Clinicians working in both primary and secondary care still do not have evidence-based guidance on the management of dyspepsia which is both clinically effective and cost-efficient. Perhaps we never will. Moving therapeutic targets often generate questions faster than researchers can answer them. Nevertheless, we do need better information about the inter-relations between dyspepsia,Helicobacter pylori infection,H pylori eradication, and endoscopy. The paper by Heaney et al (see page 186) provides a good deal of information, but also raises further questions about alternative strategies for managing dyspepsia.

The background is familiar. Until H pylori burst on to the scene, there was some controversy about empirical therapy versus early endoscopy in the initial management of dyspepsia, but the availability of accurate diagnostic and effective therapeutic methods in H pylori management means that clinicians can now choose from two further strategies—(1) test and endoscope and (2) test and treat. In the first of these theH pylori test is used as a “screen” for endoscopy, with H pylori positive patients undergoing endoscopy and H pylori negative patients treated as if they have non-ulcer dyspepsia. Patel and colleagues1 claimed that this …