Dyspepsia

Dyspepsia is very common affecting 40% of the population annually, leading to 5% of GP consultations,with 1% going on to endoscopy

Primary care assessment and management of dyspepsia in adults, indications for referral for endoscopy and further specialist management

Please note pre-referral criteria are applicable in this referral and referrals may be returned if this information is not contained within the referral letter

Key pre-referral criteria summary:

  • Primary care treatment has failed (see management section) - please provide details of treatments tried
  • H Pylori has not responded to second line eradication therapy
  • Have a lower threshold for referral if the patient has a history of Barrett's oesophagus, pernicious anaemia, peptic ulcer surgery or a family history of upper GI cancer

Assessment

Signs and Symptoms

  • This pathway uses a broad, inclusive definition of dyspepsia:
    • Upper abdominal pain or discomfort
    • Heartburn
    • Acid reflux
    • Nausea
    • Vomiting
    • Present for at least 4 weeks
    • Bloating
    • Belching
    • Feeling full after eating

History and Examination

  • Check for features suggestive of cardiac origin of pain:
    • Association with exercise
    • Radiation to arm
  • Take history of recent medication use, especially any which may be gastric irritant
  • Ask about symptoms suggestive of biliary tract disease:
    • Association with food
    • Rigors
    • Change in colour of urine or stool
  • Abdominal examination should be performed to check for any masses or gall bladder tenderness

Red Flags

Are there alert symptoms present?
  • Endoscopy (to investigate for malignancy) is indicated in patients of any age with any of the following alarm signs:
    • gastrointestinal bleeding
    • progressive weight loss (unintentional)
    • progressive difficulty swallowing
    • persistent vomiting
    • unexplained iron deficiency anaemia
    • mass in epigastrium
    • patient aged 55 and over with weight loss and any of the following:
      • upper abdominal pain
      • reflux
      • dyspepsia
    • suspicious Barium meal result
    • unexplained worsening of dyspepsia with any of the following risk factors:
      • Barrett's oesophagus
      • known dysplasia
      • atrophic gastritis
      • or intestinal metaplasia, peptic ulcersurgery more than 20 years ago
  • If YES alert symptoms are present then refer to Upper GI 2WW
  • If NO to alert symptoms follow Lifestyle advice, medication review, and symptomatic treatment in the management section

Investigations

Consider the following tests in primary care

  • Bloods – FBC Ferritin B12 folate TTG
  • Stool for H.pylori

Dyspepsia not requiring endoscopic investigation
Routine endoscopy is not indicated in patients under age 55 years if there are none of the alarm symptoms shown in the 'red flag' criteria

Management

If NO alarm symptoms present:

  • Lifestyle advice, medication review, and symptomatic treatment
    • Advise patient to avoid triggers that may be associated with dyspepsia:
      • Smoking
      • Alcohol
      • Coffee
      • Chocolate
      • Fatty foods
    • Review medications that may cause dyspepsia and whether they may be reduced or stopped, e.g.
      • Non-steroidal anti-inflammatory drugs (NSAIDs)
      • Calcium antagonists
      • Nitrates
      • Theophyllines
      • Bisphosphonates
      • Steroids
  • Consider the following to diminish reflux symptoms:
    • Advise patient on weight reduction - being overweight may cause dyspepsia
    • Raising the head of the bed and not eating close to bedtime may ease symptoms attributable to reflux
    • Antacid and/or alginate therapy - for immediate symptom relief

If reflux is predominant symptom go to Gastro-oesophageal reflux disease management guidelines

If reflux is not the predominant symptom then:

  1. Lifestyle advice and antiacids
  2. Try a full dose proton pump inhibitor (PPI) for 1 month (omeprazole 20mg daily or 30mg daily lansoprazole). Offer H2 receptor antagonist if inadequate response to PPI.
  3. If no response then check Helicobacter stool antigen test
    • Before testing for Helicobacter pylori (H. pylori), a 2 week washout period following PPI use is necessary.
    • H. pylori: Is associated with peptic ulcer disease and non-ulcer dyspepsia and can be detected using:
      • stool antigen test

If Helicobacter stool antigen test is negative the likely diagnosis is functional dyspepsia

  • This does not require endoscopic investigation.
  • In absence of red flags continue with self-care and advise patient to consult again if symptoms return despite these measures.
  • If inadequate response to lifestyle advice and antacids consider trial of low dose H2RA or PPI for 4 weeks followed by low dose H2RA or PPI on an as required basis. Although PPIs are more effective in trials, individual patients may respond to H2RA.

If H. pylori positive –

  • If ulcer associated with NSAID use then full dose PPI for 8 weeks then H. pylori eradication
  • If no NSAID then try H. pylori eradication.
  • If no response to eradication therapy or symptom relapse then retest and if negative, for low dose PPI or as required maintenance, but if non response consider other causes as above. If positive – 2nd line eradication.

Eradication Therapy
Joint formulary – Chapter 5 – Eradication therapy

Dyspepsia
Joint formulary - Chapter 1 - Dyspepsia

Proton pump inhibitors
Joint formulary - Chapter 1, section 4.2 Gastro and duodenal ulceration

Referral

Please note pre-referral criteria are applicable in this referral and referrals may be returned if this information is not contained within the referral letter.

Referral Criteria

  • Primary care treatment has failed (see management section) – please provide details of treatments tried
  • H Pylori has not responded to second line eradication therapy
  • Have a lower threshold for referral if the patient has a history of Barrett's oesophagus, pernicious anaemia, peptic ulcer surgery or a family history of upper GI cancer

Patients presenting with 'red flag' criteria should be referred for an urgent OGD via the appropriate 2WW pathway

After OGD:

  • 40% are proven to have GORD – see the management clinical referral guideline for treatment
  • 40% have functional dyspepsia – see management clinical referral guideline for dyspepsia
  • 13% have an ulcer – see management pathway for peptic ulcer

Referral Instructions

Referral to Gastroenterology
  • Refer using e-Referral Service
    • Specialty: GI and Liver (Medicine and Surgery)
    • Clinic Type: Upper GI inc Dyspepsia
    • Service: DRSS-Western-GI and Liver (Medicine and Surgery)-Devon CCG-15N
Referral to Endoscopy
  • Refer using e-Referral Service
    • Specialty: GI and Liver (Medicine and Surgery)
    • Clinic Type: Endoscopy
    • Service: DRSS-Western-GI and Liver (Medicine and Surgery)-Devon CCG-15N

Referral Forms

DRSS Referral Proforma

Supporting Information

Pathway Group

This pathway was signed off by the NEW Devon CCG Clinical Pathway Group.

Publication date: February 2016

 

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