1. SIGNIFICANT EVENT MEETING – 2 PATIENTS WITH CANCER – 2 PATIENTS WITH CANCER Dr Stephen Newell 8/10/04

2. DOUGLAS

3. Presentation & course of illness Age 76 Male Ex-smoker 14 units alcohol/week 6/03 heartburn 7/03 weight loss 7/03 2 week referral Missed initial apptmt 1/9/03 endoscopy showed oesophageal cancer Referred for consideration of surgery 11/03 adjuvant chemotherapy 26/11/03 seen for review – coping with diagnosis and treatment 12/03 intra-abdominal nodes found 12/03 oesophagectomy 8/12/03 discharged after surgery 17/1/04 further surgery for intrathoracic anastomotic leak 27/1/04 death from multiple organ failure

4. WEIGHT READINGS 20/4/9875 kg 02/7/0369 kg 20/7/0368 kg

5. PAMELA

6. Presentation & course of illness Age 71 Female Smoker Lifelong teetotaller 2/03 heartburn / wind upwards FH bowel cancer 2/03 FBC and abdo USS 2/03 anaemia found 31/3/03 referred for open access endoscopy 22/5/03 endoscopy showed carcinoma stomach 14/7/03 admitted for consideration of gastrectomy but tumour fixed to pancreas with peritoneal metastases and palliative gastrojejunostomy only done 19/7/03 discharged from hospital Went to stay with relative elsewhere and not seen again in the practice 27/9/03 admitted with abdo pain which settled 28/9/03 readmitted with bowel obstruction 3/10/03 death from carcinomatosis

7. HAEMOGLOBIN LEVELS 26/2/039.3 g/dl 18/3/039.2 g/dl 04/4/039.5 g/dl

8. NEW NICE GUIDELINES ON DYSPEPSIA 8/2004

9. NICE Clinical Guideline 17 NICE Clinical Guideline 17 August 2004 August 2004 Developed by the Newcastle Developed by the Newcastle Guideline Development and Guideline Development and Research Unit Research Unit Management of dyspepsia in Management of dyspepsia in adults in primary care adults in primary care www.nice.org.uk/CG017NICEguideline www.nice.org.uk/CG017NICEguideline

10. © Copyright National Institute for Clinical Excellence, August 2004. All rights reserved. This material may be freely reproduced for educational and not-for-profit purposes within the NHS. No reproduction by or for commercial organisations is allowed without the express written permission of the National Institute for Clinical Excellence. © Copyright National Institute for Clinical Excellence, August 2004. All rights reserved. This material may be freely reproduced for educational and not-for-profit purposes within the NHS. No reproduction by or for commercial organisations is allowed without the express written permission of the National Institute for Clinical Excellence.

11. This guidance is written in the following context: This guidance is written in the following context: It represents the view of the Institute, arrived at after careful consideration of the evidence available. Health professionals are expected to take it fully into account when exercising their clinical judgement. It represents the view of the Institute, arrived at after careful consideration of the evidence available. Health professionals are expected to take it fully into account when exercising their clinical judgement. However, it does not override the individual responsibility of health professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their guardian or carer. However, it does not override the individual responsibility of health professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their guardian or carer.

12. Key priorities for implementation Key priorities for implementation 1: Referral for endoscopy: 1: Referral for endoscopy: Review medications for possible causes of dyspepsia (e.g. calcium antagonists, nitrates, theophyllines, bisphosphonates, corticosteroids and NSAIDs). In patients requiring referral, suspend NSAID use. Review medications for possible causes of dyspepsia (e.g. calcium antagonists, nitrates, theophyllines, bisphosphonates, corticosteroids and NSAIDs). In patients requiring referral, suspend NSAID use. Urgent specialist referral for endoscopic investigation (within 2 weeks) is indicated for patients of any age with dyspepsia when presenting with any of the following: chronic gastrointestinal bleeding, progressive unintentional weight loss, progressive difficulty swallowing, persistent vomiting, iron deficiency anaemia, epigastric mass or suspicious barium meal. Urgent specialist referral for endoscopic investigation (within 2 weeks) is indicated for patients of any age with dyspepsia when presenting with any of the following: chronic gastrointestinal bleeding, progressive unintentional weight loss, progressive difficulty swallowing, persistent vomiting, iron deficiency anaemia, epigastric mass or suspicious barium meal. Routine endoscopic investigation of patients of any age, presenting with dyspepsia and without alarm signs, is not necessary. However, for patients over 55, consider endoscopy when symptoms persist despite H. pylori testing and acid suppression therapy, and when patients have one or more of the following: previous gastric ulcer or surgery, continuing need for NSAID treatment, or raised risk of gastric cancer or anxiety about cancer. Routine endoscopic investigation of patients of any age, presenting with dyspepsia and without alarm signs, is not necessary. However, for patients over 55, consider endoscopy when symptoms persist despite H. pylori testing and acid suppression therapy, and when patients have one or more of the following: previous gastric ulcer or surgery, continuing need for NSAID treatment, or raised risk of gastric cancer or anxiety about cancer.

