Although dyspepsia has many possible causes, the primary causes are peptic ulcer disease, gastro-oesophageal reflux disease, and functional (non-ulcer dyspepsia). General practitioners managing dyspepsia face several dilemmas. #### Summary points Subgrouping of symptoms should not guide empirical treatment of dyspepsia Symptoms of underlying serious disease and use of non-steroidal anti-inflammatory drugs are indications for prompt endoscopy A breath test is superior to a blood test in documenting H pylori infection and guiding the management of dyspepsia in general practice Empirical treatment with acid reducing or prokinetic drugs for all patients with dyspepsia is inappropriate as peptic ulcer disease will be inadequately treated Empirical eradication treatment of H pylori in patients with dyspepsia who are positive for the organism is preferable to other empirical treatment if prompt endoscopy is not an option ### Dyspepsia subgroups: an irrelevant concept Broad (and vague) definitions of dyspepsia have been proposed,1 but a current internationally accepted definition of dyspepsia is chronic or recurrent pain or discomfort centred on the upper abdomen.2 People with heartburn or acid regurgitation alone and those in whom reflux symptoms are dominant and epigastric pain or discomfort is minor should probably not be classed as having dyspepsia but as having symptomatic gastro-oesophageal reflux disease. The same applies to patients who have a disturbed bowel habit and dyspeptic symptoms, which should be classed as the irritable bowel syndrome.2 ### Dyspepsia subgroups During the past decade dyspepsia has been divided into clinical subgroups based on medical history: ulcer-like (typical ulcer symptoms), dysmotility-like (symptoms suggestive of gastric stasis), reflux-like (retrosternal and concomitant upper abdominal symptoms), and unspecified (symptoms cannot be classified) (box). …