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NICE guidelines: Management of dyspepsia in adults in primary care. Alistair King Consultant Gastroenterologist HHGH. - PowerPoint PPT Presentation
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NICE guidelines:Management of dyspepsia in adults in primary care
Alistair KingConsultant Gastroenterologist
HHGHNational 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
Prevalence of dyspepsia in primary care Dyspepsia occurs in 40% of the
population annually1
5% consult their GP 1% are referred for endoscopy
1Penston et al. 1996
DyspepsiaCause TreatmentGORD PPI, lifestyleNon-ulcer dyspepsia PPI, HP eradication‘Gastritis’, ‘duodenitis’
PPI, HP eradication
GU Medications, PPI, HP eradicationDU HP eradication, PPI, medicationsUpper 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
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]
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
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’
Alistair King Andrew Chafer Phil Sawyer Peter Sweeney Kate MacKay Steve Laitner
Roll out date???
Colonic cancer screening in high risk groups
Alistair KingConsultant 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 55yrs: 213 colonoscopies to
prevent 1 death Colonoscopy perforation, bleeding,
mortality rate= 0.3%, 0.3% and 0.014%
Polyp surveillance Hyperplastic/metaplastic polyps
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?