A patient with dyspepsia and a history of NSAID use. What is most appropriate initial test or management?

• A. Test for H. pylori with noninvasive testing
• B. Endoscopy
• C. Start PPI without testing
• D. Stop NSAIDs and observe

Answer: (A)

In dyspepsia without alarm features, the first step is to identify Helicobacter pylori using a noninvasive test. This test-and-treat approach is especially appropriate when NSAIDs are involved, because H. pylori infection increases ulcer risk and eradication can simplify management of NSAID-associated symptoms. If the noninvasive test is positive, treat the infection to reduce ulcer risk and optimize future NSAID use with potential gastroprotection. If the test is negative, manage with acid suppression (often a PPI) and lifestyle changes, while monitoring for persistent symptoms or red flags that would prompt endoscopy.

Endoscopy is reserved for alarm features or failure of initial therapy, not as the first step in this scenario. Simply stopping NSAIDs and observing misses the opportunity to identify and treat an infectious contributor to dyspepsia and ulcer risk. Starting a PPI without testing bypasses confirming H. pylori status and may delay appropriate eradication therapy if positive. The noninvasive tests (urea breath test or stool antigen) provide accurate, upfront information to guide treatment.