NICE guidelines: Management of dyspepsia in adults in primary care Alistair King Consultant Gastroenterologist HHGH National 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 The NICE guidelines apply a broad definition of dyspepsia in unselected patients in primary care. This definition includes patients with persistent (4 weeks or longer) epigastric pain, heartburn or acid regurgitation, with or without bloating, nausea or vomiting. This broad definition has been adopted because many patients in primary care present with multiple and varying symptoms, and can often be managed without formal diagnosis. It is based on the definitions adopted by the 1998 Working Party1 and the BSG.2 References 1 Anonymous. Management of dyspepsia: report of a working party. Lancet 1988; 1: 576-9. 2British Society of Gastroentorology. Dyspepsia management guidelines. http://www.bsg.org.uk/clinical_prac/guidelines/dyspepsia.htm .

Prevalence of dyspepsia in primary care Dyspepsia occurs in 40% of the population annually1 5% consult their GP 1% are referred for endoscopy Dyspepsia, as defined by the BSG, is a common condition in primary care. It affects approximately 40% of the general population,1 of whom about 5% consult their GPs because of their symptoms, and 1% are referred for endoscopy. Among patients referred for endoscopy, the most common findings are gastroesophageal reflux disease (GORD), peptic ulcer disease, and non-ulcer dyspepsia. References 1 Penston JG, Pounder RE. A survey of dyspepsia in Great Britain. Aliment Pharmacol Ther 1996; 10: 83-9. 1Penston et al. 1996

Dyspepsia Cause Treatment GORD PPI, lifestyle Non-ulcer dyspepsia PPI, HP eradication ‘Gastritis’, ‘duodenitis’ GU Medications, PPI, HP eradication DU HP eradication, PPI, medications Upper 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 The NICE guidelines recommend that most patients with dyspepsia can be managed in primary care without referral for investigation. The principal reason for referral is the presence of alarm signs or symptoms, rather than age alone (see also slide 19). Alarm symptoms warranting referral for endoscopy are shown on this slide.

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] The NICE recommendations for the management of uninvestigated dyspepsia are based on a Cochrane review of randomized clinical trials.1 This review has shown that: initial empirical treatment with PPIs for 1 month is significantly more effective than antacids or H2 receptor antagonists (H2RAs) in controlling dyspeptic symptoms triple therapy with a PPI, clarithromycin and either metronidazole or amoxicillin is effective in eradicating H. pylori infection. If symptoms continue or recur after initial treatment, PPI treatment can be used at the lowest dose necessary to control symptoms. Patients should be encouraged to take their medication on an as needed basis to control their symptoms. Patients requiring long-term treatment should be offered an annual review of their condition. References 1Delaney BC, et al. Initial management strategies for dyspepsia (Cochrane review). In: The Cochrane Library, Issue 3, 2004. Chichester, UK: John Wiley and Sons, Ltd.

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 No re-scopes 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’ Roll out date??? Alistair King Andrew Chafer Phil Sawyer Peter Sweeney Kate MacKay Steve Laitner Roll out date???

Colonic cancer screening in high risk groups Alistair King Consultant 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 Colonoscopy perforation, bleeding, mortality rate= 0.3%, 0.3% and 0.014%

Polyp surveillance Hyperplastic/metaplastic polyps Adenomas 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?