DYSPEPSIA

MANAGEMENT GUIDELINES
These guidelines were originally produced by a working group of he !ri ish Socie y of Gas roen erology" The

por ions in red are upda ed sec ions re#ised in April $%%$"

A draf

of

hese upda ed guidelines was sen

for

co&&en s o he clinical effec i#eness depar &en of he 'oyal (ollege of )hysicians* The &a+ori y of he original working group ,so&e had re ired-* The )ri&ary (are Socie y .or Gas roen erology* Independen General

)rac i ioners and Gas roen erologis s who had e/pressed an in eres during heir de#elop&en "

0e recognise

ha

fully sys e&a ic guidelines are in ser#es as an

produc ion by NI(E and his presen se in eri& guide o clinicians"

PREFACE
Dyspepsia is a common complaint. Treatments may often be very effective and investigations can be costly and invasive. More is spent on drugs for dyspepsia than on any other treatment for a symptom group. Rational management poses a challenge to those responsible for purchasing, promoting and providing health care.
These guidelines ha#e been co&piled on behalf of he !ri ish Socie y of Gas roen erology following consul a ion wi h he )ri&ary (are Socie y of Gas roen erology" The principal ob+ec i#e is o describe good clinical prac ice for clinicians in pri&ary and secondary care drawing on e#idence where i e/is s and recognising he need o use li&i ed resources effec i#ely" An addi ional ai& is o iden ify areas where e#idence is sparse and where fur her research is necessary" )urchasers of heal h care should be in eres ed in bo h aspec s when draf ing con rac s for ser#ice" The guidance was upda ed in April $%%$ and he re#isions are shown in red hroughou he docu&en " The 1red2 guidance supercedes he original se " KEY TO GRADING OF RECOMMENDATIONS: A 3 'eco&&enda ion based on a leas one &e a3analysis* sys e&a ic re#iew or a body of e#idence fro& '(Ts" B 3 'eco&&enda ion based on high 4uali y case con rol or cohor s udies wi h o#erall consis ency or e/ rapola ed fro& sys e&a ic re#iews* '(Ts or &e a3analyses" C 3 'eco&&enda ion based on lesser 4uali y case con rol or 2

cohor s udies wi h o#erall consis ency or e/ rapola ed fro& high 4uali y s udies" D 5 'eco&&enda ion fro& case series or repor s and e/per opinion including consensus"

SUMMA'6 7. MAIN 'E8ISI7NS $%%$

9- AGE .7' END7S(7)6 The age a which endoscopy is reco&&ended for new dyspepsia has been increased fro& :;y o ;;y in line wi h na ional cancer referral guidance" Local ad+us &en s in areas wi h a high pre#alence of gas ric cancer are appropria e" $- TEST AND T'EAT The reco&&enda ion o rea pa ien s under ;; wi h unco&plica ed dyspepsia on he basis of a posi i#e < )ylori es supercedes he pre#ious reco&&enda ion o 1 es and scope2" =- 9=( U'EA !'EAT< TESTS The bes es for iden ifica ion of < )ylori and for confir&a ion of eradica ion is he 9=( urea brea h es :- Use of ))Is 0e accep ha followed

he guidance issued by NI(E on ))Is should be

INTRODUCTION:
What is Dyspepsia?
Dyspepsia is a group of sy&p o&s which aler s doc ors o consider disease of he upper GI rac " I is no a diagnosis* bu includes sy&p o&s of upper abdo&inal disco&for * re ros ernal pain* anore/ia* nausea* #o&i ing* bloa ing* fullness* early sa ie y and hear burn a&ongs o hers" A fir& clinical diagnosis can be difficul on he basis of hese sy&p o&s as few sy&p o&s are discri&ina ory" Many diseases cause dyspepsia and hese include pep ic ulcers* oesophagi is* cancer of he s o&ach or pancreas* and galls ones" In a large propor ion of cases no clear pa hological cause for a pa ien s sy&p o&s can be de er&ined"

