Editor,—The Maastricht Consensus Report (Gut 1997;41:8–13) is a welcome benchmark summarising current opinion and scientific evidence regarding the role of Helicobacter pylori in gastroduodenal disorders. Whereas the management of peptic ulcer disease is no longer controversial and is very evidence-based the same is not yet true for the syndrome of non-ulcer dyspepsia and the management of the uninvestigated dyspeptic patient. The recommendation of the Maastricht Report reflects this uncertainty. They recommend that at the specialist level, eradication therapy for H pylori infected non-ulcer dyspepsia is “advisable”, based on supportive scientific evidence, but only after “full investigation” including endoscopy, ultrasound and other tests. However, in the management algorithm for the uninvestigated dyspeptic in primary care, non-invasive testing (with a breath test) and treatment is recommended for patients who are at a low risk of gastric carcinoma. Why such a difference? If it is recommended that a breath test is investigation enough of dyspepsia in primary care then an endoscopy and biopsy should be adequate in specialist practice if there are no other clinical indicators of another diagnosis (such as biliary colic) and the patient is at low risk of malignancy. The difficulty is that non-ulcer dyspepsia will remain a hard target and even several studies of symptom response after eradication therapy due to be reported shortly will not resolve the issues as there will be perennial debate about inclusion and exclusion criteria in such trials and these will have a great bearing on outcomes. Moreover, the ability to quantitate the lifetime risk reduction of peptic ulcer disease and perhaps even gastric carcinoma in patients who have eradication therapy will remain contentious. Medico-legal issues and patient preferences will also continue to be important factors influencing the decision to investigate and treat. At present the suggested test and treat …