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Dyspepsia Care Pathway Overview

The management of dyspepsia continues to have potentially significant costs to the NHS.  The following local pathway has been developed to clarify the appropriate use of investigations and management of dyspepsia in Gloucestershire.

Gloucestershire Hospitals NHS Foundation Trust (GHFT) has provided a GP direct access service for oesophago-gastro-duodenoscopy (OGD) for many years and continues to do so. This service is divided into the urgent (2WW) pathway and the open access (within 6 weeks) pathway. It is recommended that referrers follow the guidance and ensure that patients are referred on the appropriate pathways so as not to swamp the urgent pathway.

GP direct access for routine OGD is also offered by other providers in Gloucestershire and patients should be offered the choice of these providers where appropriate.  Further details of all endoscopy providers can be found on the Endoscopy Services & Referrals section of G-care.

The “red flag” symptoms for upper gastrointestinal (GI) cancer have altered somewhat in the latest NICE guidance – see below.  The NICE dyspepsia guidelines now provide strategies for managing gastro-oesophageal reflux disease (GORD) including consideration of anti-reflux surgery.

Please click the relevant flowchart box to be taken directly to textual information.

                

Routine endoscopy is not indicated in the following scenarios:

  • New onset dyspepsia in patients aged <55 years with no alarm symptoms/red flags
  • When previously controlled longstanding dyspepsia symptoms return on stopping treatment
  • To assess whether PPI therapy can be stopped
  • Patients with anaemia not secondary to iron deficiency or B12 deficiency

 

Referral for direct access endoscopy should, however, be considered in younger patients if:

  • There is a family history of upper GI cancer in first-degree relatives
  • There is a high level of patient anxiety and a negative test will help to manage symptoms
  • There is a longstanding history of reflux in order to look for Barrett’s Oesophagus
Red Flags
2WW Criteria
The “red flag” symptoms for Upper GI cancer have altered somewhat in the latest NICE guidance.
Only the following symptoms should lead to referral for a 2WW Upper GI outpatient appointment:
  • Jaundice (Please request an urgent Direct Access Ultrasound scan – append LFT results)
  • Abnormal imaging suspicious of Upper GI cancer (Report must be appended to referral)
  • Upper abdominal mass
Note:
  • In the latest NICE guidance “new onset dyspepsia in patients 55 and over” alone does not trigger a 2WW referral.
The following symptoms are all red flag symtpoms and should trigger a 2WW Direct Access Gastroscopy referral:
  • New onset of Dysphagia – food sticking on swallowing (any age)
  • Dyspepsia combined with one or more of the following “alarm” symptoms (cancer very rare aged <45 years):
    • Weight loss / anorexia
    • Anaemia*
    • Vomiting
  • Dyspepsia combined with at least one of the following known risk factors:
    • Family history of Upper GI cancer in more than two first-degree relatives
    • Peptic ulcer surgery over 20 years ago
    • Known dysplasia, atrophic gastritis, intestinal metaplasia
    • Barrett’s oesophagus
    • Pernicious anaemia
Note:
  • *Anaemia without dyspepsia is now no longer part of the Upper GI 2WW pathway and should be referred via the Iron Deficiency Anaemia (IDA) pathway through Lower GI.
  • Patients with iron deficiency anaemia alone should not be referred for an upper GI endoscopy.
Patients with active haematemesis or melaena should be referred to AEC via SPCA.
Presentation

Dyspepsia can be defined as ‘a group of symptoms, which are typically present for 4 weeks or more, that alert doctors to consider disease of the upper GI tract’.  This can include a range of symptoms arising from the upper gastrointestinal (GI) tract including epigastric pain, heartburn or acid reflux, nausea or vomiting, and bloating.  It has no universally accepted definition and itself is not a diagnosis.

Indigestion, heartburn and upper abdominal pain related to eating are experienced by a third of the population at least once a year, with the vast majority of such people using over-the-counter (OTC) remedies to self-medicate.

To assist with the investigation and management of patients it is worth trying to separate patients with pure reflux symptoms (heartburn, belching, waterbrash) – GORD (gastro-oesophageal reflux disease) – from those with other dyspeptic symptoms (epigastric discomfort/pain, nausea, vomiting, bloating, early satiety, dysphagia, odynophagia).

Differential Diagnosis

Pure reflux disease (GORD or reflux oesophagitis) is common and may indicate an underlying hiatus hernia. Heartburn is the most common symptom caused by hiatus hernia. Patients with longstanding (years) uninvestigated reflux are more at risk of Barrett’s oesophagus.

Other dyspeptic symptoms could be caused by a wide variety of diagnoses, but “non-ulcer or functional dyspepsia” is very common. This is a form of functional gastrointestinal disorder affecting the upper GI tract and hypersensitivity as well as dysmotility are likely to play a role.

Think about the possibility of gallstones or coronary disease as part of the differential diagnosis.