Prevalence

Dyspepsia is co&&on" Sur#eys in 0es ern socie ies ha#e recorded pre#alences of be ween $= and :9>" .or &any people dyspep ic sy&p o&s are an una#oidable par of li#ing" 0hy so&e sufferers ,abou $;>- seek help fro& doc ors is no clear bu concern abou sy&p o&s see&s o be as i&por an as he sy&p o&s he&sel#es" A &inori y of hose sufferers who do consul can beco&e &a+or consu&ers of resource" In he U? in 9@@: &ore han :%% &illion pounds was spen on Aulcer healingA drug prescrip ions issued by general prac i ioners" Abou :> of General )rac ice consul a ions are for dyspepsia and $> of he en ire adul popula ion recei#e ei her an endoscopy or bariu& &eal each year" Ti&e los fro& work and in erference wi h 4uali y of life are &ore difficul o &easure bu are likely o be considerable" 7nly 9%> of pa ien s a ending heir general prac i ioner wi h dyspepsia will be referred for hospi al consul a ion or in#es iga ion" Uni#ersal in#es iga ion for dyspepsia is nei her desirable nor affordableB hus guidelines for &anage&en would be unrealis ic if hey ad#ised no selec ion for referral"

COMMON CAUSES OF DYSPEPSIA:

The co&&on diagnoses &ade a endoscopy in all age groups areC > Duodenal ulcerD 9%39; 5

Gas ric ulcerD ;39% 7esophagoEGas ric (ancerD $ 7esophagi is 9%39F Gas ri isD* Duodeni isD or <ia us <ernia =% Nor&al =% DThese condi ions are s rongly associa ed wi h H.pylori Infec ion"

HELICOBACTER PYLORI

This organis& li#es on he gas ric &ucosa and is associa ed wi h a nu&ber of diseases" I is unclear whe her i ac ually causes all he diseases bu so&e are bes rea ed by eradica ing his infec ion" Tes ing for H.pylori H.pylori infec ion can be diagnosed by de&ons ra ing an ibodies o he organis& in seru&* by showing urease ac i#i y in he s o&ach using brea h es s or by e/a&ina ion of biopsies" An igen deri#ed fro& he organis& can also be iden ified in s ool sa&ples" Serology Serological &e hods are si&ple* non3in#asi#e* and widely a#ailable bu are no useful in de&ons ra ing successful eradica ion" So&e ki s pro#ide a rapid resul while he pa ien wai s ,1near pa ien es 2-" Labora ory based tests ith a high sensitivity are useful but much less accurate !specific" than other methods. Near patient blood tests are less accurate still and are not recommended.

!rea h es s (arbon agged brea h es s* which depend on urease degrada ion of urea o produce agged carbon dio/ide which hen appears in e/haled brea h are of in er&edia e cos * bu are non3in#asi#e" Two &e hods ha#e been used wi h ei her 9:( ,a iny radioac i#e dose* bu cheap- or 9=( ,a s able* non3 radioac i#e dose bu &ore e/pensi#e- labelled urea" #$% urea breath tests are available as &its on prescription. These es s can confir& successful eradica ion bu hey &us be perfor&ed when pa ien s are no aking pro on pu&p inhibi ors* bis&u h nor wi hin : weeks of an ibio ic use" !e most accurate test "or # P$lori is t!e urea breat! test.

Endoscopic es s Me hods of iden ifying H.pylor iwhich in#ol#e endoscopy and biopsy are e/pensi#e" Si&ple biopsy urease es s are a #ery s&all addi ional cos o ha of endoscopy" <is ology* or cul ure of he organis& add significan ly o cos s" %outine use o" endoscop$ "or dia&nosis o" #. p$lori is not recommended.

