Leeds Dyspepsia Pathway

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1.  Background Information / Scope of Pathway

Quick info:
The pathway is applicable to patients aged 18 years and over.  It provides guidance on how to manage patients presenting with dyspepsia within primary care.

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2.  Information Resources for Patients and Carers

Quick info:
Non-ulcer (functional) dyspepsia (PDF) from Patient UK
Dyspepsia (indigestion)
(PDF) from Patient UK

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3. Development and Updates to this Pathway

Quick info:
The development of the Leeds Dyspepsia Pathway was overseen by the Clinical Values Steering Group.
It has been approved and signed off by Leeds North Clinical Commissioning Group, Leeds South and East Clinical Commissioning Group and Leeds West Clinical Commissioning Group.

Key Clinicians involved:
Dr Simon Everett
Consultant in Gastroenterology
Clinical Director for GI Medicine, Specialist and Tertiary Surgery
Leeds Teaching Hospitals Trust

Dr Mark Follows
GPwSI Gastroenterology
Planned Care Lead Hull Clinical Commissioning Group

Dr Alex Ford
Senior Lecturer and Honorary Consultant Gastroenterologist
Leeds
Gastroenterology Institute
St. Jame's University Hospital

Dr Chris Mills
GP Rawdon Surgery
Planned Care Lead
Leeds West Clinical Commissioning Group

Dr Bryan Power
GP Vesper Road Surgery
Shadow Clinical Director
Leeds West Clinical Commissioning Group

Dr Andrew Robinson
GP Garforth Medical Group Practice
Executive GP & Secondary Care Lead
Leeds South and East Clinical Commissioning Group

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4.  Referral Forms

Quick info:
GI 1 Upper GI Endoscopy Form
Upper GI Malignancies Referral Form

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5.  New Onset Dyspepsia

Quick info:
Dyspepsia is broadly defined as any symptom referable to the upper gastrointestinal tract, present for four weeks or more, including upper abdominal pain or discomfort, heartburn, acid reflux, nausea, or vomiting. [1]

When broadly defined, dyspepsia occurs in 40% of the general population at any one time, leads to GP consultation in 5% and referral for endoscopy in 1% of the population annually. [2]

In patients with signs or symptoms severe enough to merit endoscopy, more than 70% have functional or non-ulcer dyspepsia, 15%

have gastro-oesophageal reflux disease and 8% have some form of ulcer. [3]

Eradication of the bacterium Helicobacter pylori (H. pylori)is important in the management of peptic ulcer disease and functional dyspepsia. [2]

Gastric and oesophageal cancers are very rare, occurring in less than 1% of endoscopies performed for uncomplicated dyspepsia without alarm symptoms or signs. [3]

Dyspeptic symptoms are a poor predictor of significant disease. Only around 25% of patients with uncomplicated dyspepsia without alarm symptoms or signs have significant disease confirmed by endoscopy. In primary care, symptoms as reported by the patient are a poor predictor of underlying pathology. [2]

References:

[1] Lancet. 1988 Mar 12; 1(8585): 576-9.

[2] National Institute for Health and Clinical Excellence (NICE). Dyspepsia: management of dyspepsia in adults in primary care. Clinical guideline 17. London: NICE; 2004.

[3] Ford AC, Marwaha A, Lim A, Moayyedi P.  Clin Gastroenterol Hepatol. 2010 Oct; 8(10): 830-7.

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6.  Alarm Symptoms Persistant New Onset Symptoms in Age over 55

Quick info:

Immediate (same day) specialist referral is indicated for patients presenting with dyspepsia together with signs that suggest significant acute gastrointestinal bleeding (haematemesis or melaena). [1]

Urgent specialist referral for endoscopic investigation (seen within 2 weeks) is indicated for patients of any age with dyspepsia when presenting with any of the following: progressive unintentional weight loss, progressive difficulty swallowing, persistent vomiting, iron deficiency anaemia, epigastric mass or suspicious barium meal. [1]

Routine endoscopic investigation of patients of any age, presenting with uncomplicated dyspepsia without alarm symptoms or signs, is not necessary. However, in patients aged 55 years and older with unexplained and persistent recent onset dyspepsia alone, an urgent referral for endoscopy should be made. [1]

The possibility of cardiac or biliary disease should be considered as part of the differential diagnosis.

Reference:

[1] National Institute for Health and Clinical Excellence (NICE). Dyspepsia: management of dyspepsia in adults in primary care. Clinical guideline 17. London: NICE; 2004.

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9.  Medication Review / Life Style Advice

Quick info:

Dyspepsia (indigestion) (PDF) from Patient UK

Review medications for possible causes of dyspepsia, for example aspirin, clopidogrel, non-steroidal anti-inflammatory drugs

(NSAIDs), corticosteroids, bisphosphonates, selective serotonin reuptake inhibitors (SSRIs), digoxin, macrolide antibiotics and iron salts. Calcium antagonists, nitrates and theophyllines may reduce lower oesophageal sphincter pressure and pre dispose patient to gastro-oesophageal reflux disease (GORD).

