Dyspepsia and Reflux

Overview

Local Guidelines for Primary Care

IhHealth (formerly Prime Endoscopy) have developed guidelines for the management of Dyspepsia and Gastro-oesophageal reflux disease (word doc) in primary care using BSG and NICE guidelines - (updated June 2022).

The Dyspepsia pathway should be used for patients with epigastric discomfort with or without symptoms of reflux.

The Reflux pathway should be used for patients with reflux symptoms alone (i.e. discomfort is retrosternal and may also present with other symptoms such as heart burn, acid brash, water brash, odynophagia (pain on swallowing)).

See the BNSSG Formulary for prescribing options. 

National Guidelines

Clinical Knowledge Summaries also has information on assessment and management of:

• Dyspepsia and Reflux - unidentified cause- covering management of patients with uninvestigated dyspepsia in primary care and when to refer.
• Dyspepsia and Reflux - proven GORD - covering management of adults with endoscopically  determined GORD

Other Remedy pages that may be relevant include:

• Eosinophilic Oesophagitis
• Barrett's Oesophagus
• Endoscopy

Red Flags

Red flags include:

• Upper abdominal mass

• Dysphagia

• Age 55 or over with weight loss and one or more of the following: upper abdominal pain, reflux, dyspepsia.

Please see Upper GI - USC (2WW) page for further information

Before Referral

Consider the appropriate reflux or dyspepsia pathway before referral. In the absence of red flags or alarm symptoms then most patients can be managed in primary care with lifestyle advice and medication, without the need for endoscopy.

Helicobacter Pylori (HP)

HP stool antigen testing* should be undertaken in patients with dyspepsia prior to starting treatment or if failure to respond to a 4 week course of PPI (1). However, if there are red flags or alarm symptoms then HP testing is not indicated and should not delay referral.

Almost all duodenal ulcers, and the majority of gastric ulcers are associated with HP and it is also an important risk factor for the future development of gastric carcinoma. Some patients with non-ulcer dyspepsia will also find that their symptoms improve after HP eradication.

Helicobacter pylori is not the cause of retrosternal reflux and this test is not usually required for patients with predominant symptoms of reflux, suggesting gastro-oesophageal reflux disease (GORD) (2).

*Stool antigen test — ensure the person has not taken a PPI in the past 2 weeks, or antibiotics in the past 4 weeks. Do not arrange for routine re-testing after treatment unless there are specific clinical circumstances. See Refractory or recurrent symptoms section in CKS for more information.

Recommended treatment regimens for Helicobacter Pylori eradication can be found on the BNSSG Formulary (section 1.4.2)

Blood tests

• FBC - may help to decide on appropriateness of urgency of referral. Anaemia and/or raised platelets are both alarm symptoms in patients >= 55 years old.
• U and E - is recommended but not essential.
• HbA1c - not essential but should be considered if the patient has diabetes or is at high risk of diabetes as patients with poorly controlled diabetes may be at risk of gastroparesis. In addition, patients aged 60 and over with new onset diabetes and weight loss should be investigated for suspected pancreatic cancer.

BMI and BP

Please include a recent BMI and BP reading to help to triage endoscopy referrals appropriately.

Referral

Endoscopy - direct access

Local specialists advise that endoscopy for dyspepsia and reflux is rarely indicated outside of red flag criteria as it does not change management. Please read NICE guidance on Dyspepsia and Reflux - unidentified cause

If referral for direct access endoscopy is indicated please see link to Endoscopy guidelines

Community Gastroenterology

A community gastroenterology service run by InHealth is also available via e-RS. New patients are booked at 30 minute intervals with a GPwER. The emphasis is on a one stop referral, either discharging to the GP with a management plan or proceeding to endoscopy if clinically indicated.

For information please refer to the PRIME service Guide 

Secondary Care

Secondary care Advice and Guidance or Referral to gastroenterology via e-RS can also be considered if the above options are not available or not appropriate.

Functional Dyspepsia

Functional dyspepsia (also known as non-ulcer dyspepsia) refers to people with dyspepsia symptoms and normal findings on endoscopy. Functional dyspepsia is the most common diagnosis arising from endoscopy for dyspepsia symptoms.

Management includes reassurance, lifestyle measures, management of aggravating factors. H Pylori eradication and trial of PPI can also be beneficial in some patients. A low dose of tricyclic anti-depressant such as amitriptyline, or an antispasmodic such as buscopan is also sometimes worth considering (these are off licence indications and not listed in the BNSSG formulary) .

Further advice can be obtained in Clinical Knowledge Summaries - Dyspepsia - proven functional.

For patients who have refractory symptoms, further advice can be obtained from the Gastroenterology Advice and Guidance service or a referral to the Community Gastroenterology Clinic (InHealth) via e-RS.

Achalasia

Achalasia is primarily a disorder of motility of the lower oesophageal or cardiac sphincter. The smooth muscle layer of the oesophagus has impaired peristalsis and failure of the sphincter to relax causes a functional stenosis or functional oesophageal stricture. Most cases have no known underlying cause but a small proportion occurs secondary to other conditions - eg, oesophageal cancer. See the article below for further details with regards presentation, investigation and treatment (3):

Achalasia (Causes, Symptoms, and Treatment) | Patient

Hiatus Hernia (under review)

Overview

The precise incidence of hiatus hernia is not known, as most studies have looked only at individuals who presented with symptoms of dyspepsia. However, it is estimated that 55-60% of over 50s have a hiatus hernia but that only 9% are symptomatic.

Over half of people with reflux oesophagitis diagnosed either endoscopically or radiologically are found to have a hiatus hernia.

The incidence increases with age and with obesity (4).

Management

Treatment is not needed in the absence of symptoms, other than in para-oesophageal hiatus hernias where the potential risks are greater and surgery may be considered even in the absence of symptoms. Management is otherwise is dependent on symptoms and includes lifestyle advice (e.g.weight loss, smoking, alcohol) and PPIs (4).

Surgery

Medical treatment is generally considered preferable to surgery. The patient.info webpage (4) has further details on indications for surgery.

Referral

Patients should initially be managed in primary care. Advice can be obtained from gastroenterology advice and guidance or referral to gastroenterology - both via eRS. If medical management is not effective or appropriate then consider referral to upper GI surgery via eRS.

IQoro Device

The iQoro device is available for treating hiatus hernia with oral, neuromuscular training and an exercise regime (5).

This device is not listed on the BNSSG formulary and the following position statement was published in the formulary newsletter in July 2022:

'IQoro device for hiatus hernia is non-formulary and not recommended by local specialists. It is not expected that this would be routinely prescribed by Primary Care in BNSSG.

There is a NICE Medtech innovation briefing (5) for its use in hiatus hernia which raises questions about evidence quality and quantity and states that the resource impact is greater than standard care.'

Resources

(1) Helicobacter Pylori in Dyspepsia: Test and Treat  - guidelines from Public Health England

(2) Bristol Helicobacter Project - RCT of effects of HP infection and its eradication on heartburn and GOR.

(3) Achalasia (Causes, Symptoms, and Treatment) | Patient

(4) Hiatus Hernia: Causes, Symptoms, and Treatment | Doctor

(5) IQoro for hiatus hernia | NICE

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.