.aecal an igen es s These ha#e beco&e a#ailable in he las e/ac role re&ains o be de er&ined"

hree years bu

heir

INVESTIGATION a ! DIAGNOSIS "# DYSPEPSIA The nu&ber of pa ien s wi h dyspepsia a ending General )rac i ioners is belie#ed o e/ceed he a#ailabili y of diagnos ic procedures" There are appro/i&a ely =% a endances per 9%%% in General )rac ice a&oun ing o abou $9% consul a ions per G) per annu&" Endoscopy is #ery safe bu is no o ally risk3free" Dea h fro& diagnos ic endoscopy is repor ed in he range of 9 in $*%%% 3 9%*%%%" In ou 3pa ien prac ice he ra e is likely o be e#en lower* bu any dea h is unaccep able" (ri eria which iden ify only hose pa ien s who &ay benefi fro& he procedure and o e/clude hose who would no are wor hwhile"

Ra$%" a&%'% ( $)* +'* "# * !"',"-./

A'E AND SYMP OMS An age hreshold as the traditional prac ical &eans of li&i ing endoscopy" This is based on he fac ha the incidence of gas ric &alignancy is age related. 't is also believed that certain associated symptoms are charac eris ic and aler clinicians o his possible diagnosis" The evidence base on hich these beliefs are founded is not strong. ( systematic revie found no evidence to suggest that initial empiric treatment adversely affects outcome in uncomplicated dyspepsia !)". That revie reported that curable gastric cancer as a chance finding at endoscopy in dyspeptics because the incidence as e*ually high in the non+ dyspeptic population. #o(e)er (e recommend endoscop$ in patients o)er t!e a&e o" ** (it! ne( onset o" uncomplicated d$spepsia t!ou&! (e accept t!at in "uture

t!is ad)ice ma$ c!an&e as e)idence is poor.

The first edition of these guidelines !#))," and other similar guidance recommend that endoscopy should be performed in all patients ith dyspepsia associated ith so+called -alarm symptoms. !Table #". Indeed &os pa ien s wi h gas ric cancer have such sy&p o&s" Thus if endoscopy in people /00y was li&i ed o hose wi h alar& sy&p o&s #ery few cancers would be &issed !#1, ##, #2". In cer ain #ery high pre#alence areas his age &ay need o be lowered bu here is no s rong e#idence on his" While there is evidence that alarm symptoms are predictive of upper gastrointestinal cancer not all studies have demonstrated this !)". Until t!is area is clari"ied (e continue to recommend upper 'I endoscop$ in all patients (it! d$spepsia associated (it! alarm s$mptoms

#E+ICO,AC E% PY+O%I In unco&plica ed dyspepsia concern abou gas ric cancer is no he only reason for in#es iga ion" There is e#idence ha subse4uen herapeu ic decisions and consul ing beha#iour change in hose in#es iga ed e#en when &a+or diagnoses are absen " The first edition of these guidelines commended the practice of underta&ing H.pylori serology before endoscopy in these young patients and restricting endoscopy to those ith H.Pylori antibodies and providing symptomatic therapy to the remainder. %onsiderable research has subse*uently been carried out in this area and e no favour a different strategy !-test and treat.", though the original strategy !-test and scope." remains valid and safe and it3s rationale is also given belo . A &e hod of iden ifying &os young pa ien s a risk of gas ric neoplasia and pep ic ulcer is by es ing for e#idence of H.pylori infec ion" Using &odern serological assays and res ric ing endoscopy in pa ien s under :; ,raised o ;; in his re#ision- wi h unco&plica ed roubleso&e dyspepsia o hose wi h e#idence of infec ion has been shown o iden ify &os pep ic ulcer disease ,9-" The &a+ori y of young pa ien s wi h gas ric cancer are seroposi i#e for <elicobac er* so hese cases oo would be diagnosed* e#en in he rare absence of alar& sy&p o&s" The

