HNY Policy and Pathway Repository - Humber

This pathway enables GPs to directly request an urgent upper GI gastroscopy for adult patients (aged 18 and over) with persistent upper gastrointestinal symptoms where:

• Malignancy is not suspected, and
• Symptoms have not improved despite appropriate first‑line management.

This pathway supports timely diagnostic investigation without the need for prior outpatient review.

It is suitable for patients presenting with:

• Dyspepsia
• Reflux symptoms
• Persistent nausea and/or vomiting

Do not use this pathway if red flag symptoms are present.

Patients with suspected serious pathology should be referred via the appropriate urgent pathways:

• Suspected upper GI cancer → USC pathway
• Acute GI bleeding (haematemesis or melaena) → emergency admission

Initial management in primary care (before referral) is in line with NICE Guidance (CG184) Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management. A NICE Clinical Knowledge Summary (CKS) advice on Dyspepsia – Unidentified Cause prior to referral is also available.

Assessment of a person with unexplained dyspepsia should include:

Asking about any alarm symptoms that may suggest a complication or serious underlying pathology.

• Asking about lifestyle factors and associated stress, anxiety, or depression.
• Reviewing the person's medication, including drugs that can cause or exacerbate dyspepsia, such as nonsteroidal anti-inflammatory drugs (NSAIDs).
• Considering differential diagnoses that can present with symptoms similar to dyspepsia.
• Considering arranging a full blood count, to check for anaemia and/or a raised platelet count, which may suggest underlying malignancy.

Initial management of a person with unexplained dyspepsia should include:

• Offering advice on lifestyle modification.
• Managing any associated stress, anxiety, or depression.
• Reducing or stopping any drugs that may cause or exacerbate dyspepsia, if possible and appropriate.

Patients should undergo appropriate first-line management including:

• Proton pump inhibitor (PPI) trial (minimum 3 months)
• H. pylori testing with eradication if positive.
• Consideration of H2 receptor antagonists, where appropriate

Referral should only be considered where:

• Symptoms persist despite treatment, and
• There are no red flag features.

Clinical Responsibility and Follow-up

• The GP retains clinical responsibility for the patient while awaiting investigation and results.
• This pathway provides diagnostic investigation only and is not a consultant-led service.

After gastroscopy

• Endoscopy reports (EDS) are returned to the GP within 24 hours.
• Histology results are typically available:
  • Within 14 days if findings are suspicious
  • Within 28 days if no concerning features are identified

Ongoing management

If no significant pathology is identified, the GP is responsible for:

• Reviewing results
• Ongoing management and treatment
• Follow-up and symptom monitoring

If significant/Sinister findings are identified

• The endoscopist will:
  • Refer directly to the Upper GI MDT
  • Involve the Upper GI CNS
• Transfer of care occurs only following MDT decision.

DO NOT REFER

Do not use this pathway for patients with:

• Alarm symptoms or suspected malignancy (use USC UDI pathway)
• Acute gastrointestinal bleeding (requires emergency admission)
• Age under 18
• Pregnancy
• Warfarin anticoagulation or prosthetic heart valve

Referral Criteria

How to refer

• Refer via eRS using Upper GI Gastroscopy (Direct Access) and choosing either DPOW or SGH under Northern Lincolnshire and Goole Hospitals NHS Foundation Trust (RJL)

Referral requirements

• Ensure all patient details (name, address, contact telephone, D.O.B and NHS number) are included.
• Ensure all relevant clinical information is included, particularly:
  • Medication history
  • Safety screening information

 Incomplete or inappropriate referrals may be rejected following clinical vetting

National Institute for Health and Care Excellence (NICE) - Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management. Clinical guideline (CG184) October 2019  Introduction | Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management | Guidance | NICE

National Institute for Health and Care Excellence (NICE) - Dyspepsia and gastro-oesophageal reflux disease in adults Quality Standard (QS96) – published date July 2015. Overview | Dyspepsia and gastro‑oesophageal reflux disease in adults | Quality standards | NICE

National Institute for Health and Care Excellence (NICE) Clinical Knowledge Summaries (CKS) - Dyspepsia - unidentified cause – last reviewed May 2024. https://cks.nice.org.uk/topics/dyspepsia-unidentified-cause/

• Northern Lincolnshire & Goole