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Rome definitions have been helpful in better-standardizing patients that are included in studies of dyspepsia but are less relevant to clinical practice as there is considerable overlap in symptom presentation (16) making classification difficult in many patients presenting in primary and secondary care.For this reason, we have used a clinically relevant definition of dyspepsia as predominant epigastric pain lasting at least 1 month.Nevertheless, the main viewpoint taken related to the US and Canada and our recommendations may not apply to other countries in some instances.We have indicated in the text specific areas where local variations in incidence of disease or availability of medication may result in different approaches being recommended in other countries. The group was chosen to represent a US and Canadian secondary and tertiary care perspective on managing dyspepsia with experience in guideline methodology, motility, endoscopy, and pharmacological therapies.We suggest that patients ≥60 years of age presenting with dyspepsia are investigated with upper gastrointestinal endoscopy to exclude organic pathology.This is a conditional recommendation and patients at higher risk of malignancy (such as spending their childhood in a high risk gastric cancer country or having a positive family history) could be offered an endoscopy at a younger age.Dyspepsia is estimated to cost the US health care service over billion per annum (8) and societal costs are likely to be double this (9) with 2–5% (7, 9, refs. Cost-effective management of dyspepsia can reduce its health and economic burdens, but it is over 10 years since either the American College of Gastroenterology (ACG) (10) or Canadian Association of Gastroenterology (CAG) (11) published guidelines on dyspepsia.We have therefore updated previous systematic review data (12) for a joint ACG and CAG guideline on dyspepsia management.

However, since this disorder is common, and since patients do not uniformly respond to one medication, we believe it important to address key clinical treatment options, despite limited data.Dyspepsia is more common in women, smokers, and those taking non-steroidal anti-inflammatory drugs (4).Patients with dyspepsia have a normal life expectancy (5), however, symptoms negatively impact on quality of life (6, 7) and there is a significant economic impact to the health service and society (8).The assumption of this latter point is that patients that continue to consult due to persistent symptoms desire further treatment.The global literature was reviewed and this guideline takes an international perspective.

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