&a+or diagnoses ha would be &issed by such a process are oesophagi is and !arre s oesophagus ,(olu&nar lined oesophagus-" <owe#er* hese condi ions are bes rea ed wi h herapy direc ed a sy&p o& con rol because rea &en direc ed a healing does no pre#en co&plica ions or decrease he recognised addi ional risk of oesophageal adenocarcino&a" In &any cases gas ro3oesophageal reflu/ does no cause erosi#e oesophagi is and a clinical diagnosis is of en he bes indica ion for rea &en " In &any cases gas ro3oesophageal reflu/ is a long3 er& proble& and so&e argue ha endoscopy should be perfor&ed before ins iga ing long3 er& acid suppressi#e herapy" .ur her da a are re4uired in his area bu endoscopy decreases prescribing cos s* consul a ion ra es and leads o &anage&en changes e#en in pa ien s in who& no significan disease is found ,$*=*:*-" The assu&p ion is ha he procedure pro#ides reassurance o pa ien s and doc ors allowing &ore ra ional prescribing" Si&ilar benefi s ha#e been repor ed following nega i#e H.pyloriserology wi hou endoscopy in hose in who& endoscopy would o herwise ha#e been perfor&ed ,;-" The -Test and Treat. strategy involves testing for H.pylori by breath test or serology follo ed by H.pylori eradication in cases ith H.pylori and symptomatic therapy for the remainder. ( number of management trials have been published hich demonstrate that the strategy is as effective as endoscopy in determining therapy for dyspepsia. 4uch a strategy should provide appropriate treatment for peptic ulcer including reduction of relapse, should benefit a minority of patients ith H.pylori associated ulcer negative dyspepsia !see later", should lessen concerns about orsening gastritis during treatment of reflu5 ith PP's and potentially could reduce gastric cancer ris&. -Test and treat. ill e5pose more patients to broad spectrum antibiotics but there are no other &no n significant disadvantages of such an approach. The effectiveness of this strategy il need to be re+assessed if the prevalence of H Pylori falls to very much lo er levels than at present. Ho ever, e are no convinced by the substantial evidence base that this approach is both cost effective and safe and therefore (e no( "a)our a - #.p$lori test and treat. strate&$ "or uncomplicated d$spepsia in patients under **. !#2+#6".

'UIDE+INES

The guidelines which follow co&bine re4uire&en o pro ec resources* li&i pro#ide high 4uali y care"

he assu&p ion of a unnecessary risk and

1/ INVESTIGATION 0ai ing i&es for in#es iga ion should no e/ceed four weeks and ideally in#es iga ions should be a#ailable wi hin wo weeks" 7ational %ancer guidelines have determined that a ait of greater than t o ee&s hen cancer is suspected is unacceptable. The bes in#es iga ion for unco&plica ed dyspepsia is endoscopy" A endoscopy* biopsy urease es s should be perfor&ed in all pa ien s wi h ulcer in who& he < )ylori s a us is no already known" .ur her assess&en o iden ify NSAID and aspirin use* (rohns* Ly&pho&a and o her unusual causes of ulcera ion is necessary in such pa ien s wi hou e#idence of < )ylori" Double con ras bariu& radiology &ay be e4ually accura e* bu does no allow for biopsies o be aken and is hus considered second bes " <owe#er in cer ain circu&s ances i pro#ides #aluable co&pli&en ary infor&a ion" These circu&s ances include diagnosis of &inor s ric ures which &ay be &issed endoscopically* &o ili y disorders* e/ rinsic and possibly in ra3 &ural abnor&ali ies as well as he diagnosis of &alro a ions* hernia ions and o her s ruc ural abnor&ali ies"

TABLE 1 A/ Pa$%* $' 3%$) !.'-*-'%a %

12

3)"4 !%a( "'$%,

* !"',"-. %' a--5"-5%a$*/

9" A . !.'-*-$%, -a$%* $ 3%$) a&a54 '.4-$"4' "5 '%( ':

Unin en ional weigh loss ,GH=?g-* Une/plained Iron deficiency anae&ia* Gas ro3in es inal bleeding* Dysphagia and 7dynophagia* )re#ious gas ric surgery* )ersis en continuous #o&i ing* Epigas ric &ass* Suspicious bariu& &eal* )re#ious gas ric ulcer* $" A . -a$%* $ "6*5 $)* a(* "# ** 3%$) 5*,* $ 781 .*a59

" '*$ !.'-*-'%a "# a$ &*a'$ 4 3**:' !+5a$%" /

B/ Pa$%* $' 3%$) !.'-*-'%a % % a--5"-5%a$*/

3)"4 * !"',"-. %'

9" )a ien s known o ha#e duodenal ulcer who ha#e responded sy&p o&a ically o rea &en " $" )a ien s under ;; wi h unco&plica ed dyspepsia" =" )a ien s who ha#e recen ly endoscopy for he sa&e sy&p o&s" undergone a sa isfac ory

