This is an updated guideline from Nice on dyspepsia and GORD. It updates the guideline from 2004 and I must say I found it quite non-specific and a little confusing about certain aspects, e.g. when endoscopy is needed, so this is my interpretation of what it is saying.
Really, the overall advice is the same as before - check for red flags, test or treat (i.e. just treat, or do H Pylori testing, whichever is preferred first), step-down treatment to the lowest possible dose and only refer for endoscopy if people don't respond to treatment.
I'll summarise some of the things I found a bit different, or wasn't maybe doing as this guideline suggests, but otherwise I think that the changes really are minimal.
- Check for GI bleeding
- Check for red flags
- Check for aggravants (including medications, which include calcium channel blockers, nitrates, theophylline, bisphosphonates, steroids and NSAIDs).
Who needs referring for endoscopy or other investigation or specialist review?
- People non-responsive to treatment (they don't specify how long this should be, though by the time you've tried a PPI for the suggested 1/12, tested for H Pylori and then tried an H2RA (H2 receptor antagonist - eg ranitidine) for 1/12, you're probably 3/12 down the road).
- People with 'unexplained symptoms' (it isn't clear what they mean by this, but I guess it means if you're not sure if it is dyspepsia or not).
NB - they say than in GORD 'don't routinely offer endoscopy to diagnose Barrett's oesophagus', though that it can be 'considered'. They suggest considering the risk factors for Barrett's (eg long duration of symptoms, increased frequency of symptoms, previous oesophagitis or hiatus hernia or oesophageal stricture or ulcer and also in male patients).
How should you manage uninvestigated dyspepsia, uninvestigated GORD or 'functional dyspepsia'?
Functional dyspepsia is where endoscopy has been done, but no abnormality has been found.
- Test-or-treat (the main guideline lists treating first, the pathway puts testing for H Pylori first - so take your pick!).
- Offer full dose PPI for 4/52 (20mg omeprazole, 20mg esomeprazole, 30mg lansoprazole or 40mg pantoprazole).
- If symptoms recur, then step down to the lowest possible dose, or 'as-needed' dosing, or even back to self-management with OTC meds.
- Annual review thereafter.
- Offer H2RA if PPI is ineffective.
- They do advise that patients can be referred for laparoscopic fundoplication if they prefer not to take long term medications, or if they can't tolerate them. CBT is also suggested as a possible aid to management in some patients.
How should you manage endoscopically proven GORD?
- There is specific advice on this on this in the guideline, but we are normally advised on what to do in the endoscopy report, so I'm not going to go into it.
- It is worth noting that in 'severe oesophagitis', higher PPI doses should be used (eg 40mg omeprazole, 40mg esomeprazole, 30mg lansoprazole or 40mg pantoprazole). If they don't respond, you can either try a different PPI, or switch to the above doses, but BD (eg 40mg omeprazole BD).
- PPI should then be used long-term.
If the oesophagitis isn't felt to be 'severe', then H2RA can be tried as an alternative.
What if there is an oesophageal stricture?
Use long term PPI
What should we do if an ulcer is found on endoscopy?
Again we'll normally be given advice on this and re-scoping may be done at 6-8/52, depending on 'the size of the lesion'.
- NSAIDs being used by patient. PPI or H2RA needs to be given for 8/52. The NSAID should be stopped or cut down as much as possible. COX2 selective NSAID can be considered.
- NSAIDS not being used. PPI or H2RA for 4-8/52
- If symptoms recur on stopping the above, use the lowest dose possible to control symptoms.