The updated guideline from the BSG should help to streamline endoscopy referrals in patients with dyspepsia, says Dr Roland Valori

Dyspepsia is a common term used to label upper gastrointestinal symptoms. Dyspepsia may be indicative of a wide range of conditions including gastro-oesophageal reflux, peptic ulcer, Helicobacter pylori-related disorders, functional upper gut symptoms, upper gastrointestinal cancer and many others.

Dyspepsia is a common problem that consumes a vast quantity of healthcare resources.1 Medications used to treat dyspepsia cost more than £400 million per year, and at least 1% of the population has an upper gastrointestinal endoscopy each year. The lifetime chance of having an endoscopy is nearly 1:10.

The BSG released its original set of dyspepsia guidelines in 1996. They were among the first produced by the BSG and the most popular in terms of copies requested. However, they also caused controversy. On the one hand, the guidelines were applauded for their pragmatic and down to earth view, and their applicability to clinicians in both primary and secondary care. On the other hand, they were criticised for the lack of quoted evidence to support the recommendations. Concerns were also raised about the methodology.

Why did the guidelines need to be updated?

The BSG commissioned revised dyspepsia guidelines because a significant amount of time had elapsed since the first set but also in response to the criticism that they were not truly evidence-based. The most recent BSG dyspepsia guidelines were released earlier this year. Much of the original text has been preserved and in the latest version, available on the BSG website, the changes have been conveniently highlighted in red.

How robust is the evidence?

In the new version, the grading of evidence for each recommendation is explicit, and the gradings are appropriate for the evidence quoted. The authors of the revised version tried to be inclusive by circulating the guidelines to key stakeholders such as the Primary Care Society for Gastroenterology and the clinical effectiveness unit of the Royal College of Physicians.

While this is an improvement on the methodology used for the first set of guidelines, it could be argued that it is not an adequate substitute for a rigorous search strategy and critical appraisal process. Unfortunately, it is not clear what databases were searched and what search terms and search strategies were used. But the more important question is how much does this matter?

Vast resources would be required to carry out an exhaustive search. A small army of people with dedicated time and appropriate skills would be required to do justice to the subject of dyspepsia.

A compromise must be reached between the methodology and the resources and time available to put the guidelines together. It is difficult to determine what value would be added to a heavily resourced set of guidelines on dyspepsia. Clearly a point is reached where further effort adds very little. It seems likely that the core messages of the forthcoming NICE document on dyspepsia will not look very different from those of this one.

Figure 1: Algorithm for investigation and treatment of dyspepsia
Adapted from Dyspepsia Management Guidelines, www.bsg.org.uk

The key new messages of the current document are:

  • The age threshold for endoscopy in a patient with uncomplicated dyspepsia can be raised from 45 to 55 years (Figure 1, above). This is in line with the recommendations for the 2-week wait rule for patients with suspected upper gastrointestinal cancer. The chance of missing a cancer in a patient aged under 55 years without alarm symptoms is extremely low.
  • Patients below the age of 55 years who do not have alarm symptoms (Box 1, below) can be managed effectively with a test for H. pylori and a ïtreat if positiveÍ policy.
  • Whenever possible, the 13C breath test should be used to determine H. pylori status but if it is not readily available, a high quality serological test for H. pylori is an acceptable alternative.
  • Use of proton pump inhibitors should follow the NICE guidance.2

The guidelines are explicit when there is poor or insufficient evidence to support a recommendation.

Box 1: Alarm symptons
  • Unintentional weight loss >=3kg
  • Gastrointestinal bleeding
  • Previous gastric surgery
  • Epigastric mass
  • Previous gastric ulcer
  • Unexplained iron deficiency anaemia
  • Dysphagia and odynophagia
  • Persistent continuous vomiting
  • Suspicious barium meal

What do the guidelines leave out?

With such a vast and varied topic as dyspepsia it is not surprising that the guidelines are not comprehensive. The controversies surrounding management of BarrettÍs oesophagitis are avoided. There is little reference to NSAID-related dyspepsia. There is barely a mention of the role of H. pylori in reflux oesophagitis and NSAID-related peptic ulcer.

Perhaps the greatest disappointment is the incomplete review of the important economic evaluations that have been performed in dyspepsia in recent years.3 Excellent summary evidence of dyspepsia economic evaluations3 and also of the role of H. pylori eradication in non-ulcer dyspepsia4 was published by the Cochrane Group around the same time as the updated BSG guidelines were published.

These reviews support the ïtest and treatÍ strategy in younger patients but dismiss the ïtest and scopeÍ approach because it costs more and adds no benefit. They add a further dimension by encouraging endoscopy as a cost-effective measure in the older patient (compared with an empirical treatment strategy), providing the cost of an endoscopy is not too high.5

Will the guidelines improve patient care?

The principal effect of the guidelines should be to reduce demand for endoscopy by raising the age threshold for endoscopy in uncomplicated dyspepsia and by using a ïtest and treatÍ strategy in younger patients. If the same clinical outcome is achieved with fewer invasive and inconvenient tests the patient will clearly benefit.

If the strategies are successful, demand for endoscopy should fall, or at least stabilise. This should free up capacity and benefit other patients needing endoscopy who might otherwise wait months for it to be done.

I hope that the guidelines will lead to the withdrawal of near-patient testing and the less reliable serological methods for testing for H. pylori. The guidelines should encourage wider access to the gold standard non-invasive H. pylori test (13C).

Will the guidelines help to promote best practice?

Guidelines in isolation are not considered a very effective way of changing professional behaviour.6 However, it seems likely that if implementation of best practice leads to a reduction in healthcare expenditure, the PCTs will use other change techniques to ensure that GPs follow them. As a general principle, the more of these different techniques that are employed the more likely it is that change will occur.6 If this happens, the guidelines will probably achieve the goal of promoting best practice.

It will be interesting to see how extensive the NICE guidelines on dyspepsia are and to what extent they differ from the BSG guidelines. Despite considerably more expenditure and effort they will not be very different, I suspect.

Copies of Dyspepsia Management Guidelines can be obtained from Chris Romaya, British Society of Gastroenterology, 3 St Andrews Place, RegentÍs Park, London NW1 4LB; tel: 020 7935 2815; fax: 020 7487 3734; email: bsg@mailbox.ulcc.ac.uk or can be downloaded from the BSG website: www.bsg.org.uk

References

  1. Logan R, Delaney B. ABC of the upper gastrointestinal tract: implications of dyspepsia for the NHS. Br Med J 2001; 323: 675-7.
  2. NICE Technology Appraisal Guidance No 7. Guidance on the use of Proton Pump Inhibitors in the Treatment of Dyspepsia. London: NICE, July 2000. www.nice.org.uk
  3. Delaney BC, Innes MA, Deeks J et al. Initial management strategies for dyspepsia (Cochrane Review). In: The Cochrane Library, Issue 2 2002. Oxford: Update Software.
  4. Moayeddi P, Soo S, Deeks J et al. Eradication of Helicobacter pylori for non-ulcer dyspepsia (Cochrane Review). In: The Cochrane Library, Issue 2 2002. Oxford: Update Software.
  5. Delaney BC, Wilson S, Roalfe A et al. Cost effectiveness of initial endoscopy for dyspepsia in patients over age 50 years: a randomised controlled trial in primary care. Lancet 2000; 356: 1965-9.
  6. NHS Centre for Reviews and Dissemination. Getting evidence into practice. Effective Health Care Bulletin 1999; 5(1).

Guidelines in Practice, November 2002, Volume 5(11)
© 2002 MGP Ltd
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