Download Policy (Word)

Management of Dyspepsia in Primary Care
and Referral for Endoscopy
Definition
Upper Gastrointestinal Endoscopy or Gastroscopy is an examination of the upper digestive tract
using an endoscope. Dyspepsia is defined broadly to include recurrent epigastric pain, heartburn
or acid regurgitation, with or without bloating, nausea or vomiting.
Policy
It is the responsibility of referring and treating clinicians to ensure compliance with this
policy. Referral proforma should be attached to the patient notes to aid clinical audit and
evidence compliance with the policy. For patients not meeting the policy criteria, clinicians
can apply for funding to the Exceptional Cases Panel by completing the exceptional
funding section of the referral proforma: Click policies – select the Endoscopy Policies drop
down option and select the Management of Dyspepsia… Policy to access the referral proforma.
Surgical Threshold Policy
1. Urgent (two week wait fast track) with Dyspepsia
The CCG will fund fast track (two week wait) referral for upper GI endoscopy in dyspepsia
only when there are alarm or red flag symptoms (as below), and when the referral is being
made in order for the GP to exclude a diagnosis of cancer.
ALARM and RED FLAG symptoms in patients with dyspepsia
 Patients of any age with any of: chronic gastrointestinal bleeding; progressive
unintentional weight lossi; progressive dysphagiaii; persistent vomitingiii; iron deficiency
anaemiaiv; epigastric mass or suspicious barium meal.
OR
 Aged 55 years and older with unexplainedv and persistentiii recent-onsetvi dyspepsia.
OR
 Unexplainedv worsening of dyspepsia AND Barrett’s oesophagus; or dysplasia (abnormal
development of cells, tissues or structures in the body); or atrophic gastritis (pernicious
anaemia); or intestinal metaplasia (the term applied to a change of one kind of tissue into
another); or peptic ulcer (ulcer in the stomach or the duodenum) surgery more than 20
years ago.
Notes:
i More than 3kg or more than 5% body weight lost over 6-12 months, which cannot be explained by
changes to diet or by comorbidities such as depression or dementia.
ii Interference with the swallowing mechanism.
iii Persistent means more than would be normally expected for self limiting conditions, usually more
than 4-6 weeks.
iv Iron deficiency anaemia and Hb 11g/100ml or below for men, Hb 10g/100ml or below for nonmenstruating women, which cannot be explained by other reasons.
v ‘Unexplained' is defined as 'a symptom(s) and/or sign(s) that has not led to a diagnosis being made
by the primary care professional after initial assessment of the history, examination and primary
care investigations (if any)'. In the context of this recommendation, the primary care professional
should confirm that the dyspepsia is new rather than a recurrent episode and exclude common
precipitants of dyspepsia such as NSAIDs and other medication.
vi Recent onset means new within the last year and not a recurrence.
Immediate (same day) specialist referral should be made for dyspepsia with significant
acute gastrointestinal bleeding (decision on endoscopy will be by the examining specialist).
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2. Urgent (two week wait fast track) without Dyspepsia
Consider two week wait fast track referral for:
 dysphagiaii
 unexplained upper abdominal pain and weight lossI, with or without back pain
 upper abdominal mass
 obstructive jaundice (refer to fast-track jaundice service)
 persistent iii vomiting and weight lossI in the absence of dyspepsia
 unexplained weight lossI
 iron deficiency anaemia iv (refer to Digestive Diseases)
3. Non-urgent Dyspepsia
The CCG will fund non-urgent referral for upper GI endoscopy or a specialist opinion in
dyspepsia patients without alarm or red flag symptoms only in the following circumstances:

Persistent clinically significant symptoms after trial of over-the-counter medications;
lifestyle modifications; review of NSAID/other prescribed medications; and NICE-advised
proton pump inhibitors (Omeprazole 20mg or Lansoprazole 30mg for at least 4 weeks),
H Pylori “test and treat”, Histamine2 receptor antagonist (H2RA) or higher dose PPI for 4
weeks has been completed as per the Dyspepsia pathway (Page 4).
AND
Blood tests for Hb, MCV, ESR, coeliac serology, CRP, LFT and GGT as well as tests of
ferritin level (if patient presents with dyspepsia and anaemia) and H pylori tests (together
with results of eradication therapy), must be available or accessible at the hospital
assessment. (See Dyspepsia pathway on Page 4).
AND
A specialist opinion is required to assess possible underlying pathology and to advise on
further management.


Management of Non-Urgent Dyspepsia in Primary Care
1. Age of the patient:
 Routine endoscopic investigation of patients of any age, presenting with dyspepsia, but
without alarm signs, is not necessary.

