Despite progress in knowledge and effective therapies for acid-sensitive problems the indications for gastroscopy seem even more confusing than before. The primary care physician, faced with the patient with undifferentiated symptoms, is now less sure when to seek an endoscopy which is actively discouraged in many health care settings. Management guidelines, based essentially on maximizing the yield from endoscopy, may define the direction of travel but do not sit comfortably in the consultation setting.