Guidelines for the Management of Dyspepsia and GORD Document type: Version: 3.0 Author (name): Author (designation): Validated by Prescribing Dr. G. Lipscomb Date validated October 2015 Ratified by: Date ratified: October 2015 Name of responsible committee/individual: Name of Executive Lead (for policies only) Master Document Controller: Consultant Gastroenterologist Gastroenterology/ Acute Adult Governance Drugs and Therapeutics Committee Dr. G. Lipscomb N/A Suzanne Schneider Date uploaded to intranet: October 2015 Key words Dyspepsia, GORD, Oesophagitis, Proton Pump Inhibitor, PPI, H. Pylori Review date: October 2018 Version control Version Type of Change Date Revisions from previous issues 3.0 Minor October 15 Previously joint with CCG, CCG have updated there guidance. Trust guidance updated, clinical content same as CCG guidance. Simplified and format changes Equality Impact Bolton NHS Foundation Trust strives to ensure equality of opportunity for all service users, local people and the workforce. As an employer and a provider of healthcare Bolton NHS FT aims to ensure that none are placed at a disadvantage as a result of its policies and procedures. This document has therefore been equality impact assessed to ensure fairness and consistency for all those covered by it regardless of their individuality. The results are shown in the Equality Impact Assessment (EIA). Page 1 of 5
Contents Purpose 2 Content 3-4 Monitoring 4 References 4 Equality Impact Assessment Tool 5 Purpose Guidelines to aid the safe management of and prescribing for patients with dyspepsia. Dyspepsia, also known as indigestion, is a feeling of fullness, heartburn and nausea caused by impaired digestion. Page 2 of 5
Guidelines for the Management of Dyspepsia and GORD NEW PRESENTATION Upper abdominal discomfort, epigastric pain or burning Heartburn; acid regurgitation Nausea or vomiting Bloating, belching, wind Early satiety and post-prandial fullness ASSESSMENT History and examination, in particular looking for red flag symptoms, abdominal masses, clinical signs suggestive of anaemia. Consider FBC. REVIEW MEDICATION That may be causing or exacerbating symptoms e.g. NSAIDs, aspirin, clopidogrel, nitrates, SSRIs, steroids, bisphosphonates, calcium-channel blockers, theophylline OFFER LIFESTYLE ADVICE To all patients diet, smoking, alcohol, weight, stress, caffeine, physical activity RED FLAG SYMPTOMS Refer for endoscopy/ gastroenterology opinion urgently for patients of any age with dyspepsia and: Chronic gastrointestinal bleeding (if evidence of acute bleeding, ADMIT) Iron deficiency anaemia Persistent vomiting Dysphagia Progressive unintentional weight loss Epigastric mass Age > 55 years with new onset, persistent, unexplained dyspepsia. GORD Predominant symptoms of heartburn, belching, acid regurgitation MANAGEMENT Prescribe antacids or alginates and continue PRN use if effective NON-GORD DYSPEPSIA TEST FOR H. PYLORI Stool antigen test Stop PPI/ H 2 antagonists 2 weeks before Refer Gastroenterology/ Upper GI for specialist H. PYLORI NEGATIVE And still symptomatic TRIAL OF TREATMENT 8 WEEKS Full dose PPI (e.g. omeprazole 20mg) or H 2 receptor antagonist H. PYLORI POSITIVE Triple therapy one week eg. omeprazole 20mg, clarithromycin 500mg & amoxicillin 1g all BD (or clarithromycin 250mg, metronidazole 400mg & omeprazole 20mg all BD if penicillin allergic) If still symptomatic If H.pylori persists Second line therapy See BNF If < 55 years Likely diagnosis is NON-ULCER/ FUNCTIONAL DYSPEPSIA Treat symptomatically e.g. Increasing acid suppression, prokinetics, dietary, alginates. PLEASE REMEMBER: If > 55 years Consider increasing PPI therapy Consider further investigations if still symptomatic If still symptomatic Consider referral for diagnostic endoscopy PPIs can cause hypomagnesaemia Treat patients on basis of previous endoscopy (if within 3-5 years) and if no new alarm symptoms Once Version symptoms 3.0 are controlled, Document continue on Management lowest effective of Dyspepsia dose and GORD of acid suppression on an intermittent basis Page 3 of 5 For Date doses October of omeprazole 15 Next above Review 20mg, Date prescribe October 18 as twice If patient develops C.difficile, stop all PPIs and H2 receptor antagonists.
Management of Dyspepsia Guidance Indication Drug and dose Duration Comments Grade 1-2 1 month Oesophagitis Omeprazole 10-20mg (diagnosed by Grade 3-4 4-8 weeks then step endoscopy) down to Grade 1-2 BD NSAID associated ulcers NSAID gastroprotection Peptic Ulcer Disease (PUD) -Duodenal Ulcer Omeprazole 20-40mg 4 weeks STOP any NSAID STOP when GI toxic drug stopped Review regularly, particularly if patient is taking NSAID when required For H.Pylori see overleaf. Check H.Pylori status with H.Pylori stool antigen test Treatment: OD or BD Maintenance: 1-2 months 1 month then STOP STOP any NSAID For H.Pylori see overleaf. Check Repeat endoscopy H.Pylori status with H.Pylori stool antigen after 6-8 weeks Gastric ulcer test. Maintenance: for 2 months In patients with GORD & non-ulcer dyspepsia higher doses of PPI may be required under the instruction of or prescribed by a Consultant Gastroenterologist or Upper GI Surgeon n-steroidal Anti-Inflammatory Drugs (NSAIDs): If NSAIDs must be used, prescribe the least GI toxic (e.g. ibuprofen) Consider cardiovascular risk Consider any renal impairment For patients at high risk of developing serious GI adverse effects, prescribe gastroprotection if an NSAID is deemed essential; review regularly, consider stopping gastroprotective agent if NSAID is discontinued Monitoring Any uncertainties regarding the management of dyspepsia and related medications should be discussed with the ward pharmacist or doctor. Prescription charts will be monitored on a basis by pharmacy staff. Any issues or incidents will be fed back to the relevant individuals and escalated as necessary. References: NICE: www.nice.org.uk CG17 Dyspepsia management of dyspepsia in adults in primary care Patient information leaflets: www.patient.co.uk Page 4 of 5
Equality Impact Assessment Tool To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval. 1. Does the document/guidance affect one group less or more favourably than another on the basis of: Yes/ Comments Race Ethnic origins (including gypsies and travellers) Nationality Gender (including gender reassignment) Culture Religion or belief Sexual orientation Age Disability - learning disabilities, physical disability, sensory impairment and mental health problems 2. Is there any evidence that some groups are affected differently? 3. If you have identified potential discrimination, are there any valid exceptions, legal and/or justifiable? 4. Is the impact of the document/guidance likely to be negative? 5. If so, can the impact be avoided? 6. What alternative is there to achieving the document/guidance without the impact? 7. Can we reduce the impact by taking different action? If you have identified a potential discriminatory impact of this procedural document, please refer it to the Equality and Diversity Co-ordinator together with any suggestions as to the action required to avoid/reduce this impact. Page 5 of 5