1. ORGANIC Peptic ulcer Reflux Cholelithiasis Pancreatic Malignancy Musculoskeletal Drugs, medication and rarities ischaemic metabolic

2. Functional Sensory motor dysfunction H pylori Gastritis (peptic ulcer Psychosocial factors Idiopathic

3. History Examination Overall assessment –likelihood of disease - needs for reassurance Trial of PPI and reassessment

4. Red flag symptoms: Dysphagia Vomiting Increasing Age Bleeding New onset of symptoms Anaemia Looks ill Drs ‘gut’ feeling

5. Disease more common in men versus women Men Short history Age over 55 years Irregular attributes Women Long history Young Nausea ++ Stressed Frequent attendees

6. No red flag  Age under 55 or Previously investigated with negative results  Screen for Helicobacter  Empirical treatment (PPIs)  Consider other avenues  Resist but don’t exclude Endoscopy

7. Guidelines Dyspepsia  Clinical evaluation – History physical examination  Age over 55 years or red flag symptoms or Patient has strong fear of organic disease  Endoscopy

8. HELICOBACTER To test or not to test prior to referral Screening – serology faecal testing breath testing Endoscopy (including cultures) Treatment benefits – symptoms cancer preventative

9. Reasons for not doing Endoscopy in low risk patients: 1.Price 2.Low yield 3.Pressure from PCT

10. Reasons for doing Endoscopy in low risk patients: 1.Reassurance (including medico-legal) 2.Fewer OPD and prescriptions 3.The risk of disease is never zero 4.Barrett’s oesophagus

11. Points: 1.Method of referral: 2.Ultrasound 3.Limit but do not deny Endoscopy in low low risk patient 4.Don’t repeat procedure unless the need 5.Once done modify drug use 6.Concentrate on life style issues

12. Guidelines: 1.Never apply to the individual patient 2.When introduced clearly increases referrals

13. A plan regarding Choose & Book Price of endoscopy - £485 Price of consultation £195 + £92.97 = £278