TREATMENT BEFORE INVESTIGATION

I is accep able o ins i u e rea &en wi h an an i3secre ory agen in pa ien s under 00 wi h roubleso&e sy&p o&s bu wi hou alar& sy&p o&s" 0hile his rea &en is a e&p ed i is reco&&ended ha H.pylori es ing is under aken" Endoscopy is no reco&&ended in such pa ien s" )a ien s o#er ;; years of age wi h firs onse dyspepsia should undergo prompt endoscopy. There is evidence that pretreatment ith antisecretory drugs may mas& significant diagnoses at that endoscopy. !2#" We believe that such treatments should be itheld or stopped four ee&s before endoscopy. D

11

TREATMENT POST DIAGNOSIS

MAI7' DIAGN7SES 'n our original guidelines e recommended treatment of H.pylori infection only for duodenal and gastric ulcer. The test and treat strategy no favoured in uncomplicated dyspepsia assumes that all cases of .undiagnosed. functional dyspepsia associated ith H Pylori ill receive eradication therapy and thus it follo s that eradication of H Pylori in &no n cases of functional dyspepsia is an acceptable therapy.

DUODENAL ULCER 7DU9

HP;6* !+"!* a& +&,*5: @;> are associa ed wi h H.pylori and should recei#e rea &en direc ed agains his organis&" 0e ad#ise confir&a ion of H.pylori infec ion before rea &en * bu accep ha he pre#alence of < )ylori infec ion is so high in DU ha his &ay be considered unnecessary" We recognise that there is no &no n single best eradication regime but the highest e5pected eradication results are associated ith these regimens recommended by consensus !21". 85perience ith the second line regimen belo is relatively limited9

7ne week Triple TherapyC .irs Line !no continued antisecretory re*uired" PP' !standard dose t ice daily" or R:% !ranitidine bismuth citrate", plus (mo5ycillin 011 ; #g t ice daily or Metronida<ole =11+011mg t ice daily,plus %larithromycin 011mg t ice daily. B

't is sensible to avoid metronida<ole if the patient has had a previous course of treatment ith this agent. >uadruple Therapy9 4econd line9 PP' !standard dose t ice daily", plus :ismuth 4ubcitrate #21mg *ds", plus metronida<ole =11+011mg tds, plus tetracycline 011mg *ds (o&pliance wi h rea &en has been shown o be #ery i&por an 12

in de er&ining he success of riple herapy regi&ens"

13

F"&&"3<+-: Asy&p o&a ic pa ien sC 'epea endoscopy is no needed" A urea brea h es ,ideally 9=(- should be perfor&ed in all pa ien s ,one &on h or longer af er he end of < )ylori eradica ion rea &en - if sy&p o&s persis or recur" A urea brea h es is also re4uired in any pa ien whose ulcer had presen ed wi h co&plica ions and who would o herwise be gi#en long3 er& an i3secre ory rea &en o pre#en recurrence" If he resul of he brea h es is nega i#e we reco&&end no fur her rea &en " If he resul is posi i#e a second course of eradica ion herapy should be prescribed" Assess&en of an ibio ic sensi i#i y &ay be considered in hose wi h persis en < )ylori"

Sy&p o&a ic af er ini ial sy&p o& responseC A urea brea h es is indica ed " If nega i#e clinical re3e#alua ion is necessary and if posi i#e repea an i3H.pylori rea &en "

HP<6* D+"!* a& U&,*5: An isecre ory herapyB (i&e idine J%%&g noc e is cheapes " Gas roen erological referral is ad#ised if ulcers are no associa ed wi h NSAID" NSAID should be s opped if possible and if sy&p o&s persis pa ien s &ay need gas roen erological re#iew Long er& an isecre ory drugsC ?o dose PP' -maintenance. is re*uired only in patients ith persistent H Pylori infection or those at ris& of serious complications hile receiving 74('D4. 7'%8 guidance on %@A2 specific antagonists should be considered in these instances. !22"

2/ EROSIVE DUODENITIS:
In he absence of o her e#idence we consider erosi#e duodeni is o be par of he spec ru& of duodenal ulcer and ad#ise rea &en as in his condi ion"

