HNY Policy and Pathway Repository - Humber

• The British Society of Gastroenterology (BSG) defines dyspepsia as a group of symptoms that alert doctors to consider disease of the upper GI tract, but is not itself a diagnosis. Symptoms, typically present for 4 weeks or more, include upper abdominal pain or discomfort, heartburn, gastric reflux, nausea or vomiting.
• Dyspepsia in primary care is defined broadly to include people with recurrent epigastric pain, heartburn or acid regurgitation, with or without bloating, nausea or vomiting.
• NICE guidelines refer to GORD as endoscopically determined oesophagitis or endoscopy negative reflux disease.
• Management of dyspepsia incurs significant costs to the NHS, due to increasing overall use of treatments. 
• This updated pathway, which replaces previous guidance for dyspepsia and the direct access endoscopy service, aims to provide effective and efficient primary and secondary care. It is for patients under 55 with dyspepsia and no alarm features (see flowchart), and is in accordance with national Guidelines for dyspepsia 
• This pathway does not cover patients who fulfil the criteria of 2WW referrals (NICE Guidelines NG 12), which should continue as per current practice.
• Specialist Gastroenterology support for referral advice, or to arrange endoscopy without specialist clinic assessment (where appropriate), is provided through Referral Assessment Service (RAS) - Gastroenterology Community Dyspepsia (+/- Endoscopy)
• The patient remains the responsibility of the primary care team throughout, unless specifically taken over by Gastroenterology
• Clear advice will be provided should further out-patient follow-up be necessary (with or without endoscopy), with primary care colleagues expected to arrange this via Choose and Book system as in current practice

No Red Flag Symptoms listed

Patients 55 and over without red flag symptoms:

• Patients meeting the criteria for suspected Upper GI malignancy should be referred via the 2WW referral system (NG 12).
• For others over 55, please use the existing clinic referral system on Choose and Book
  • Gastroenterology Advice & Guidance can be used for specific queries in non-2ww patients, e.g. about appropriateness of referral, or advice needed whilst awaiting planned investigations

Patients under 55 without red flag symptoms:

Primary Care/Community management:

• Community pharmacists should offer initial and ongoing help for people with symptoms of dyspepsia. This includes advice about lifestyle changes, over-the-counter medication, help with prescribed drugs and advice about when to consult a GP.
• Offer simple lifestyle advice, including advice on healthy eating, weight reduction and smoking cessation.
• Advise people to avoid known precipitants they associate with their dyspepsia where possible. These include smoking, alcohol, coffee, chocolate, fatty foods and being overweight. Raising the head of the bed and having a main meal well before going to bed may help some people.
• Provide people with access to educational materials to support the care they receive.
• Review medications for possible causes of dyspepsia (for example, calcium antagonists, nitrates, theophyllines, bisphosphonates, corticosteroids and non-steroidal anti-inflammatory drugs [NSAIDs]).
• In people needing referral, suspend NSAID use if possible. Paracetamol or COX-2 inhibitor could be considered instead.
• If people have had a previous endoscopy and do not have any new alarm signs, consider continuing management according to previous endoscopic findings.
• Further guidance on optimisation of pharmacological therapies can be found in the detailed NICE guideline (CG 184)
• Offer Helicobacter Pylori (H. Pylori) 'test and treat' to people with dyspepsia.
  • Leave a 2-week washout period after PPI use before testing for H pylori.
  • Re-testing for H. Pylori post eradication is not routinely indicated unless symptoms persist.
  • Re-testing for H. Pylori post eradication treatment should be done in patients with endoscopically confirmed peptic ulcer disease and H. Pylori.
  • If symptoms persist post first line eradication therapy, then treat with PPI for 4-8 weeks and then offer H. Pylori re-testing (following 2 week washout period)
  • If H. Pylori still positive, offer 2nd line eradication therapy
  • For H. Pylori negative patients with ongoing dyspepsia, offer empirical full-dose PPI therapy for 4 weeks.
• Think about the possibility of cardiac or biliary disease as part of the differential diagnosis.

When to refer to this service (see accompanying flowchart)

• Dyspepsia/GORD that is non-responsive to treatment.
• Patients with H. pylori who have not responded to second-line eradication therapy.
• Exclusion Criteria:
  • Dyspepsia with acute gastrointestinal bleeding (haematemesis or melaena) – admit (same day) to hospital
  • Anyone meeting criteria for 2WW referral (NG 12)
  • Suspected Intestinal obstruction
  • Those being referred to consider anti-reflux surgery (refer direct to Upper GI Surgery)
  • Over 55’s

What to expect after making a Community Dyspepsia (+/- Endoscopy) RAS referral (see accompanying flow chart)

• Gastroenterology will review the referral within agreed eRS time frames
• If agreed suitable for routine endoscopy (based on clinical history and current expected waiting times for procedure), Gastroenterology will accept the referral in RAS, and request the upper GI endoscopy on behalf of the GP. It will be booked and clearly marked as a community initiated referral
  • Any biopsies taken at the time of endoscopy will be requested under a dedicated Consultant Gastroenterologist, who oversees all community initiated referrals
  • Procedure reports will be sent to the referring GP, but also reviewed by the Gastroenterology consultant. Any action required for abnormal or unexpected findings, will be arranged by the Gastroenterology consultant, including arranging necessary follow-up
  • Correspondence regarding histology results should be expected to reach primary care within 1 month of the procedure. If communication has not been received from Gastroenterology regarding significant endoscopy findings and/or biopsy within 6 weeks, please contact us via RAS - Gastroenterology Community Dyspepsia (+/- Endoscopy).
• If endoscopy is not indicated, or it is felt that endoscopy alone would insufficient to manage a particular patient, Gastroenterology will reject the referral with advice to arrange out-patient referral via Choose and Book.

• Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management (NICE Guidelines CG184) https://www.nice.org.uk/guidance/cg184/resources/gastrooesophageal-reflux-disease-and-dyspepsia-in-adults-investigation-and-management-pdf-35109812699845
• Suspected cancer: recognition and referral. 2015 Jun. (NICE Guidelines NG12) https://www.nice.org.uk/guidance/ng12.
• Test and treat for Helicobacter pylori (HP) in dyspepsia Quick reference guide for primary care: For consultation and local adaptation: Public Health England https://www.gov.uk/government/publications/helicobacter-pylori-diagnosis-and-treatment