Dyspepsia Care Pathway

Review in progress

Disclaimer: The guidance contains helpful primary care information for management of referrals and up to date referral criteria. These guidelines are locality specific to best reflect local services. This guidance does not override or replace the individual responsibility of healthcare and social care professionals involved in the delivery of care to make informed professional judgements appropriate to the circumstances of the individual.

Scope

This guidance refers to:

  • Primary care assessment and management of dyspepsia in adults aged 18 years and over.
  • Managing patients presenting with dyspepsia in primary care and indications for referral for endoscopy and further specialist management

This guidance does not refer to:

  • Under 18s

Commissioning Statements:

  • Referrals for Diagnostic fibreoptic endoscopic examination of the colon, and diagnostic fibreoptic sigmoidoscope examination of the lower bowel with or without biopsy are subject to an eligibility criteria that must be met before a referral is made - please see Commissioning Statement for further information
  • For those patients who are not eligible for treatment under these policies consideration will be on an individual basis via the CCGs Prior Approval Process in accordance with NHS North Kirklees and NHS Wakefield CCG Commissioning Policy

Assessment

Assessment of new onset dyspepsia

Signs and Symptoms

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
  • Nausea
  • 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 e.g. non-steroidal anti-inflammatory drugs (NSAIDs)
  • Abdominal examination should be performed to check for any masses or gall bladder tenderness

Red Flags

Patients of any age presenting with the following red flags symptoms should be referred for an urgent endoscopy via the Upper GI 2ww Pathway

  • gastrointestinal bleeding
  • progressive weight loss (unintentional)
  • progressive difficulty swallowing
  • persistent vomiting
  • unexplained iron deficiency anaemia
  • patient aged 55 and over with weight loss and any of the following:
    • upper abdominal pain
    • reflux
    • dyspepsia
  • unexplained worsening of dyspepsia with any of the following risk factors:
    • Barrett's oesophagus
    • known dysplasia
    • atrophic gastritis
  • or intestinal metaplasia, peptic ulcers surgery more than 20 years ago

Investigations

Undertake the following to aid diagnosis, inform management or prior to referral:

  • Bloods – Generic gastroenterology blood tests (on ICE)
  • H.pylori stool antigen test. All acid suppression treatment (excluding simple antacids) should be stopped 2 week before testing.

Dyspepsia not requiring endoscopic investigation

  • Routine endoscopy is not indicated in patients under age 55 years if there are no 'red flag symptoms present

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

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 PPI
  • 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.
  • Review diagnosis and consider ultrasound scan
  • Likely Functional Dyspepsia-manage accordingly
  • Failed Therapy and persistent symptoms - refer to endoscopy as per referral guidelines

If H.pylori positive – See PHE Primary Care Summary Table for further information

  • If ulcer associated with NSAID use then full dose PPI for 4 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. Retest H.pylori after 4 weeks PPI and with 2 weeks without PPI prior to test; prescribe – 2nd line eradication.
  • If symptoms persist refer to endoscopy as per referral guidelines

Referral

Referral Criteria

  • Patients of any age presenting with red flags symptoms should be referred for an urgent endoscopy via the Upper GI 2ww Pathway
  • Failed therapy (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
  • Diagnostic fibreoptic endoscopic examination of the colon, and diagnostic fibreoptic sigmoidoscope examination of the lower bowel with or without biopsy are NOT routinely commissioned where patients are under 45 years of age

Referral Requirements

  • All referrals should be supported by a completed Upper GI Endoscopy Referral Form (also available on SystmOne & Emis) and may be returned if not
  • Documented evidence that the patient meets the commissioning statement criteria
  • For those patients who do not meet the commissioning statement eligibility criteria evidence of prior approval authorisation is required

Commissioning Statement

  • Referrals for Diagnostic fibreoptic endoscopic examination of the colon, and diagnostic fibreoptic sigmoidoscope examination of the lower bowel with or without biopsy are subject to an eligibility criteria that must be met before a referral is made - please see Commissioning Statement for further information
  • For those patients who are not eligible for treatment under these policies consideration will be on an individual basis via the CCGs Prior Approval Process in accordance with NHS North Kirklees and NHS Wakefield CCG Commissioning Policy

Referral Instructions

  • e-Consulation - is currently unavailable for this specialty
  • Referrals should be made via ICG to TRISH (if training has been undertaken) - See user guides (EMIS & S1) for further information.
  • For those Practices who have not received ICG training referrals should be made via eRS
  • Please identify speciality and clinic type
  • Referrals for endoscopy:
    • Wakefield Only - Referrals to Community providers (Living Care, Phoenix, The Grange) using ICG (if training has been undertaken and eRS for those practices who have not been trained
      • Specialty: GI Liver (Medicine and Surgery) and Diagnostic Endoscopy
      • Clinic Type: Upper GI inc Dyspepsia

Supporting Information

Shared Decision Making

  • Patients have a right to make decisions about their care and should be fully informed about the options they face. They should be provided with reliable evidence-based information on the likely benefits and harms of interventions or actions, including any uncertainties and risks, eliciting their preferences and supporting implementation.

Patient Information/Public Health/Self Care

Evidence/Additional Information

Assurance & Governance

  • This guidance was developed on: 03.2017
  • This guidance was ratified by: The OSCAR Assurance Group
  • Date ratified: 08.2017
  • Publication Date: 08.2017
  • Review Date: 03.2019
  • Ref No: GA1 - 03.2017
Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk
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