Offer older patients (over 80 years of age) the same treatment as younger patients, taking
account of any comorbidity and their existing use of medication.
2. Review medications for possible causes of dyspepsia:



calcium antagonist
theophyllines
steroids



nitrates
bisphosphonates
non-steroidal anti-inflammatory drugs (NSAIDs)

advise patients to avoid other known precipitants
of dyspepsia: coffee, chocolate and fatty foods
raising the head of the bed
having the main meal well before going to bed
may also help
3. Offer lifestyle advice:




healthy eating
weight reduction
smoking cessation
promote continued use of
antacid/alginates


4. Consider alternative diagnoses and treat accordingly:
 Irritable bowel syndrome or gall stones, particularly in young patients.
 Ischaemic heart disease.
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5
Treatment with PPI (Proton Pump Inhibitor) – drugs that reduce the amount of acid made by
the stomach:

Always prescribe generic PPI:
 Omeprazole 20 mg or Lansoprazole 30 mg are treatment of choice (Lansoprazole-FT is
not generic PPI).
 It is worth remembering that a second line PPI or addition of H2RA could be more
useful and could be tried for one more month before referral.
 If symptoms recur following initial treatment, offer a PPI at the lowest dose possible to
control symptoms, with a limited number of repeat prescriptions.
 It is not necessary to endoscope patients who require maintenance PPI.
Offer patients requiring long-term treatment for dyspepsia an annual review and encourage them
to try stepping down to effective lowest dose or stopping treatment and trying as-required use
when appropriate; and by returning to self-treatment with antacid or alginate therapy.
6. Investigation and treatment for H. pylori:
 H. pylori status should not affect the decision to refer for suspected cancer.
 Prior to testing for H pylori, patients should be free from acid suppression medication,
including proton pump inhibitors or H2 receptor agonists, for a minimum of 2 weeks
 NICE recommends the ‘test and treat’ strategy: test for H. pylori and give eradication
therapy if positive, but only expect 1:15 patients to make a lasting response.
 Treat if positive with full-dose PPI and a 7-day twice-daily course consisting of either
metronidazole 400mg and clarithromycin 250mg; or amoxcycillin 1g and clarithromycin
500mg. Click here for formulary for details and second-line treatment options
 Seek advice from gastroenterologist if eradication failure with second-line treatment.
Non responders and H. pylori negative patients can be treated empirically with antacids and acidsuppressing agents– they do not need endoscopy at this stage.
7. Offer H2RA (histamine 2 receptor antagonist) if there is an inadequate response to a PPI for
one month.
8. If the patient is unresponsive to management according to the given pathway, or has atypical
symptoms, refer for specialist opinion to the Consultant Gastroenterologist. Please give the
relevant clinical details and explain the reasons for referral.
Investigations prior to referral
The following investigations should be done before referral to secondary care for non-urgent
presentations. These investigations may help the primary care physicians in the diagnosis:
 Full blood count (Hb, MCV) – presence of anaemia would lead to a fast-track referral.
Serum Ferritin if anaemic.
 LFTs – to exclude alternative explanations for the symptoms such as cholelithiasis.
 Coeliac serology – important in all patients with unexplained GI symptoms. Genetic testing
or gastroscopy with duodenal biopsy on gluten diet may be required to confirm a diagnosis
of Coeliac disease.
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Pathway for Management of Dyspepsia in Primary Care






Calcium antagonist
Theophylline
Steroids
Nitrates
Bisphosphonates
NSAIDs




Healthy eating
Weight reduction
Smoking cessation
Avoid precipitant foods
(coffee, chocolate, fatty)
 Raise head of bed
 Have main meal well
before bedtime
Dyspepsia
‘Alarm features’ present
No ‘Alarm features’
present
=>Refer to Fast-Track
Dyspepsia Service
+
Suspend NSAID
Review medications
+
Life style changes
+
Consider alternative
diagnoses
Symptoms resolved:
return to self-care #
Symptoms not resolved
Full dose PPI for 1
month
Symptoms resolved:
return to self-care #
Symptoms not resolved
Note: Prior to testing for
H pylori, patients should
be free from acid
suppression medication,
including proton pump
inhibitors or H2RA, for a
minimum of 2 weeks
Investigations
abnormal, treat
accordingly
H. pylori test and treat
FBC, LFT, Coeliac
Serology
Symptoms resolved:
return to self-care #
Investigations normal
and symptoms not
resolved
Offer H2RA or higher
dose PPI for 1 month
Symptoms not resolved
Refer to
Non fast-track
Dyspepsia
Service
Symptoms resolved:
return to self-care #
# Symptoms resolved:
return to self-care.
If symptoms recur
following initial treatment
offer a PPI at the lowest
dose to control
symptoms.
Referral of these
patients is not
necessary
*PLEASE NOTE THIS REFERRAL WILL RESULT IN GASTROSCOPY.
IT IS THE RESPONSIBILITY OF THE REFERRER TO SURE THAT THE PROFORMAS ARE
COMPLETE AND MEET THE GUIDELINES
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Rationale
Dyspepsia is a common condition affecting approximately 40% of the population annually, but only
a very few people are likely to have significant morbidity such as gastric cancer. It is, therefore,
neither practical nor desirable to refer patients routinely for endoscopic investigation. NICE
commissioning tool recommends an annual benchmark endoscopy rate of 0.75%.
Although clinical evidence shows that symptoms of gastric cancer may be non-specific, and that
alarm symptoms do not predict cancer as accurately as would be desired, at the present time,
there are no available methods of testing in primary care that would give a greater sensitivity and
specificity in identifying potential pathology.
The rationale for the CCG policy on indications for funding of endoscopy, therefore, remains as set
out by NICE in its advice on the potential benefits of commissioning an effective service for upper
GI endoscopy which is as follows:

effective management of patients with dyspepsia in primary care, in line with NICE guidance
on dyspepsia CG184, to ensure that patients receive the most appropriate and effective
treatments, and that endoscopies are carried out only when necessary;

referral for endoscopy is prioritised, especially for those with alarm symptoms detailed in NICE
guidance on referral for suspected cancer NG12;

reduction in unnecessary referrals – there is a small risk following upper GI endoscopy: in the
UK one in 200 patients experience adverse events and the risk of mortality is one in 2000.
However, the mortality for ambulatory patients attending an outpatient endoscopy service is
much lower;

optimising availability of endoscopy resources for appropriate cases;

helping GP practices to manage their commissioning budgets more effectively – this may
include opportunities to undertake local service redesign to meet local requirements.
Evidence
The evidence was obtained from NICE guidance CG184 and NG12.
OPCS Codes
G161
G162
G163
G168
G169
G191
G192
G198
G199
G451
G452
G453
G454
G458
G459
G551
G558
G559
Diagnostic fibreoptic endoscopic examination of oesophagus and biopsy of lesion of oesophagus.
Diagnostic fibreoptic endoscopic ultrasound examination of oesophagus.
Diagnostic fibreoptic insertion of Bravo pH capsule into oesophagus.
Other specified diagnostic fibreoptic endoscopic examination of oesophagus.
Unspecified diagnostic fibreoptic endoscopic examination of oesophagus.
Diagnostic endoscopic examination of oesophagus and biopsy of lesion of oesophagus using rigid
oesophagoscope.
Diagnostic endoscopic insertion of Bravo pH capsule using rigid oesophagoscope.
Other specified diagnostic endoscopic examination of oesophagus using rigid oesophagoscope.
Unspecified diagnostic endoscopic examination of oesophagus using rigid oesophagoscope.
Fibreoptic endoscopic examination of upper gastrointestinal tract and biopsy of lesion of upper
gastrointestinal tract.
Fibreoptic endoscopic ultrasound examination of upper gastrointestinal tract.
Fibreoptic endoscopic insertion of Bravo pH capsule into upper gastrointestinal tract.
Fibreoptic endoscopic examination of upper gastrointestinal tract and staining of gastric mucosa.
Other specified diagnostic fibreoptic endoscopic examination of upper gastrointestinal tract.
Unspecified diagnostic fibreoptic endoscopic examination of upper gastrointestinal tract.
Diagnostic endoscopic examination of duodenum and biopsy of lesion of duodenum.
Other specified diagnostic endoscopic examination of duodenum.
Unspecified diagnostic endoscopic examination of duodenum.
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References
1. NICE CG184 (September 2014), Dyspepsia and gastro-oesophageal reflux disease
http://www.nice.org.uk/guidance/cg184
2. NICE NG12 Suspected cancer: recognition and referral. Published June 2015:
https://www.nice.org.uk/guidance/ng12/resources/suspected-cancer-recognition-and-referral1837268071621
Glossary
Barium meal:
Endoscope:
H. pylori:
H2 Receptor
Antagonists
(H2RA)
PPI:
A radio-opaque white power used in x-ray examinations of the stomach and
gastrointestinal tract. The barium meal is swallowed to enable the oesophagus,
stomach, and small and large intestines to be assessed for disorders.
A tube shaped instrument that is flexible and equipped with lenses and a light source
that is inserted into a cavity of the body to investigate and treat disorders.
Helicobacter pylori bacterium present in the stomach cavity of people with peptic ulcers.
The ulcers heal if the bacterium is eradicated.
Drugs that heal gastric and duodenal ulcers by reducing gastric acid output as a result
of histamine H2-receptor blockade; they are also used to relieve symptoms of gastrooesophageal reflux disease.
Proton Pump Inhibitor.
Policy effective from/
developed:
Reviewed policy endorsed by CCG Governing Body on 15 September 2015
Reviewed policy approved by SCPG on 29 July 2015
Reviewed policy approved by CPF on 3 July 2015
Policy adopted by CCG 1 April 2013
Effective from September 2015
Policy to be reviewed:
September 2017
Reference:
R:\CPF Pols & working Area\Surg Threshold Pols - Draft and Agreed\CCG Policies\Upper GI Endoscopy\Agreed\
DYSPEPSIA UGI THRSHLD - SEPT 2015 V6
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