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NICE guidelines: Management of dyspepsia in adults in primary care

NICE guidelines: Management of dyspepsia in adults in primary care. Alistair King Consultant Gastroenterologist HHGH.

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NICE guidelines: Management of dyspepsia in adults in primary care

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  1. NICE guidelines:Management of dyspepsia in adults in primary care Alistair King Consultant Gastroenterologist HHGH National Institute for Clinical Excellence (2004). Dyspepsia. Management of dyspepsia in adults in primary care. NICE clinical guideline No. 17 London: National Institute for Clinical Excellence. Available from: www.nice.org.uk/CG017NICEguideline.

  2. Definition of dyspepsia • Recurrent epigastric pain, heartburn or acid regurgitation, with or without bloating, nausea or vomiting

  3. Prevalence of dyspepsia in primary care • Dyspepsia occurs in 40% of the population annually1 • 5% consult their GP • 1% are referred for endoscopy 1Penston et al. 1996

  4. Dyspepsia

  5. Uninvestigated or investigated dyspepsia? • Most patients with dyspepsia can be managed without investigation • Indication for referral is based on alarm signs/symptoms: • chronic gastrointestinal bleeding • progressive unintentional weight loss • progressive dysphagia • persistent vomiting • iron deficiency anaemia • epigastric mass

  6. A ‘NICE’ U turn?? • Guidelines modified June 2005 in line with NICE Referral Guidelines for suspected cancer • Recommend urgent 2/52 ‘scope’ in over 55s if: • Unexplained • Recent onset • Persistent symptoms

  7. Treatment for uninvestigated dyspepsia • Initial empirical therapy • full–dose treatment for 1 month [Grade A recommendation] • H. pylori testing plus eradication therapy • bd PPI for 7 days, plus either metronidazole plus clarithromycin 250 mg (PMC250), or amoxicillin plus clarithromycin 500 mg (PAC500) [Grade A recommendation] • Persistent symptoms: • step-down therapy: discuss on demand use [Grade Brecommendation]

  8. HP testing • Serology • Do not routinely re-test • Serology remains positive after eradication • Re-check HP breath test (10 weeks after Rx)

  9. So what’s different? • Most do not need OGD • Empiric PPI • HP eradication • Algorithms for stepping up & down Rx • No re-scopes • Gone is age criteria (>45, >55yrs) • Alarm symptoms are mainstay • Gentle ‘refusal’ letter…….!

  10. What’s being done • PCT ‘committee’ • Alistair King • Andrew Chafer • Phil Sawyer • Peter Sweeney • Kate MacKay • Steve Laitner • Roll out date???

  11. Colonic cancer screening in high risk groups Alistair King Consultant Gastroenterologist BSG 2002

  12. Family History • One first degree relative diagnosed <45yrs • Two first degree relatives diagnosed at any age • Multiple generations affected within family • NB Marginal benefit! (Grade B)

  13. Screening protocol • At presentation or aged 35-40yrs, whichever is the later • Repeat aged 55yrs • If polyps found polyp screening guidelines • Otherwise reassure

  14. Risk • Age is a much stronger determinant! • 70yrs with no FH: 4% risk in 10 years • 40-60 with FH: 1.1% risk over 10 years

  15. Other considerations • 35-40yrs: 3618 colonoscopies to prevent 1 death • 55yrs: 213 colonoscopies to prevent 1 death • Colonoscopy perforation, bleeding, mortality rate= 0.3%, 0.3% and 0.014%

  16. Polyp surveillance • Hyperplastic/metaplastic polyps • Predominantly small/rectal • No malignant potential • Adenomas • Malignant potential • Number, size • Average 10yrs cancer • Cut off age 75yrs

  17. Conclusions • FH – screening colonoscopy only for those that fit the guidelines • Polyps • Adenoma? • Size? • Number? • Full colonoscopy? • Age?

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