14

3/ GASTRIC ULCER 7GU9

H.pylori is presen in abou F%> and &os of he re&ainder are associa ed wi h NSAIDs" (y ological s&ears and biopsies should be aken for his ology and a urease es should be perfor&ed a endoscopy" D HP;6* Ga'$5%, +&,*5 : An i H.pylori herapy as for duodenal ulcer A followed by an isecre ory herapy for wo &on hs" The reason for his la er reco&&enda ion is he lack of e#idence ha gas ric ulcers heal as 4uickly as DU af er H.pylori eradica ion alone" D Long er& rea &en wi h a ))I or &isopros ol should be considered in pa ien s wi h pro#en ulcer who continue o ake NSAIDs" 7'%8 guidance on %@A2 specific antagonists should be considered in these instances. !22"

HP<6* Ga'$5%, U&,*5C S andard an isecre ory herapy for wo &on hs" NSAIDs should be s opped if possible" .ull dose ))I is &ore effec i#e han <$ an agonis if NSAID is con inued" Long er& rea &en wi h &isopros ol or PP' should be considered in pa ien s wi h pro#en ulcer who can no s op he NSAID" 7'%8 guidance on %@A2 specific antagonists should be considered in these instances. !22" D

F"&&"3<+- "# a&& ,a'*' "# (a'$5%, +&,*5C 'epea endoscopy wi h biopsies is essen ial un il co&ple ely healed because of he s&all risk ha a cancer is presen " If he ulcer re&ains unhealed for si/ &on hs hen surgery should be considered" D

15

4/ OESOPHAGITISC
< )ylori infec ion is no &ore likely o be associa ed wi h his condi ion han in he nor&al popula ion" )a ien s should be infor&ed of he associa ion of obesi y and hear burn" 0eigh loss is belie#ed o be effec i#e rea &en in so&e hough e#idence is anecdo al" )ropping up he head of he bed has been shown o be beneficial in so&e s udies and pa ien s should be ad#ised o a#oid hings which pro#oke sy&p o&s a&ongs which bending* alcohol and fa y foods are pro&inen " Trea &en should pro#ide sy&p o& relief" : weeks is a reasonable s ar ing course" !es relief is pro#ided by pro on pu&p inhibi ors bu &any pa ien s ob ain ade4ua e sy&p o& con rol fro& an acids* raf prepara ions* <$ an agonis s or prokine ic agen s" 0ha e#er herapy is chosen an a e&p should always be &ade o i ra e o he agen which pro#ides sy&p o&a ic relief a he lowes cos !2#". /e recommend t!at t!e NICE &uidance on PPIs be "ollo(ed.

F"&&"3<+-C 'epea ed endoscopy is no +us ifiable e/cep o check for healing of oesophageal ulcers* dila a ion of s ric ures or when anae&ia which is belie#ed o be secondary o oesophagi is fails o resol#e on rea &en " The i&pac of endoscopic sur#eillance on he long er& &anage&en and ou co&e of !arre s oesophagus re&ains o be de er&ined" So&e pa ien s &ay need longer er& rea &en o &ain ain sy&p o& relief" <owe#er* such prescrip ions should be re#iewed and a e&p s o i ra e he dose agains sy&p o& relief* or o swi ch o cheaper re&edies should be &ade regularly"

5/ FUNCTIONAL DYSPEPSIA
This condi ion* which is poorly defined* is presen when no &acroscopic &ucosal abnor&ali y Knon3ulcer dyspepsiaL* non erosi#e reflu/* hia us hernia* non erosi#e duodeni is and gas ri is are repor ed a endoscopy" These diagnoses are of en recorded bu he correla ion of he endoscopic finding wi h ei her sy&p o&s* or his ological

16

abnor&ali y is poor" The cause of sy&p o&s in hese pa ien s* who accoun for a large propor ion of hose in#es iga ed* is usually unclear" I is likely ha &ul iple fac ors are in#ol#ed including acid* defec i#e &o ili y* < )ylori infec ion and depression" Trea &en is sy&p o&a ic bu of en ineffec i#e" 'esearch in his area has been ha&pered by poor defini ions and he &ul ifac orial na ure of he proble&s" Thus he reco&&enda ions below are based on consensus" ?ifestyle (dvice There is insufficient evidence to recommend any particular lifestyle advice. 4mo&ers should be advised not to smo&e for general health reasons and healthy eating should be encouraged, though neither are &no n to affect these symptoms. D

