Download Dyspepsia - Northumbria NHS Trust

Pre-referral checklists GASTROENTEROLOGY
DYSPEPSIA
Definition:
Dyspepsia refers to persistent or recurrent abdominal discomfort / pain located in the upper
abdomen i.e. below the diaphragm present for at least 4 weeks
General points
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Routine endoscopy (and hence secondary care referral) is not indicated for
dyspepsia without alarm symptoms or risk factors for cancer
The incidence of upper GI cancer in those under 55y without alarm features is 1 per
million population per year
The majority of cases of dyspepsia can be treated in primary care
Are there any RED FLAGS? = consider 2 week wait referral
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Weight loss (unintentional)
Iron deficiency anaemia
Vomiting - persistent
Dysphagia
Epigastric mass
Patients aged 55 years and over with unexplained, persistent and recent
onset dyspepsia
Patients 55 and over with WEIGHT LOSS AND
o Upper abdominal pain
o Reflux
o dyspepsia
Have medications been reviewed? eg
o
o
o
o
o
o
o
o
NSAIDs
Aspirin
SSRIs
corticosteroids
Calcium antagonists
Nitrates
Theophylline
Bisphosphonates should be stopped immediately
Has lifestyle advice been given?
o
o
y/n
Weight optimisation / exercise / minimise alcohol / stop smoking / certain
foodstuffs as a trigger / over the counter alginate or ranitidine therapy
Patient education and reassurance
Have other diagnostic possibilities been considered?
o
o
y/n
y/n
USS if history suggests pancreatic or biliary abnormality
Consider whether symptoms might be cardiac ischaemia
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Have Investigations been performed?


y/n
FBC, LFT ,HP stool
USS if history suggests pancreatic or biliary abnormality
y/n
Medications:

Test and treat for H Pylori or

4week trial full dose PPI (30 minutes before food)
H Pylori eradication therapy
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In functional dyspepsia – is only effective in a minority (8%) of patients benefit
Triple therapy attains >85% eradication
Do not use clarithromycin or metronidazole if used in the past year for any
infection.
1st line: twice daily omeprazole PLUS amoxicillin PLUS clarithromycin or
metronidazole. All for 7 days
If penicillin allergic: twice daily omeprazole PLUS clarithromycinPLUS
metronidazole. All for 7 days
If penicillin allergic and clarithromycin exposure in the last year: twice daily
omeprazole PLUS bismuth PLUS metronidazole PLUS tetracycline. All for 7
days
Only if still symptomatic- re-test for helicobacter with a breath test – see BNF here.
This test should not be performed within 4 weeks of treatment with an antibacterial or
within 2 weeks of treatment with a PPI
If breath test positive then re-treat – discuss with microbiologist

Persistent symptoms: treat as FUNCTIONAL DYSPEPSIA see appendix 2
references
http://www.nice.org.uk/guidance/NG12/chapter/1recommendations#lower-gastrointestinal-tract-cancers
y/n
CONSIDER ROUTINE REFERRAL if no RED FLAGS:

Primary care treatment fails

H Pylori has not responded to second line therapy

2ww features
·
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
APPENDIX 1
Prescribing notes:
 NB – DOMPERIDONE has a safety warning from the MHRA issued in April
2014. The only indication now is for relief of nausea and vomiting and for a week
maximum and at a dose not exceeding 30mg per day. This is because of
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concerns of cardiac side effects. It is contraindicated in those with a cardiac
history.

Possible risks of long term PPI use:
·
Epidemiological evidence of modest increase in fracture predominantly in
the elderly (consider other risks for osteoporosis and treat accordingly)
[3]
·
Controversial observational evidence of increased risk of c-difficile
diarrhoea and pneumonia
APPENDIX 2

Functional dyspepsia:
o
o
o
patient education that
o the condition is poorly understood
o some treatments help some people – use a trial and error
approach
o the aetiology is multifactorial and a complex interaction between
upper GI motility and the brain-gut nervous system including gut
hypersensitivity, hyperacidity and CNS processing dysfunction
o it is often not cureable and runs a fluctuating course which may
be worse under times of stress
dietary manipulation: try excluding the following:
o dairy products
o wheat containing foodstuffs
o spicy and acidic foods
o citrus fruits
o resistant starch
antacid medication
o Step up / step down approach
 Step 0- lifestyle advice as described above +/- over the
counter treatments (alginates / ranitidine)
 Step 1– maintenance PPI using lowest dose which
controls symptoms or use when required
 Step 2- maximise PPI dose or try different PPI
 Step 3 - add ranitidine (max 300mg per day) +/- alginates
o antispasm drugs e.g buscopan / colpermin
Thanks to Dr Les Ashton, November 2015
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