1. Managing Dyspepsia & GORD in 2015
Dr Alan Desmond
Consultant Gastroenterologist
UGI MDT Lead
Mount Stuart & Torbay Hospital

2. NAEDI Campaign runs January 22nd to February 22nd

3. 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

5. 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 £ £2.30 per month
H pylori stool test £20
Gastroscopy £375
Abdominal ultrasound £44-56

6. 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

7. 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

8. 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”

9. 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

10. 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!

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

12. 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

13. 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

14. Paragraph on eradiation failure below this table

15. 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.)

17. 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

18. 2. Deciding to refer to UGI 2WW pathway

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. Managing Dyspepsia and GORD in 2015
Dr Alan Desmond
Consultant Gastroenterologist
UGI MDT Lead
Mount Stuart & Torbay Hospital