Pharmacological interventions a" H Pylori eradication + R%Ts of H.pylori eradication in functional dyspepsia have sho n that any benefit is small and not consistently significant. Meta+analysis of these studies suggests that none as large enough to demonstrate significant symptomatic improvement. The %ochrane revie studied nine trials published to May 2111 and sho ed a significant )B increase in the number of asymptomatic patients after eradication of H Pylori.!#=" @ther meta+analyses give different conclusions and thus it is clear that any benefit from eradication of H Pylori in this condition is small at best. /e recommend t!at # P$lori eradication is used in t!is condition in 0eepin& (it! t!e test and treat strate&$.

b" (ntisecretory treatments ; R%Ts have demonstrated small but significant benefits of PP' or H2 receptor antagonist use. Responses are best if dyspepsia is -ulcer+li&e. or reflu5 type. /e recommend t!at antisecretor$ treatment be considered o" potential use in t!is condition.

c" 4top 74('Ds if possible and consider other drugs as provo&ing agents

17

d" Repeat investigations if serious symptoms develop !see table #".

e" Ceneral reassurance may be sufficient. D

10

POIN S COMMISSIONE%S
'ES7U'(E 'EMUI'EMENTS

FO%

9" General prac i ioners and pa ien s should ha#e easy access o 9=( Urea brea h es ing" <igh 4uali y serological assays for < )ylori an ibodies should be a#ailable un il 9=( urea brea h es ing is uni#ersally a#ailable" $" Easy and rapid access o endoscopy is a re4uire&en for good prac ice and endoscopy uni s should be able o pro#ide his ology* urease es ing and 9=( brea h es s" 'esources for he pro#ision of his le#el of ser#ice should be a#ailable na ionwide" =" In so&e labora ories he facili ies needed for full bac eriological assess&en of H.pylorisensi i#i y and resis ance should be pro#ided" 7ne in each &a+or ci y could pro#ide a na ionwide ser#ice"

(7NT'78E'S6C T<E NEED .7' .U'T<E' 'ESEA'(<"

These guidelines a e&p o pro&o e prag&a ic &anage&en s based on e/is ing e#idence or consensus when e#idence is lacking" Many clinical prac ices which are belie#ed o be beneficial ,financially and clinically- are a presen l e&pirical and no based on sound e#idence" These includeC A" Screening and rea &en of asy&p o&a ic pa ien s for < )ylori in an a e&p o pre#en gas ric cancer" !" Selec i#e screening and rea &en for H.pylori in pa ien s on 11

long3 er& an i3secre ory agen s er& NSAIDs

or hose con e&pla ing long

There is a belief ha such prac ices will reduce cos s and pro#ide clinical benefi " The fre4uency of significan side3effec s* and of failure3rela ed consul a ion is no known fro& general usage" If ei her of hese is i&por an such prac ices &ay increase cos s" (linical benefi is ye o be con#incingly de&ons ra ed" 0e ha#e herefore adop ed he s ance of reco&&ending prac ices for which con#incing ,albei li&i ed- e#idence e/is s while awai ing o her e#idence" The guidance will be upda ed as e#idence accrues" In he &ean i&e i is i&possible o be proscrip i#e for large areas of dyspepsia &anage&en " )urchasers of heal hcare research need o be aware of he deficiencies in our knowledge base and are ad#ised o suppor research which will fill such gaps"

