Managing Dyspepsia & GORD in 2015 Dr Alan Desmond Consultant Gastroenterologist UGI MDT Lead Mount Stuart & Torbay Hospital alan.desmond@nhs.net

NAEDI Campaign runs January 22nd to February 22nd

Impact of this campaign? 52% increase in UGI 2WW referrals to UGI Locally this would be 35 – 45 extra per month More cancers diagnosed in the 2WW pathway (shifted from urgent & routine pathway) Campaign doesn’t mention age range, but is aimed at over 50’s Local practices will see more patients with dyspepsia/reflux without red flags In 2014 we diagnosed 81 OGC, 37 via 2WW 97.3% of OGDs = not cancer Locally “urgent” waiting is 3-4 weeks Locally “routine” 5-6 weeks NAEDI Campaign runs January 22 to February 22nd

Your dyspepsia/reflux tool kit Lifestyle and dietary advice Free (NHS Choices) Stopping offending medications Free or low cost OTC medications/remedies Low cost Omeprazole 20mg – 40mg daily £1.15 - £2.30 per month H pylori stool test £20 Gastroscopy £375 Abdominal ultrasound £44-56

NICE Guidance 2014: Management of Dyspepsia and GORD Treating the un-investigated patient Deciding to refer to UGI Cancer 2WW pathway Deciding to refer for a specialist opinion

1. Treating the un-investigated patient Dyspepsia is a range of symptoms Affects 25% of the population Typically present for four weeks or more Upper abdominal pain or discomfort Heartburn and reflux Nausea and vomiting “symptoms that suggest UGI pathology” Dyspepsia with heartburn and reflux is suggestive of GORD Think about biliary and cardiac causes of pain

1. Treating the un-investigated patient Diet & Lifestyle Healthy eating, weight reduction, smoking cessation Avoid known precipitants (smoking, alcohol, chocolate, fatty foods, being overweight. Go to bed on an empty stomach, raise the head of the bed etc. Use prescribed medications in a step-wise way, use it, then reduce it, use as needed, return to OTC remedies if possible “Indigestion”

1. Treating the un-investigated patient Culprit meds Drugs that cause LOS relaxation Antidepressants: amitryptyline, dosulopin Anticholinergics: prochlorperazine, promethiazine, solifenacin Asthma medications: beta-agonists Sedatives: diazepam, temazepam Drugs that promote GI erosions: Bisphosphonates Potassium & iron tablets Doxycycline, tetracyclines Quinidine NSAIDs Aspirin & clopidogrel SSRIs Corticosteroids

1. Treating the un-investigated patient Culprit meds Drugs that reduce gastric emptying: BP medications: calcium channel blockers, beta blockers Narcotics: morphone, oxycodone etc Focus on recently introduced medications.. Is there an explanation? If so, stop the culprit!

1. Treating the un-investigated patient Self-management with OTC meds

1. Treating the un-investigated patient Managing with prescription meds South & West Devon Formulary updated December 2014 Acid-related dyspepsia: Omeprazole 20mg once daily (before breakfast) Good response: Return to as needed use or OTC Poor response: Use the lowest dose of PPI needed to control symptoms Double dose is omeprazole 40mg once daily for dyspepsia Double dose is omeprazole 40mg twice daily for severe oesophagitis Consider rantidine 150mg daily (I advise PRN use) If previously investigated, consider managing as per previous findings

1. Treating the un-investigated patient Using the H pylori faecal antigen test Faecal antigen test, costs about £20 Need to stop PPIs for 2 weeks prior to sample submission Sensitivity 94% Specificity 97% Useful for patients with acid related dyspepsia/duodenitis type symptoms and no “red flags” Eradication requires 7 days of antibiotics + PPI Once eradicated, faecal antigen becomes negative within 7 days

Paragraph on eradiation failure below this table

2. Deciding to refer to UGI 2WW pathway Receive approximately 900 UGI 2WW referrals Diagnosis of UGI cancer each year 75 oesophago-gastro-duodenal 75 hepato-pancreato-biliary Nationally about 20% of UGI malignancies diagnosed via 2WW In the SW, conversion rate for all 2WW is 12% But >90% of 2WW UGI Cancer referrals do not result in an UGI Cancer diagnosis About 70% leave with a benign diagnosis (hiatus hernia, GORD, duodenitis etc.)

SUSPEND NSAIDS IN PATIENTS REFERRED VIA 2WW UGI PATHWAY 2. Deciding to refer to UGI 2WW pathway SUSPEND NSAIDS IN PATIENTS REFERRED VIA 2WW UGI PATHWAY

2. Deciding to refer to UGI 2WW pathway

3. Consider Referring for a Specialist Opinion patients who may benefit from an OGD but don’t meet 2WW criteria Any age with gastro-oesophageal symptoms that are non‑responsive to treatment or unexplained With suspected GORD who are thinking about surgery With H pylori that has not responded to second-line eradication therapy

NICE 2014: Managing the difficult case Consider managing as per previous investigations Re-emphasise diet and lifestyle advice, check compliance Proven GORD with “severe oesophagitis” OTC medications omeprazole 40mg daily (40mg twice daily?) Consider ranitidine 150mg PRN