In patients requiring referral suspend NSAID use. [1]

Offer simple lifestyle advice, including healthy eating, weight reduction and smoking cessation. [1] Available trials of lifestyle advice to reduce symptoms of dyspepsia are small and inconclusive.

Epidemiological studies show a weak link between obesity and GORD but no clear association between dyspepsia and lifestyle factors such as smoking, alcohol, coffee or diet. However, individual patients may be helped by lifestyle advice and there may be more general health benefits that make lifestyle advice important. [1]

Self-treatment with antacid and/or alginate therapy may continue to be appropriate for many patients, either prescribed or purchased over-the-counter and taken as required for immediate symptom relief, However, additional therapy becomes appropriate to manage symptoms that persistently affect patients' quality of life. [1]

Reference:

[1] National Institute for Health and Clinical Excellence (NICE). Dyspepsia: management of dyspepsia in adults in primary care. Clinical guideline 17. London: NICE; 2004.

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10. Refer on 2 Week Wait

Quick info:

Upper GI Malignancies Referral Form

In a recent prospective observational study the prevalence of gastric cancer was 4% in a cohort of patients referred urgently for alarm features. Referral for dysphagia or significant weight loss at any age plus age greater than 55 with alarm symptoms would have detected 99.8% of the cancers found in the cohort. These findings are supported by other retrospective studies. [1]

Retrospective studies have found that cancer is very rarely detected in patients under the age of 55 years without alarm symptoms, and, when found, the cancer is usually inoperable. [1]

In the UK, morbidity (non-trivial adverse events) and mortality rates for upper gastrointestinal endoscopy may be as high as 1 in 200 and 1 in 2000 respectively. [1]

Reference:

[1] National Institute for Health and Clinical Excellence (NICE). Dyspepsia: management of dyspepsia in adults in primary care. Clinical guideline 17. London: NICE; 2004.

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11. H.pylori Stool Antigen Test and Blood Tests

Quick info:
References:

[1] Leeds Health Pathways

[2] NICE Quick Reference Guide Dyspepsia Page 8 - 2004

All acid suppression treatment (excluding simple antacids) should be stopped 2 week before testing, Bismuth compounds and antibiotics should be stopped 4 weeks before testing. [1]

The sensitivity and specificity of the H. pylori stool antigen test are both around 95%. [1] Blood tests - to exclude iron deficiency anaemia and coeliac disease.

There is currently inadequate evidence to guide whether full dose 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. NICE

The Leeds dyspepsia pathway group decided to opt for test and treat first because the prevalence of H pylori in Leeds is high enough to make it cost effective. You may decide to prescribe full dose PPI for one month first (see attached NICE pathway) and this would still be considered appropriate care.

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12. H.pylori POSITIVE Prescribe Eradication Therapy

Quick info:
Do not use clarithromycin if used in the past year for any infection

Option 1
Full dose(Low cost)PPI (Lansoprazole 30mg or Omeprazole 20mg BD)
and Clarithromycin 500mg BD
and Amoxicillin 1g BD All for 7 days

Option 2 (without penicillin)
Full dose(Low cost)PPI (Lansoprazole 30mg or Omeprazole 20mg BD)
and Clarithromycin250mg BD
and Metronidazole 400mg BD All for 7 Days

Option 3
Full dose(Low cost) PPI (Lansoprazole 30mg or Omeprazole 20mg BD)
and Bismuth (De-noltab®) 120mg QDS
and Metronidazole 400mg TDS
and Oxytetracycline 500mg QDS
All for 7 Days

Eradication regime as suggested on Leeds Health Pathways PPI dose from BNF

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13. H.pylori NEGATIVE Prescribe 4 Weeks Full Dose PPI Therapy

Quick info:
Offer empirical full dose proton pump inhibitor (PPI) therapy (Lansoprazole 30mg OD in the morning before food, or Omeprazole 20mg OD or Pantoprazole 40mg OD) for four weeks to patients with dyspepsia. [1]

PPIs are more effective than antacids at reducing dyspeptic symptoms in trials of patients with uninvestigated dyspepsia. The average rate of response taking antacid was 37% and PPI therapy increased this to 55%: a number needed to treat for one additional responder of 6. [1]

PPIs are more effective than H2 receptor antagonists (H2RAs) at reducing dyspeptic symptoms in trials of patients with uninvestigated dyspepsia. The average response rate in H2RA groups was 36% and PPI increased this to 58%: a number needed to treat for one additional responder of 5. [1]

Early endoscopy has not been demonstrated to produce better patient outcomes than empirical treatment, and while providing some reassurance in the short-term, this beneficial effect soon ameliorates. [1]

Doses of medication came from the BNF

References:

[1] National Institute for Health and Clinical Excellence (NICE). Dyspepsia: management of dyspepsia in adults in primary care. Clinical guideline 17. London: NICE; 2004.

