NICE are updating their cancer referral guidelines (due May
2015) which will provide further guidance on referral pathways. In the
meantime, any clinical suspicion of cancer ‘red flags’ obviously warrants
urgent referral. There are some significant changes, including a more active
approach to test and treat for HP, lowering threshold for endoscopy in GORD, cutting back on long-term full dose PPIs and
lowering the threshold for consideration of surgical referral in persistent
GORD.
Common elements of care
·
Diagnosis
o
Consider cardiac or biliary disease in the
differential diagnosis
o
If people have had a previous OGD and have no
new alarm signs, manage according to previous endoscopic findings
·
Appropriate lifestyle
advice, including avoidance of known precipitants
o
Smoking, alcohol, caffeine, chocolate, fatty
foods and being overweight
·
Review medications
for possible causes, including
o
CCBs, nitrates, bisphosphonates, NSAIDs
(including OTC) and steroids
·
Encourage people using medication long-term to reduce stepwise
o
Lowest dose, intermittent use and returning to
self treatment with antacid therapy as needed
Who should we refer?
·
If present with dyspepsia and significant GI
bleeding, refer immediately (as if we wouldn’t!)
·
Consider endoscopy if the person has GORD (to
diagnose Barrett’s) based on patient preference and risk factors (e.g. long
duration of symptoms, increased frequency of symptoms, previous oesophogitis
ort hiatus hernia, male gender)
·
At any age with symptoms which are non-explained
or unresponsive to treatment
·
With suspected GORD and considering surgery
·
With HP that has not responded to second-line
therapy
How should we manage uninvestigated & functional dyspepsia?
·
Offer empirical full-dose PPI for 4 weeks
·
Offer HP ‘test and treat’
o
HP Testing
§
Leave a 2 week washout after PPI therapy
§
Use a breath or stool antigen test
§
Consider re-testing with a breath test if
symptoms persist and offering second-line eradication (see below on
eradication)
·
If symptoms recurrent, use lowest possible doses
on as needed basis to control symptoms
·
Offer an annual review and encourage them to
step-down meds or return to self-treatment with antacids
How should we manage reflux symptoms?
·
Manage uninvestigated reflux symptoms as for uninvestigated
dyspepsia
·
If GORD is confirmed on OGD, offer a full dose PPI
(Omeprazole 40mg or equivalent) for 8 weeks to heal severe oesophogitis
o
If initial treatment fails, consider a high ‘double’
dose PPI (Omeprazole 40mg bd or equivalent), or switch to another full dose PPI
·
Offer a full dose PPI for maintenance long-term
if severe oesophogitis
How should we eradicate HP?
·
Offer a 7 day twice daily course of
o
PPI + amoxicillin + clarithromycin or metronidazole
o
If penicillin allergic: PPI + clarithromycin + metronidazole
§
If pen allergic people have had previous
exposure to clarithromycin, offer PPI + bismuth + metronidazole + tetracycline
o
If symptoms persist after first-line therapy,
offer a second course of therapy with different components (see full guideline)
o
Refer if symptoms persist after second-line
eradication
For further information, please see the full guideline at NICE
2014 Guideline
