NICE guidelines:Management of dyspepsia in adults in primary care

Alistair KingConsultant Gastroenterologist

HHGHNational Institute for Clinical Excellence (2004). Dyspepsia. Management of dyspepsia in adults in primary care. NICE clinical guideline No. 17 London: National Institute for Clinical Excellence. Available from: www.nice.org.uk/CG017NICEguideline.

Definition of dyspepsia Recurrent epigastric pain,

heartburn or acid regurgitation, with or without bloating, nausea or vomiting

Prevalence of dyspepsia in primary care Dyspepsia occurs in 40% of the

population annually1

5% consult their GP 1% are referred for endoscopy

1Penston et al. 1996

DyspepsiaCause TreatmentGORD PPI, lifestyleNon-ulcer dyspepsia PPI, HP eradication‘Gastritis’, ‘duodenitis’

PPI, HP eradication

GU Medications, PPI, HP eradicationDU HP eradication, PPI, medicationsUpper GI cancer Needs Endoscopy!

Uninvestigated or investigated dyspepsia? Most patients with dyspepsia can be

managed without investigation Indication for referral is based on alarm

signs/symptoms: chronic gastrointestinal bleeding progressive unintentional weight loss progressive dysphagia persistent vomiting iron deficiency anaemia epigastric mass

A ‘NICE’ U turn?? Guidelines modified June 2005 in

line with NICE Referral Guidelines for suspected cancer

Recommend urgent 2/52 ‘scope’ in over 55s if: Unexplained Recent onset Persistent symptoms

Treatment for uninvestigated dyspepsia Initial empirical therapy

full–dose treatment for 1 month [Grade A recommendation]

H. pylori testing plus eradication therapy bd PPI for 7 days, plus either metronidazole plus

clarithromycin 250 mg (PMC250), or amoxicillin plus clarithromycin 500 mg (PAC500) [Grade A recommendation]

Persistent symptoms: step-down therapy: discuss on demand use

[Grade B recommendation]

HP testing Serology

Do not routinely re-test Serology remains positive after

eradication Re-check HP breath test (10 weeks

after Rx)

So what’s different? Most do not need OGD

Empiric PPI HP eradication Algorithms for stepping up & down Rx

No re-scopes Gone is age criteria (>45, >55yrs) Alarm symptoms are mainstay Gentle ‘refusal’ letter…….!

What’s being done PCT ‘committee’

Alistair King Andrew Chafer Phil Sawyer Peter Sweeney Kate MacKay Steve Laitner

Roll out date???

Colonic cancer screening in high risk groups

Alistair KingConsultant Gastroenterologist

BSG 2002

Family History One first degree relative diagnosed

<45yrs Two first degree relatives

diagnosed at any age Multiple generations affected

within family

NB Marginal benefit! (Grade B)

Screening protocol At presentation or aged 35-40yrs,

whichever is the later Repeat aged 55yrs

If polyps found polyp screening guidelines

Otherwise reassure

Risk

Age is a much stronger determinant! 70yrs with no FH: 4% risk in 10 years 40-60 with FH: 1.1% risk over 10 years

Other considerations 35-40yrs: 3618 colonoscopies to

prevent 1 death 55yrs: 213 colonoscopies to

prevent 1 death Colonoscopy perforation, bleeding,

mortality rate= 0.3%, 0.3% and 0.014%

Polyp surveillance Hyperplastic/metaplastic polyps

Predominantly small/rectal No malignant potential

Adenomas Malignant potential Number, size Average 10yrs cancer

Cut off age 75yrs

Conclusions FH – screening colonoscopy only

for those that fit the guidelines

Polyps Adenoma? Size? Number? Full colonoscopy? Age?