e.g. dysphagia, weight loss, GI bleeding, persistent vomiting, iron deficiency anaemia) that warrant urgent referral for endoscopy following suspected cancer pathway criteria.
• In the absence of alarm features, review medications for possible causes of dyspepsia (e.g. NSAIDs, calcium channel blockers, nitrates, theophyllines, bisphosphonates) and address these first.
• Offer lifestyle advice (weight loss, smoking cessation, avoiding trigger foods, raising the head of the bed) as an adjunct to pharmacological management, though evidence for lifestyle measures alone is limited.
• For uninvestigated dyspepsia, offer a full-dose proton pump inhibitor (PPI) for 4 weeks, or test for and treat Helicobacter pylori infection, as initial empirical management strategies.
• Use a carbon-13 urea breath test, stool antigen test, or laboratory-based serology to test for H. pylori; do not use office-based serology due to inadequate accuracy.
• If H. pylori eradication therapy fails, offer a second-line eradication regimen using antibiotics the patient has not previously received where possible.
• For endoscopically diagnosed GORD, offer a full-dose PPI for 4-8 weeks; if symptoms recur after stopping treatment, consider a low-dose PPI used on an as-needed basis for long-term management.
• For functional (non-ulcer) dyspepsia, offer H. pylori test-and-treat if not already done, or a PPI or H2-receptor antagonist for 4 weeks if H. pylori negative or if symptoms persist after eradication.
• Do not routinely offer long-term acid suppression without attempting to step down to the lowest effective dose or stopping treatment periodically to reassess need.
• Consider referral for specialist assessment, including possible fundoplication, in patients with confirmed GORD who have an inadequate response to optimised medical therapy or who wish to stop long-term medication.

Practice points for students

• Alarm features should always prompt urgent referral rather than empirical treatment, regardless of age.
• Office-based (near-patient) serology testing for H. pylori is not recommended due to poor sensitivity and specificity.
• The 'test and treat' and 'empirical PPI' strategies for uninvestigated dyspepsia are considered broadly equivalent first-line options.
• Long-term PPI use should be regularly reviewed with an aim to use the lowest effective dose or intermittent therapy.

Condition

Other guidelines on this topic

• ACG Clinical Guideline for the Diagnosis and Management of Gastroesophageal Reflux DiseaseACG2022Summary

Independent educational summary written by the WhiteCoat Pro editorial team with AI assistance and checked by a second AI model. It does not reproduce the guideline text, tables or figures, and it is not affiliated with or endorsed by NICE. It is not medical advice: always read the original guideline before applying it to patients.