Initial Primary Care Assessment

  • Symptoms: Common descriptions a patient may use include 'indigestion', 'burning sensation', 'chest pain', 'sensation of acid in the throat' and 'nausea'.
  • Duration:
    • How long has the patient had the symptom?
    • Find out what brings it on and if it is worse after food or at night.
    • Are the symptoms intermittent, resolve completely between bouts and radiate through to the back? (consider gallstones as an alternative diagnosis)
  • Direct questions:
    • Vomiting: If so, explore this in detail and establish if there has been any haematemesis.
    • Odynophagia or dysphagia.
    • Unintentional weight loss
    • Smoking and drinking history
    • Females: menstrual history
    • Abdominal mass
  • Medication:
    • Use of aspirin or NSAIDs
    • PPI usage
  • Past investigations:
    • Endoscopy: If so, how long ago and what were the results?
    • Helicobacter pylori infection testing: If so, what were the results?
  • Past treatment:
    • Helicobacter eradication therapy
    • Gastric bypass surgery
  • Family history:
    • Upper GI malignancy
    • Duodenal or gastric ulceration
    • Barrett’s oesophagus
  • Ideas, Concerns and Expectations (ICE):
    • What re the patient’s ideas, concerns and expectations relating to their problem? Patients will often have their own thoughts as to the aetiology of the problem and understanding their health beliefs may be an important part of the consultation.

  • FBC, TTG, U&Es .
  • Ferritin and glucose may be necessary for some patients.
  • Check LFTs if symptoms could be biliary.
  • Amylase level may be appropriate if there is a history of acute pain.
  • Pregnancy test if appropriate.
  • Helicobacter pylori (H. pylori) testing initially with serology. Do not repeat serology as it will always remain positive.

 

2WW Direct Access Gastroscopy Criteria

The following symptoms are all red flag symptoms and should trigger a 2WW Direct Access Gastroscopy referral if the 2WW criteria are not met:

  • New onset of Dysphagia – food sticking on swallowing (any age)
  • Dyspepsia combined with one or more of the following “alarm” symptoms (cancer very rare aged <45 years):
    • Weight loss / anorexia
    • Anaemia*
    • Vomiting
  • Dyspepsia combined with at least one of the following known risk factors:
    • Family history of Upper GI cancer in more than two first-degree relatives
    • Peptic ulcer surgery over 20 years ago
    • Known dysplasia, atrophic gastritis, intestinal metaplasia
    • Barrett’s oesophagus
    • Pernicious anaemia

 

Routine Direct Access Gastroscopy Criteria

Routine endoscopy is NOT indicated in the following scenarios:

  • New onset dyspepsia in patients aged <55 years with no alarm symptoms/red flags
  • When previously controlled longstanding dyspepsia symptoms return on stopping treatment
  • To assess whether PPI therapy can be stopped
  • Patients with anaemia not secondary to iron deficiency or B12 deficiency (patients with iron deficiency anaemia alone should not be referred for an upper GI endoscopy).

 

There is no need to refer patients with pure reflux symptoms (classic heartburn or acid reflux symptoms) for endoscopy unless:

  • The symptoms are very longstanding and the test is to screen for Barrett’s Oesophagus
  • They also describe dysphagia
  • They are over 55 years with new onset symptoms
  • They are being considered for anti-reflux surgery

 

Referral for routine direct access endoscopy should, however, be considered in younger patients if:

  • There is a family history of upper GI cancer in first-degree relatives
  • There is a high level of patient anxiety and a negative test will help to manage symptoms
  • There is a longstanding history of reflux in order to look for Barrett’s Oesophagus
Initial Primary Care Management

          

Un-investigated Dyspepsia

                              

  1. Avoid causative medication:
    • Where possible reduce or stop all potential causes of dyspepsia including NSAIDs, steroids, calcium antagonists, nitrates, theophyllines and biophosphonates.
    • Encourage people who need long-term management of dyspepsia symptoms to reduce their use of prescribed medication stepwise: by using the effective lowest dose, by trying ‘as needed’ use when appropriate, and by returning to self-treatment with antacid and/or alginate therapy.
  2. a) Lifestyle advice:
    • Offer simple lifestyle advice regarding healthy and regular eating, weight reduction, smoking cessation and alcohol intake, promoting continued use of antacid/alginates.  Raising the head of the bed and having a main meal well before going to bed may also help.
    • Advise people to avoid known triggers they associate with their dyspepsia where possible e.g. smoking, alcohol, coffee, chocolate, fatty foods.

b) Psychological therapies:

  • CBT and psychotherapy may reduce dyspeptic symptoms in the short term in appropriate people.
  1. There is currently inadequate evidence to guide whether full-dose PPI for 1 month or H.pylori test and treat should be offered first. Either treatment may be tried first with the other being offered if symptoms persist or return.
  2. H.pylori detection – use serology testing.  H.pylori eradication – see Prescribing section
  3. H2RA or pro-kinetic - consider using Ranitine or Metoclopramide.
Peptic Ulcer Disease

        