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17. Prescribe 4 Weeks Full Dose PPI Therapy

Quick info:

Offer empirical full dose proton pump inhibitor (PPI) therapy (Lansoprazole 30mg OD in the morning before food, or Omeprazole 20mg OD or Pantoprazole 40mg OD) for four weeks to patients with dyspepsia. [1]

PPIs are more effective than antacids at reducing dyspeptic symptoms in trials of patients with uninvestigated dyspepsia. The average rate of response taking antacid was 37% and PPI therapy increased this to 55%: a number needed to treat for one additional responder of 6. [1]

PPIs are more effective than H2 receptor antagonists (H2RAs) at reducing dyspeptic symptoms in trials of patients with uninvestigated dyspepsia. The average response rate in H2RA groups was 36% and PPI increased this to 58%: a number needed to treat for one additional responder of 5. [1]

Early endoscopy has not been demonstrated to produce better patient outcomes than empirical treatment. [1]

Doses of medication came from the BNF

References:

[1] National Institute for Health and Clinical Excellence (NICE). Dyspepsia: management of dyspepsia in adults in primary care. Clinical guideline 17. London: NICE; 2004.

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19. RESPONSE Low Dose Treatment as Required

Quick info:

Offer patients requiring long-term management of symptoms for dyspepsia an annual review of their condition, encouraging them to try stepping-down the dose of their medication or stopping treatment altogether, unless there is an underlying condition or co- medication requiring continuing treatment. [1]

Dyspepsia is a relapsing and remitting disorder, with symptoms recurring annually in about half of patients. [1]

Patients requiring long-term management of symptoms for dyspepsia should be encouraged to reduce their use of prescribed medication stepwise: by using the lowest effective dose, by trying ‘on demand' use when appropriate, and by returning to self treatment with antacid and/or alginate therapy. [1]

Reference:

[1] National Institute for Health and Clinical Excellence (NICE). Dyspepsia: management of dyspepsia in adults in primary care. Clinical guideline 17. London: NICE; 2004.

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20. Recheck H.pylori Stool Antigen

Quick info:
Re-test for H. pylori at least 4 weeks after treatment. [1]

All acid suppression treatment (excluding simple antacids) should be stopped 2 week before testing, Bismuth compounds and antibiotics should be stopped 4 weeks before testing. [1]

H. pylori is causally implicated in the pathogenesis of peptic ulcer, MALT lymphoma, and gastric cancer, and is classed as a human carcinogen by the World Health Organisation. For this reason, all patients whose symptoms persist and who remain H. pylori- positive on re-testing after eradication therapy should be offered endoscopy.

Reference:

[1] Leeds Health Pathways

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23. Direct Access OGD

Quick info:

GI 1 Upper GI Endoscopy Form

Some providers are not on choose and book so please use existing paper routes for these providers. Choose and Book

You can find some providers of direct access endoscopy under:

Speciality: Diagnostic Endoscopy

Clinic Type: Gastroscopy

or

Speciality: GI and Liver (Medicine and Surgery)

Clinic Type: Upper GI including Dyspepsia

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24. Review Diagnosis and Consider Abdominal Ultrasound Scan

Quick info:

Differential diagnoses and other conditions to consider in any patient presenting with unexplained upper gastrointestinal symptoms include gallstones, biliary dyskinesia, and coeliac disease, hence the need for bloods (including coeliac serology) and abdominal ultrasound in patients whose symptoms do not settle. However, the vast majority of these individuals will have functional dyspepsia.

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26. Likely Functional Dyspepsia Manage Accordingly

Quick info:

Non-ulcer (functional) dyspepsia (PDF) from Patient UK

Management of endoscopically-confirmed functional dyspepsia involves initial treatment for H. pylori if present, followed by symptomatic management and periodic monitoring.