NICE 2014: Managing the difficult case “If the person's severe oesophagitis fails to respond to maintenance treatment, carry out a clinical review. Consider switching to another PPI at full dose or high dose” Omeprazole Lansoprazole Pantoprazole Esomeprazole

Mike: 42 year old male PMH: Meds: Family history: Nil of note OA of knees due to his job Asthma Meds: Salbutamol inhaler (recently used 5-6 times daily) Paracetamol 1g a few days per week for knees Family history: Nil of note

Mike: 42 year old male PC: Examination: Healthy BMI, NAD Daily burning retrosternal chest discomfort for 3 weeks Worse after meals, especially heavy meals Using gaviscon three times a day with some benefit No weight loss or anorexia Examination: Healthy BMI, NAD

Mike: 42 year old male NHS Choices & omeprazole 20mg OD day for 4 weeks NHS Choices, omeprazole 20mg OD for 4 weeks and review asthma control Omeprazole 40mg once a day and refer for 2WW OGD Omeprazole 40mg once a day and faecal antigen for H pylori

Mike: 42 year old male NHS Choices & omeprazole 20mg OD day for 4 weeks NHS Choices, omeprazole 20mg OD for 4 weeks and review asthma control Omeprazole 40mg once a day and refer for 2WW OGD Omeprazole 40mg once a day and faecal antigen for H pylori

Susan: 58 year old female PMH: Meds: Family history: Father had CRC THR 18 months ago Type 2 DM 9 months ago Paroxysmal atrial fibrillation BCSP colonoscopy normal 3 months ago Meds: Ibuprofen 400mg three times a week since THR Metformin 1g BD PO for 6 months Family history: Father had CRC

Susan: 58 year old female PC: Daily burning retrosternal chest discomfort for 7 weeks Worse after food, especially after alcohol No weight loss Examination: Healthy BMI, mild RUQ tenderness, Murphy negative

Susan: 58 year old female NHS Choices & omeprazole 20mg OD day for 4 weeks Suspend metformin and refer for routine OGD Suspend ibuprofen, check routine bloods and refer to 2WW UGI pathway Omeprazole and check faecal antigen for H pylori

Susan: 58 year old female NHS Choices & omeprazole 20mg OD day for 4 weeks Suspend metformin and refer for routine OGD Suspend ibuprofen, check routine bloods and refer to 2WW UGI pathway Omeprazole and check faecal antigen for H pylori

Anne: 21 year old female PMH: Meds: Family history: Nil of note Migraine (occasional) Meds: Ibuprofen 400mg occasionally for headache Family history: Nil of note

Anne: 21 year old female PC: Epigastric pain after food Worse after fatty food, especially after alcohol Pain radiates to her back Saw an ad about cancer and is afraid that she has it Examination: BMI 32, epigastric tenderness, Murphy sign negative

Anne: 21 year old female Reassure, suggest NHS choices and OTC medications Omeprazole 20mg OD PO for 4 weeks & H pylori faecal antigen test Suspend ibuprofen, check routine bloods and refer to 2WW UGI pathway 4. Reassure, routine bloods & abdominal USS

Anne: 21 year old female Reassure, suggest NHS choices and OTC medications Omeprazole 20mg OD PO for 4 weeks & H pylori faecal antigen test Suspend ibuprofen, check routine bloods and refer to 2WW UGI pathway 4. Reassure, routine bloods & abdominal USS

Anne: 21 year old female Reassure, suggest NHS choices and OTC medications Omeprazole 20mg OD PO for 4 weeks & H pylori faecal antigen test Suspend ibuprofen, check routine bloods and refer to 2WW UGI pathway 4. Reassure, routine bloods & abdominal USS

Anne: 21 year old female Reassure, suggest NHS choices and OTC medications Omeprazole 20mg OD PO for 4 weeks & H pylori faecal antigen test Suspend ibuprofen, check routine bloods and refer to 2WW UGI pathway 4. Reassure, routine bloods & abdominal USS

Bill: 48 year old male PMH: Meds: Family history: Nil of note Treated hypertension Inguinal hernia repair Obesity GORD (Grade 4 oesophagitis & peptic stricture 2014, two OGDs, biopsies benign) Meds: Ramipril 5mg once daily Aspirin 75mg once daily Omeprazole 20mg three times a week Family history: Nil of note

Bill: 48 year old male PC: Heartburn after food & liquids Worse when lying down (in bed) No dysphagia Saw an ad about cancer and is afraid that he has it Examination: BMI 38, abdomen soft and non-tender

Bill: 48 year old male Reassure, suggest NHS choices and OTC medications. Suspend aspirin. Omeprazole 40mg OD PO for 4 weeks & then maintain on 20mg once daily long-term. Suspend aspirin Suspend aspirin, check routine bloods and refer to 2WW UGI pathway 4. Reassure, routine bloods & abdominal USS

Bill: 48 year old male Reassure, suggest NHS choices and OTC medications. Suspend aspirin. Omeprazole 40mg OD PO for 4 weeks & then maintain on 20mg once daily long-term. Suspend aspirin Suspend aspirin, check routine bloods and refer to 2WW UGI pathway 4. Reassure, routine bloods & abdominal USS

Managing Dyspepsia and GORD in 2015 Dr Alan Desmond Consultant Gastroenterologist UGI MDT Lead Mount Stuart & Torbay Hospital alan.desmond@nhs.net