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Group A: Assess symptoms / relevant history 1,2

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Group A: Assess symptoms / relevant history 1,2

  1. 1. Rotherham Primary Care Trust THE PRIMARY CARE MANAGEMENT OF DYSPEPSIA RECENT ONSET OF DYSPEPSIA (CONSIDER CONCURRENT THERAPY) GROUP B GROUP AWARNING SIGNS:- dysphagia/ odynophagia Patient < 55 years + no warning signs Patient > 55 years- weight loss- anaemia REFER for endoscopy or- iron def. anaemia Visit 1 - LIFESTYLE ADVICE Gastroenterology appointment +- persistent vomiting - smoking - alcohol LIFESTYLE ADVICE - overweight - NSAID- recurrent problems use - caffeine Refer as urgent Alginate/simple antacid therapy at adequate dosageVisit 3 -Symptom Visit 2 – free after 4 Symptoms uncontrolled- weeks- ANTIBODY TEST for H.pylori CONTRA-INDICATIONS TO CIMETIDINE Discontinue (blood test to hospital lab.) - on Theophylline Warfarin, drugs and Plus Antiarrhythmics (see BNF for others) discharge CIMETIDINE 400 mg bd - Severe renal or hepatic impairment For 4 weeks Symptoms Persist Uncontrolled Positive GROUP C - Negative Visit 3 –TREAT SYMPTOMATICALLY- Analyse dyspepsia – Consider trial of PPI/ Prokinetic agent. Consider further Visit 3 - Decide on investigation e.g. bloods, ERADICATION THERAPY for imaging Open Access H.pylori Gastroscopy Visit 4- Symptom free after 4 UREA BREATH TEST PLUS Antacid/H2RA weeks - always check for H.pylori eradication rescue Reduce dose to maintenance success 8 weeks after completion of level or attempt withdrawal therapy - Use special request forms from Medical Physics Dept. RDGH - Test will give false negative if patient is on a PPI Positive (Failed eradication) DISCUSS COMPLIANCE WITH PATIENT Further 1 week course of ALTERNATIVE TRIPLE THERAPY: Symptoms persist – any licenced PPI BD (full dose) CONSIDER REFERRAL +CLARITHROMYCIN (500 mgs BD) For open access gastroscopy +IMIDAZOLE (500 mgs BD) For more comprehensive guidelines see the British Society of Gastroenterology Website http://www.bsg.org.uk
  2. 2. MANAGEMENT OF PEPTIC ULCER DISEASE & NON-ULCER DYSPEPSIA IN PRIMARY CAREGroup A: Assess symptoms / relevant history1,2• Urgent referral: ALARM symptoms e.g. anaemia; unexplained loss of weight; anorexia; recurrent problems; melaena; or swallowingproblems.• Refer quite soon dyspepsia in patients o =55 with recent onset dyspepsia (< 1 year) & / or continuous symptoms o previously diagnosed as Barretts oesophagus or with a FHx of GI Ca.• Consider referral of dyspepsia with any of the following: pernicious anaemia; PU surgery > 20 years ago; atrophic gastritis, intestinal metaplasia.• Concurrent NSAID then use dyspepsia guideline for NSAID-induced ulcer.Group B: Treatment with Antacid / H2 Receptor Antagonists3,4• For patients < 55 years (without alarm symptoms), treat with an antacid Cost / 28 days OTC coste.g. Co-Magaldrox 195/220 Susp: low Na+, sugar-free £1.82 / 500ml £3.21/500ml• Advise patients regarding appropriate lifestyle behaviour• Symptoms unresolved after 2-4 weeks then try H2- receptor antagonist for 2 to 4 weeks4 Cost / treatment e.g. cimetidine 400mg bd5 £5.71/28 days• If symptoms do not improve then check for H.pylori serologically.Assess H.pylori status4,5,6,7,8• If positive, then offer eradication therapy.• If H. pylori negative treat empirically (see alogarithim- Group C)Eradication therapy• Advise patient with respect to triple therapy and the importance of compliance7-day course of PPI + dual antibiotic therapy:EXAMPLE: Cost / treatmentHeliclear- (+ 21 Lansoprazole 30mg) £54.63/28 dayslansoprazole 30mg, amoxicillin 500mg, clarithromycin 500mg• Continue treatment with PPI for further 8 weeks to promote ulcer healing 1• At 8 weeks, re-test using urea breath test (serology can remain positive for many years).Still HP positive after eradication• Check compliance- may have caused treatment failure• If H. pylori positive offer second course of eradication.• If H. pylori negative then refer for open access gastroscopy-Group C: H.pylori negative Cost for 28 days• Empirical therapy with PPI9 e.g. Rabeprazole 20mg od for 4 weeks £22.75• Step-down to antacid after treatment period10. Late or infrequent relapse restart PPI.• Early or frequent relapse (e.g. within 6 months) refer for open access gastroscopyGastroscopy11 References 1 British Society of Gastroenterology. No 1 September 1996 updated 2002.• Stop PPI/ H2-RA two weeks prior to gastroscopy http://www.bsg.org.uk• Helps rationalise therapy DOH upper GI cancer referral guidelines. 2000 2 3 Fisher RS, Parkman HP.Management of non ulcer dyspepsia. N Engl J Med 1998;• Biopsy for gold standard H.pylori test 339: 1376-1381• Will detect cancer 4 Soo S, Moayyedi P, Deeks J et al Pharmacoligical interventions for NUD in Cochrane Library 1, 2002. 5 BMA, RPSGB. British National Formulary. 2002; 43: 38-39. 6 Moayyedi P, Soo S, Deeks J, Delaney B et al Eradications of H pylori for NUDJuly 2002 in Cochrane Library1, 2002. 7 McColl K et al. BMJ 2002; 324: 999 8 Chiba N, et al. BMJ 2002; 324: 1012-4 9 Anon. Proton pump inhibitors: their role in dyspepsia. MEREC 1998; 11: 41-44Review: July 2004 10 NICE Technology Appraisal No 7.Guidance on PPI use in dyspepsia. 2000or in the light of new evidence 11 Prodigy Guidance http://www.prodigy.nhs.uk
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