NICE guidance - management of univestigated dyspepsia in primary care

Management of Uninvestigated Dyspepsia in Primary Care

Make sure criteria for referral are NOT met.

Referral criteria:

• immediate referral is indicated for significant acute gastrointestinal bleeding. Consider the possibility of cardiac or biliary disease as part of the differential diagnosis (1)
  
  
• NICE urgent cancer referral guidance states (2)
  • Suspected Oesophageal cancer Suspected Stomach cancer Non Urgent Referral guidance: Suspected stomach cancer/oesophageal cancer:
    • offer urgent direct access upper gastrointestinal endoscopy (to be performed within 2 weeks) to assess for oesophageal cancer n people:
      • with dysphagia or
      • aged 55 and over with weight loss and any of the following:
        • upper abdominal pain
        • reflux
        • dyspepsia
    • consider a suspected cancer pathway referral (for an appointment within 2 weeks) for people with an upper abdominal mass consistent with stomach cancer
    • offer urgent direct access upper gastrointestinal endoscopy (to be performed within 2 weeks) to assess for stomach cancer in people:
      • with dysphagia or
      • aged 55 and over with weight loss and any of the following:
        • upper abdominal pain
        • reflux
        • dyspepsia
          
          
    • consider non-urgent direct access upper gastrointestinal endoscopy to assess for stomach cancer/oesophageal cancer in people with haematemesis
      
      
    • consider non-urgent direct access upper gastrointestinal endoscopy to assess for stomach cancer/oesophageal cancer in people aged 55 or over with:
      • treatment-resistant dyspepsia or
        
        
      • upper abdominal pain with low haemoglobin levels or
        
        
      • raised platelet count with any of the following:
        • nausea
        • vomiting
        • weight loss
        • reflux
        • dyspepsia
        • upper abdominal pain, or
          
          
      • nausea or vomiting with any of the following:
        • weight loss
        • reflux
        • dyspepsia
        • upper abdominal pain
          
          
• routine endoscopic investigation of patients of any age, presenting with dyspepsia and without alarm signs, is not necessary (1)

If referral criteria are NOT met:

(A) Review medications for possible causes of dyspepsia, for example, calcium antagonists, nitrates, theophyllines, bisphosphonates, steroids and NSAIDs.

(B) Offer lifestyle advice, including advice on healthy eating, weight reduction and smoking cessation, promoting continued use of antacid/alginates

1. if response to life-style advice then return to self-care
2. if no response to life-style advice (or relapse) then goto (C)

(C) Full-dose proton pump inhibitor for one month - note NICE state that there is currently inadequate evidence to guide whether fulldose PPI for one month or H. pylori test and treat should be offered first. Either treatment may be tried first with the other being offered where symptoms persist or return

1. if response then return to self-care
2. if no response (or relapse) then goto (D)

(D) Test and treat

1. detection: use carbon-13 urea breath test, stool antigen test or, when performance has been validated, laboratory-based serology.
   1. eradication as per linked item
2. if response to test and treat then return to self-care
3. if relapse then
   1. offer low-dose treatment with a limited number of repeat prescriptions. Discuss the use of treatment on an as-required basis to help patients manage their own symptoms then (E)
4. if no response then
   1. H2RA or prokinetic for one month
      1. if response then offer low-dose treatment with a limited number of repeat prescriptions. Discuss the use of treatment on an as-required basis to help patients manage their own symptoms then (E)
      2. if no response then (E)

(E) in some patients with an inadequate response to therapy it may become appropriate to refer to a specialist for a second opinion. Emphasise the benign nature of dyspepsia. Review long-term patient care at least annually to discuss medication and symptoms.

Summary of Interventions for uninvestigated dyspepsia (1)

• be aware that dyspepsia in unselected people in primary care is defined broadly to include people with recurrent epigastric pain, heartburn or acid regurgitation, with or without bloating, nausea or vomiting
• leave a 2-week washout period after proton pump inhibitor (PPI) use before testing for Helicobacter pylori (hereafter referred to as H pylori) with a breath test or a stool antigen test
• offer empirical full-dose PPI therapy for 4 weeks to people with dyspepsia
• offer H pylori 'test and treat' to people with dyspepsia
  
• if symptoms return after initial care strategies, step down PPI therapy to the lowest dose needed to control symptoms. Discuss using the treatment on an 'as-needed' basis with people to manage their own symptoms
• offer H2 receptor antagonist (H2RA) therapy if there is an inadequate response to a PPI

For full details of NICE guidance then refer to the full guideline (1).

Notes (3):

• a trial comparing test and treat versus empirical antisecretory therapy concluded that:
  • strategies based on H. pylori test enjoyed similar symptom resolution, but reduced endoscopic workload and lower 1-yr total costs compared with empirical antisecretory therapy

Reference:

1. NICE (September 2014).Dyspepsia and gastro-oesophageal reflux disease - Investigation and management of dyspepsia, symptoms suggestive of gastro-oesophageal reflux disease, or both
2. NICE (June 2015). Referral Guidelines for Suspected Cancer.
3. Jardol DE et al. Proton pump inhibitor or testing for Helicobacter pylori as the first step for patients presenting with dyspespia? A cluster-randomized trial. Am J Gastroenterol 2006;101:1200-8.