Dyspepsia

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

Scope:

  • 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 Message:

Routine referrals for dyspepsia now mandate an H. Pylori test.

Referral Criteria

Routine Referrals

1. Primary Care treatment for dyspepsia has failed (see management section) – please provide details of:

a) treatments tried. Please state if a medication has been declined by the patient or they have a medical contraindication

AND

b) Negative H. Pylori result confirmed in letter (tested after appropriate washout period and performed within a year of the referral date)

2. Persistent H. Pylori infection that has not responded to second line eradication therapy (see management section for details on retesting)

Assessment

Signs and Symptoms

This pathway uses a broad, inclusive definition of dyspepsia of over 4 weeks duration of:

  • Upper abdominal pain or discomfort
  • Heartburn or Acid reflux
  • Nausea or Vomiting
  • Bloating or 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

Also consider Ca125 +/- ovarian USS in women over 35 presenting with a feeling of fullness.

Abdominal examination should be performed to check for any masses or gall bladder tenderness.

Red Flags

Patients with symptoms that may require urgent admission, e.g., upper GI bleeding, should be discussed with the on call medical team: Switchboard 01271 322577

  • Refer to the upper GI 2ww pathway for patients of any age with:
    • Dysphagia
    • Aged 55 and over with weight loss and any of the following:
      • Upper Abdominal Pain
      • Reflux
      • Dyspepsia
    • Upper abdominal mass consistent with stomach cancer
  • Urgent endoscopy should be considered in patients of any age presenting with any of the following alarm signs:
    • persistent vomiting
    • suspicious fluoroscopy (previously Barium) meal or swallow result
    • unexplained worsening dyspepsia with known:
      • Barrett’s oesophagus on previous OGD
      • Dysplasia on previous OGD
      • Atrophic gastritis on previous OGD
      • Intestinal metaplasia on previous OGD
      • Pepticulcer surgery over 20yrs ago

Primary care investigations are still appropriate in these patients, but if clinical concern warrants, referrals need not be delayed whilst waiting for test results e.g., H. Pylori.

Referral letters are still expected to state that an H. Pylori has been requested.

Investigations

  • Stool testing for H. pylori antigen

Before testing for Helicobacter pylori (H. pylori), a 2-week washout period following PPI use is necessary. Consider offering an H2RA, other than ranitidine, to control symptoms during this period.

H. Pylori is a mandated test prior to referral. Referrals may be returned if this information is not contained within the referral letter.

  • Blood tests (recommended minimum, but not mandated)
    • FBC +/- Ferritin, B12, Folate.
    • TTG and IgA for coeliac

Management

Lifestyle advice:

  • Avoid triggers i.e., smoking, alcohol, caffeine, chocolate, fatty / spicy foods, carbonated drinks
  • Weight loss if appropriate
  • Raising the head of the bed, not eating close to bedtime
  • Antacid / alginate therapy for immediate symptom relief

Review causative medications:

  • NSAIDS, calcium antagonists, nitrates, theophylline, bisphosphonates, steroids

Medication:

The pharmacological management is outlined on the Formulary sections:

Dyspepsia
Joint formulary - Chapter 1 - Dyspepsia

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

H Pylori Eradication Therapy
Joint formulary – Chapter 5 – Eradication therapy

Retesting for H pylori:

The majority of patients with functional dyspepsia (64%) will have persistent symptoms despite eradication, therefore routine retesting is not recommended.

Consider if:

  • Compliance poor
  • Initial test performed too soon (within 2 weeks of PPI, 4 weeks of any antibiotics)
  • Patients with associated peptic ulcer, MALT lymphoma, early gastric cancer (Gastric Intestinal Metaplasia, dysplasia, or cancer on biopsies)
  • Patients with severe persistent or recurrent symptoms

If retesting, wait at least 4 weeks, ideally 8 weeks, and use the H. pylori stool antigen test. Offer an H2RA, other than ranitidine, to control symptoms during this period.

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

Routine Referrals

1. Primary Care treatment for dyspepsia has failed (see management section) – please provide details of:

a) treatments tried. Please state if a medication has been declined by the patient or they have a medical contraindication

AND

b) Negative H. Pylori result confirmed in letter (tested after appropriate washout period and performed within a year of the referral date)

2. Persistent H. Pylori infection that has not responded to second line eradication therapy (see management section for details on retesting)

Urgent Referrals

Urgent endoscopy should be considered in patients of any age with any of the following alarm signs:

  • persistent vomiting
  • suspicious fluoroscopy (previously Barium) meal or swallow result
  • unexplained worsening dyspepsia with known:
    • Barrett’s oesophagus on previous OGD
    • Dysplasia on previous OGD
    • Atrophic gastritis on previous OGD
    • Intestinal metaplasia on previous OGD
    • Pepticulcer surgery over 20yrs ago

Primary care investigations are still appropriate in these patients, but if clinical concern warrants, referrals need not be delayed whilst waiting for test results e.g., H. Pylori.

Referral letters are still expected to state that an H. Pylori has been requested.

2ww Referrals

1. Refer to the upper GI 2ww pathway for patients of any age with:

  • Dysphagia
  • Aged 55 and over with weight loss and any of the following:
    • Upper Abdominal Pain
    • Reflux
    • Dyspepsia
  • Upper abdominal mass consistent with stomach cancer


2. Refer to Colorectal (lower GI) 2ww pathway for patients with unexplained iron deficiency anaemia that meet the criteria outlined

Urgent admissions

Patients with symptoms that may require urgent admission, e.g., upper GI bleeding, should be discussed with the on call medical team: Switchboard 01271 322577

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-Eastern-GI & Liver (Medicine & Surgery)-Devon CCG -15N

Referral to Endoscopy

Refer using e-Referral Service
Specialty: GI and Liver (Medicine and Surgery)
Clinic Type: Endoscopy
Service: DRSS-Eastern-GI & Liver (Medicine & 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

Date Updated: August 2021

Publication date: February 2016


Last updated: 23-08-2021

 

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