  1. If NSAID continuation is necessary, after ulcer healing offer long-term gastric protection with a full dose PPI or consider substitution to a Cox-2-selective NSAID.
  2. If H.pylori not tested at Gastroscopy, serology testing will be needed
  3. Eradication therapy for H.pylori - see Prescribing section
  4. Decision to continue either as needed or ongoing low dose treatment dependent on whether there was a reversible cause for the ulcer (medication/H.pylori) and whether the patient has ongoing symptoms
  5. Patients with persistent gastric ulcer will usually be under secondary care
Functional Dyspepsia

                                   

  1. See Prescribing section
  2. Avoid causative medication:
    • Where possible reduce or stop all potential causes of dyspepsia including NSAIDs, steroids, calcium antagonists, nitrates, theophyllines and biophosphonates.
    • Encourage people who need long-term management of dyspepsia symptoms to reduce their use of prescribed medication stepwise: by using the effective lowest dose, by trying ‘as needed’ use when appropriate, and by returning to self-treatment with antacid and/or alginate therapy.
  3. a) Lifestyle advice:
    • Offer simple lifestyle advice regarding healthy and regular eating, weight reduction, smoking cessation and alcohol intake, promoting continued use of antacid/alginates.  Raising the head of the bed and having a main meal well before going to bed may also help.
    • Advise people to avoid known triggers they associate with their dyspepsia where possible e.g. smoking, alcohol, coffee, chocolate, fatty foods.

b) Psychological therapies:

  • CBT and psychotherapy may reduce dyspeptic symptoms in the short term in appropriate people.
  1. Low dose amitriptyline – Start at 10mgs od at night.  Can increase by 10mgs increments to a maximum of 50mgs od.  Warn patient that they may have to take treatment for 6 weeks before they see any symptom improvement.
Reflux Oesophagitis

                                                                                          

  1. Obesity, smoking, alcohol, coffee and chocolate may cause transient lower oesophageal sphincter relaxations, whereas fatty foods delay gastric emptying.  Raising the head of the bed and having a main meal well before going to bed may help.
  2. H2RA or pro-kinetic - consider using Ranitine or Metoclopramide.
  3. Refer to secondary care if patient has ongoing symptoms affecting quality of life.

 

There is no need to refer patients with pure reflux symptoms (classic heartburn or acid reflux symptoms) for endoscopy unless:

  • The symptoms are very longstanding and the test is to screen for Barrett’s Oesophagus
  • They also describe dysphagia
  • They are over 55 years with new onset symptoms
  • They are being considered for anti-reflux surgery
Endoscopy Negative Reflux Disease

                                                    

  1. Obesity, smoking, alcohol, coffee and chocolate may cause transient lower oesophageal sphincter relaxations, whereas fatty foods delay gastric emptying.  Raising the head of the bed and having a main meal well before going to bed may help.
  2. Volume reflux – large volume reflux of stomach contents, worse when lying flat or bending
  3. Low dose amitriptyline – Start at 10mgs od at night.  Can increase by 10mgs increments to a maximum of 50mgs od.  Warn patient that they may have to take treatment for 6 weeks before they see any symptom improvement.
Testing for H.pylori

Serology Testing for Initial Diagnosis

  • Serology testing is available locally from GHFT
  • Serology is not recommended for children.
  • Serology demonstrates previous exposure to H.pylori. It will always remain positive so there is no need to repeat testing.
  • Serology can be used a screening test but does not confirm current infection.

C13 Urea Breath Testing for Current Infection

  • Breath testing and stool antigen testing is not offered locally by GHFT. 
  • Leave a 2 week washout period after PPI use before breath testing for H.pylori. 
  • To test for current infection use a home breath test kit which can be prescribed to patients on FP10.  The test involves collecting a breath sample before and after a dose of C13 urea to see if there is an increase in C13 CO2 given off in the breath.
  • Breath tests available for H.pylori include:
  • Most patients should be able to administer the test themselves at home however a judgement about whether or not the patient has the physical or cognitive ability to do so will be required.  The patient will need to send off the samples themselves, will receive the results directly and then will need to contact the GP to discuss the results and next steps.

It is not necessary to test for H.pylori when there are clear reflux symptoms (GORD) responding to therapy.

Secondary Care Management

Direct access endoscopy provides a prompt investigation and the endoscopist should provide some advice following the test.

The endoscopist will be responsible for any histology taken during a direct access procedure and communicating these results to the referrer.

Patients referred for consideration of anti-reflux surgery will need to undergo oesophageal manometry and 24 hour pH monitoring as part of the work up for surgery.

Ongoing Care
  • If symptoms recur after initial treatment, offer the lowest-dose PPI that will control symptoms.
  • Remember that visceral hypersensitivity may be causing symptoms so medications like amitriptyline might help.
  • Offer people who need long-term management of dyspepsia symptoms an annual review of their condition, and encourage them to try stepping down or stopping treatment (unless there is an underlying condition that needs continuing treatment).
  • Advise patients that it may be appropriate for them to return to self-treatment with antacid and/or alginate therapy (either prescribed or purchased OTC) and taken as needed.
Record Keeping and Audit

Direct access endoscopy referral vetting and the outcome of referrals will be subject to continuous audit.

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