13. 2: Interventions for uninvestigated dyspepsia 2: Interventions for uninvestigated dyspepsia Initial therapeutic strategies for dyspepsia are empirical treatment with a proton pump inhibitor (PPI) or testing for and treating H. pylori. There is currently insufficient evidence to guide which should be offered first. A 2-week washout period following PPI use is necessary before testing for H. pylori with a breath test or a stool antigen test. Initial therapeutic strategies for dyspepsia are empirical treatment with a proton pump inhibitor (PPI) or testing for and treating H. pylori. There is currently insufficient evidence to guide which should be offered first. A 2-week washout period following PPI use is necessary before testing for H. pylori with a breath test or a stool antigen test. 3: Interventions for gastro-oesophageal reflux disease (GORD) 3: Interventions for gastro-oesophageal reflux disease (GORD) Offer patients who have GORD a full-dose PPI for 1 or 2 months. Offer patients who have GORD a full-dose PPI for 1 or 2 months. If symptoms recur following initial treatment, offer a PPI at the lowest dose possible to control symptoms, with a limited number of repeat prescriptions. If symptoms recur following initial treatment, offer a PPI at the lowest dose possible to control symptoms, with a limited number of repeat prescriptions.

14. 4: Interventions for peptic ulcer disease 4: Interventions for peptic ulcer disease Offer H. pylori eradication therapy to H. pylori-positive patients who have peptic ulcer disease. Offer H. pylori eradication therapy to H. pylori-positive patients who have peptic ulcer disease. For patients using NSAIDs with diagnosed peptic ulcer, stop the use of NSAIDs where possible. Offer full-dose PPI or H2 receptor antagonist (H2RA) therapy for 2 months to these patients and, if H. pylori is present, subsequently offer eradication therapy. For patients using NSAIDs with diagnosed peptic ulcer, stop the use of NSAIDs where possible. Offer full-dose PPI or H2 receptor antagonist (H2RA) therapy for 2 months to these patients and, if H. pylori is present, subsequently offer eradication therapy. 5: Interventions for non-ulcer dyspepsia 5: Interventions for non-ulcer dyspepsia Management of endoscopically determined non-ulcer dyspepsia involves initial treatment for H. pylori if present, followed by symptomatic management and periodic monitoring. Management of endoscopically determined non-ulcer dyspepsia involves initial treatment for H. pylori if present, followed by symptomatic management and periodic monitoring. Re-testing after eradication should not be offered routinely, although the information it provides may be valued by individual patients. Re-testing after eradication should not be offered routinely, although the information it provides may be valued by individual patients.

15. 6: Reviewing patient care 6: Reviewing patient care Offer patients requiring long-term management of dyspepsia symptoms an annual review of their condition, encouraging them to try stepping down or stopping treatment. Offer patients requiring long-term management of dyspepsia symptoms an annual review of their condition, encouraging them to try stepping down or stopping treatment. A return to self-treatment with antacid and/or alginate therapy (either prescribed or purchased over-the-counter and taken as required) may be appropriate. A return to self-treatment with antacid and/or alginate therapy (either prescribed or purchased over-the-counter and taken as required) may be appropriate. 7: H. pylori testing and eradication 7: H. pylori testing and eradication H. pylori can be initially detected using either a Carbon-13 urea breath test or a stool antigen test, or laboratory-based serology where its performance has been locally validated. H. pylori can be initially detected using either a Carbon-13 urea breath test or a stool antigen test, or laboratory-based serology where its performance has been locally validated. Office-based serological tests for H. pylori cannot be recommended because of their inadequate performance. Office-based serological tests for H. pylori cannot be recommended because of their inadequate performance. For patients who test positive, provide a 7-day, twice-daily course of treatment consisting of a full-dose PPI with either metronidazole 400 mg and clarithromycin 250 mg or amoxicillin 1 g and clarithromycin 500 mg. For patients who test positive, provide a 7-day, twice-daily course of treatment consisting of a full-dose PPI with either metronidazole 400 mg and clarithromycin 250 mg or amoxicillin 1 g and clarithromycin 500 mg.

16. How do these comments relate to the patients discussed? Did they have any sinister features? Douglas - dyspepsia - age 76 - weight loss Pamela - dyspepsia - bowel disturbance - age 69 - iron deficiency anaemia

17. Translating NICE guidance into practice: Under 55, no endoscopy necessary unless alarm signs Over 55, consider endoscopy when: symptoms persist despite H. pylori testing and acid suppression therapy previous gastric ulcer or surgery continuing need for NSAID treatment raised risk of gastric cancer anxiety about cancer Urgent specialist referral for patients of any age with dyspepsia with any of the following: chronic gastrointestinal bleeding progressive unintentional weight loss progressive difficulty swallowing persistent vomiting iron deficiency anaemia epigastric mass suspicious Barium meal

18. What have I learned and what will I do in the future? Remember the alarm symptoms - GI bleeding; unintended weight loss – weigh everyone; dysphagia; persistent vomiting; iron deficiency anaemia – FBC on everyone; epigastric masses – examine everyone; (abnormal Ba meal – not likely to do this investigation) – urgent referral for all these patients Under 55, no endoscopy necessary unless alarm signs Over 55, think about referral when: symptoms persist despite empirical acid suppression therapy – H. pylori testing not easy to do previous gastric ulcer or surgery - PMH continuing need for NSAID treatment raised risk of gastric cancer – ask about FH, smoking anxiety about cancer - discuss with patient

19. Current 2 week urgent referral form for upper GI symptoms indicates urgent referral for: Jaundice Jaundice Palpable upper abdominal mass Palpable upper abdominal mass Dysphagia Dysphagia Dyspepsia (> 55) Dyspepsia (> 55) onset < 1 year ago continous symptoms since Dyspepsia (any age) with one or more of Dyspepsia (any age) with one or more of weight loss proven anaemia vomiting at least one high risk factor FH of upper GI cancer in more than 2 first degree relatives Barrett’s oesophagus pernicious anaemia previous ulcer surgery > 20 years ago known dysplasia, atrophic gastritis, intestinal metaplasia