  • The number needed to treat with H. pylori eradication therapy in functional dyspepsia to improve or cure one patient’s symptoms is 13.
  • Retesting after eradication should not be offered routinely, although the information it provides may be valued by individual patients.
  • The effect of repeated eradication therapy on H. pylori status or dyspepsia symptoms in functional dyspepsia is unknown. [1]
    If H. pylori has been excluded or treated and symptoms persist, offer either a low dose PPI (Lansoprazole 15mg OD in the morning before food or Omeprazole 10mg OD or Pantoprazole 20mg OD) or a H2 receptor antagonist (Ranitidine 150mg BD) for four weeks.
  • Full dose PPIs are no more effective than maintenance or low dose PPIs in the management of functional dyspepsia. [1]
    If PPIs or H2 receptor antagonists provide inadequate symptomatic relief, offer a trial of a prokinetic (Domperidone 10mg TDS before meals or Metoclopramide 10mg TDS) for four weeks. [1]
    If symptoms continue or recur following initial treatment, offer a PPI or H2 receptor antagonist to be taken at the lowest dose possible to control symptoms, with a limited number of repeat prescriptions. [1]
    Discuss using PPI treatment on an ‘on demand' basis with patients to manage their own symptoms.
  • Evidence is taken from patients with endoscopy negative reflux disease. Patients using PPI therapy as needed (waiting for symptoms to develop before taking treatment) reported similar ‘willingness to continue' to those on continuous PPI therapy.
  • Patients taking therapy as needed used about 0.4 tablets per day, averaged across studies of 6 to 12 months duration. Taking therapy when symptoms occur may help patients to tailor their treatment to their needs
    Long term, frequent dose continuous prescription of antacid therapy is inappropriate and only relieves symptoms in the short term rather than preventing them.
  • Antacid therapy is no more effective than placebo in reducing the symptoms of functional dyspepsia. [1]

Doses of medication came from the BNF References:

[1] National Institute for Health and Clinical Excellence (NICE). Dyspepsia: management of dyspepsia in adults in primary care. Clinical guideline 17. London: NICE; 2004.

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28. Direct Access OGD

Quick info:

GI 1 Upper GI Endoscopy Form

Some providers are not on choose and book so please use existing paper routes for these providers. Choose and Book

You can find some providers of direct access endoscopy under:

Speciality: Diagnostic Endoscopy

Clinic Type: Gastroscopy

or

Speciality: GI and Liver (Medicine and Surgery)

Clinic Type: Upper GI including Dyspepsia

Key Dates

Published: 15-Jan-2013, by Leeds
Valid until: 25-Feb-2016

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References

This is a list of all the references that have passed critical appraisal for use in the care map Gastroenterology - Dyspepsia

ID  Reference

1   National Institute for Health and Clinical Excellence. Dyspepsia: managing dyspepsia in adults in primary care. Clinical guideline 17. London: NICE; 2004. http://www.nice.org.uk/nicemedia/live/10950/29459/29459.pdf

2   Contributors representing the Royal College of Physicians. 2011.

3   Clinical Knowledge Summaries (CKS). Dyspepsia - proven non-ulcer. Version 1.2. Newcastle upon Tyne: CKS; 2009.

4   Scottish Intercollegiate Guidelines Network (SIGN). Dyspepsia. 68. Edinburgh: SIGN; 2007. http://www.sign.ac.uk/pdf/sign68.pdf

5   Health Protection Agency (HPA). Diagnosis of . Helicobacter pylori . (HP) in Dyspepsia Quick Reference Guide for Primary Care. Quick reference guide for primary care (for consultation and local adaption). London: HPA; 2008. http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1194947347671

6   Clinical Knowledge Summaries (CKS). Dyspepsia - proven gastro-oesophageal reflux disease. Version 1.0. Newcastle upon Tyne: CKS; 2009.

7   Drossman DA. The functional gastrointestinal disorders and the Rome III process. Gastroenterology 2006; 130: 1377-1390. http://www.ncbi.nlm.nih.gov/pubmed/16678553

8   McColl KE. Clinical practice. Helicobacter pylori infection. N Engl J Med 2010; 362: 1597-1604. http://www.ncbi.nlm.nih.gov/pubmed/20427808

9   Donnellan C, Sharma N, Preston C et al. Medical treatments for the maintenance therapy of reflux oesophagitis and endoscopic negative reflux disease. Cochrane Database Syst Rev 2005; CD003245. http://www.ncbi.nlm.nih.gov/pubmed/15846653

10 El-Serag H, Becher A, Jones R. Systematic review: persistent reflux symptoms on proton pump inhibitor therapy in primary care and community studies. Aliment Pharmacol Ther 2010; 32: 720-737. http://www.ncbi.nlm.nih.gov/pubmed/20662774

11 Raghunath AS, Hungin AP, Mason J et al. Symptoms in patients on long-term proton pump inhibitors: prevalence and predictors. Aliment Pharmacol Ther 2009; 29: 431-439. http://www.ncbi.nlm.nih.gov/pubmed/19035981

12 Mainie I, Tutuian R, Shay S et al. Acid and non-acid reflux in patients with persistent symptoms despite acid suppressive therapy: a multicentre study using combined ambulatory impedance-pH monitoring. Gut 2006; 55: 1398-1402. http://www.ncbi.nlm.nih.gov/pubmed/16556669

13 Zerbib F, Roman S, Ropert A et al. Esophageal pH-impedance monitoring and symptom analysis in GERD: a study in patients off and on therapy. Am J Gastroenterol 2006; 101: 1956-1963. http://www.ncbi.nlm.nih.gov/pubmed/16848801

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