22

'E.E'EN(ESC 9- Mendall MA* Goggin )M* Marrero IM* Molineau/* Le#y I* !ad#e S* e al <elicobac er Screening prior o endoscopy" European Iournal of Gas roen erology and <epa ology 9@@$B :C F9=3F $- <ungin A)S* Tho&as )'* !ra&ble MG* (orbe 0A* Idle N* (on rac or !'* !erridge D(* (ann G" 0ha happens o pa ien s following open access gas roscopyN An ou co&e s udy fro& general prac ice" !ri I Gen )rac 9@@:B::C;9@3;$9 =- Iones '" 0ha happens o pa ien s wi h non3ulcer dyspepsia af er endoscopyN )rac i ioner 9@JJB$=$CF;3FJ :"- !y Oer )* <ansen I M* de Muckadell 7!S" E&pirical <$ blocker herapy or pro&p endoscopy in &anage&en of dyspepsia" Lance 9@@:B=:=CJ9939P ;"- )a el )* ?hulusi S* Mendall MA* Lloyd '* Ma/well ID* Nor hfield T(" )rospec i#e screening of dyspep ic pa ien s by <elicobac er )ylori serology" Lance 9@@;B=:PC9=9;39J P"- The Manage&en of Dyspepsia 3 A (onsensus De#elop&en (onference 'epor o he Na ional Ad#isory (o&&i ee on (ore <eal h and Disabili y Suppor Ser#ices" IS!N %3:FF3%9F%@3P F"- <elicobac er )ylori in )ep ic Ulcer Disease" NI< (onsensus S a e&en 9@@:B 9$C9 J"- !ri ish Na ional .or&ulary 2111D =1. )." @fman E. The effectiveness of endoscopy in the management of dyspepsia9 a *ualitative systematic revie . (m E Med #)))D#1,9$$0+=, #1" %hristie E, 4hepherd 7(, %odling :W, Falori RM. Castric cancer belo the age of 009 implocations for screening patients ith uncomplicated dyspepsia Cut #))GD=#90#$+#G, ##" Cillen D, Mc%oll H8?. Does concern about missing malignancy Iustify endoscopy in uncomplicated dyspepsia in patients less than 00. (m E Castroenterol #)))D )=9 G0+G)

21

#2" Heaney (, %ollins E4, Tham T% et al ( prospective study of the management of the young helicobacter negative dyspeptic patient ; can gastroscopies be saved in clinical practice? 8ur E Castroenterol #))6D#19)0$+)0," #$" The management of Dyspepsia9 ( systematic Revie . HT( 2111D=9$) #=" Delaney :% 'nnes M( et al 'nitial Management 4trategies for Dyspepsia. The %ochrane ?ibrary, 'ssue $, 211# @5ford. #0" Heaney (, %ollins E4(, Watson RCP et al. ( prospective randomised trial of a -test and treat. policy versus endoscopy based management in young Helicobacter Pylori positive patients ith ulcer+li&e dyspepsia referred to a hospital clinic. Cut #)))D=09#6,+)1 #," ?assen (T, Pedersen JM, :yt<er P, 4chaffalit<&y @:. Helicobacter Pylori test+and+eradicate versus prompt endoscopy for management of dyspeptic patients9 a randomised trial. ?ancet 2111D$0,9=00+,1 #G" Eones R, Tait %, 4laden C, Weston+:a&er E. ( trial of a test+ and+treat strategy for Helicobacter Pylori positive dyspeptic patients in general practice. 'E%P, #)))D0$9=#$+#, #6" WeiInen %J, 7umans M8, deWit 7E, et al. Testing for Helicobacter Pylori in dyspeptic patients suspected of peptic ulcer disease in primary care9 cross sectional study. :ME 211#D $2$9G#+G0 #)" Detection of upper gastrointestinal cancer in patients ta&ing antisecretory therapy prior to gastroscopy. Cut. 2111 (prD=,!="9=,=+G 21" 8uropean Helicobacter pylori 4tudy Croup. %urrent %oncepts in the Management of Helicobacter pylori 'nfection. The Maastricht 2 +2111 %onsensus Report. 2#" 7ice Technology (ppraisal Cuidance 7o G, Cuidance on the use of Proton Pump 'nhibitors in the treatment of dyspepsia. '4:79 #+6=20G+1#6+6 Euly 2111

22

22" 7ice Technology (ppraisal Cuidance 7o 2G, Cuidance on the use of cyclo+o5ygenase !%o5"'' selective inhibitors, celeco5ib, rofeco5ib, melo5icam and etodolac for osteoarthritis and rheumatoid arthritis. '4:7 #+6=20G+##=+#

23

25

26