Dyspepsia/GORD
NHS Tayside RefGuide
Warning
Primary care management
In the absence of alarm symptoms:
- Consider lifestyle measures.
- Achieve and maintain healthy weight, avoid food triggers, avoid smoking.
- Test and treat Helicobacter pylori if symptoms mainly dyspepsia.
- Check H pylori stool antigen and treat if positive.
- Stop PPI for at least 2 weeks prior to test.
- See formulary for H. pylori treatment regimes (scroll to bottom of link)
- Treat with full dose PPI as per Tayside formulary choices for 4 weeks, if H pylori negative or symptoms are mainly of GORD.
- If symptoms recur offer ongoing PPI therapy but step down treatment to lowest effective dose.
- Discuss use of "as required" treatment to encourage self- management of symptoms.
- Offer annual review to assess symptom control and reduce or withdraw treatment if possible.
Who to refer
Refer for upper GI endoscopy as URGENT SUSPECTED CANCER if any of following apply:
- Dysphagia (interference of the swallowing mechanism that occurs within five seconds of the swallowing process) or unexplained odynophagia (pain on swallowing) at any age.
- Unexplained weight loss, particularly >55 years, combined with one or more of the following features:
- new or worsening upper abdominal pain or discomfort
- unexplained iron deficiency anaemia
- reflux symptoms
- dyspepsia resistant to treatment
- vomiting.
- New vomiting persisting for more than two weeks.
Consider routine referral for upper GI endoscopy if any of the following apply:
- New upper gastrointestinal pain or discomfort combined with any of the following risk factors:
- family history of oesophago-gastric cancer in a first-degree relative
- Barrett’s oesophagus
- pernicious anaemia
- previous gastric surgery
- achalasia (dysfunction of the oesophageal muscle)
- known dysplasia, atrophic gastritis or intestinal metaplasia.
Consider advice referral Gastroenterology, depending on clinical judgement, if there are refractory or recurrent symptoms despite optimal primary care management.
Who not to refer
Before considering referral for endoscopy
- Consider the age of the patient
- Serious pathology is rare in those <55 years with no alarm symptoms.
- Undertake medication review to look for drugs which make cause or exacerbate symptoms
- NSAIDs
- Corticosteroids
- Calcium channel antagonists
- Nitrates
- Theophyllines
- Bisphosphonates.
- Consider other diagnoses
- Gallstone or biliary disease (especially if severe, episodic pain)
- Cardiac disease.
- In those who have had a previous endoscopy but no new alarm symptoms, consider treatment in line with the results of that previous endoscopy
- Normal endoscopy & USS- treat as functional dyspepsia
- Previous oesophagitis - treat as GORD.
How to refer
'SCI Gateway/ Upper Endoscopy (Direct Access)' or 'SCI Gateway/ Gastroenterology' for advice/opinion.
Information to please include in referral:
- Detailed clinical history to characterise symptoms is important.
- Presence or absence of alarm symptoms.
- Dysphagia- level of dysphagia, solids and/or liquids, intermittent or constant, progressive.
- Weight loss – amount of weight loss and time scale.
- Anaemia – Hb, MCV and results of iron studies/ ferritin.
- Results of previous upper GI endoscopies.
Useful resources
Scottish referral guidelines for suspected cancer
NICE- Dyspepsia and gastro-oesophageal disease
Tayside area formulary
NHS Tayside Endoscopy page
NHS Inform Gastro-oesophageal reflux disease
NHS Inform Indigestion
NHS Website Endoscopy