Dr Tom Kennedy describes how the PCSG guidelines helped his practice agree on a strategy for managing dyspepsia and peptic ulcer disease
Few discoveries have captured the attention of GPs and the public so readily as the discovery of the aetiological role of Helicobacter pylori in peptic ulcer disease and the use of eradication therapy.
Although further refinements to theories on the pathogenesis of H. pylori are being made, the basic picture is in place and acceptable eradication therapies are available.
I work in an eight-partner inner-city practice covering a population with a high deprivation index. The area is an ideal breeding ground for H. pylori, but it does not have an open-access endoscopy service.
One year ago the waiting list for endoscopy was up to three months long. Consequently, we were under considerable pressure from our patients to prescribe acid suppressants in the interval between referral and investigation.
We wondered whether a test-and-treat policy might be more appropriate than a test-and-refer option, and also wished to decide on a strategy for the management of patients with a history of peptic ulcer disease who had not had eradication therapy.
It was agreed that we would schedule the management of dyspepsia and H. pylori as a topic for one of our regular clinical meetings.
Our practice is used to change, having recently moved to new premises and become a paperless practice. We have also introduced regular clinical meetings and found them beneficial in formulating management strategies. Relationships within the group are good and we can usually reach agreement.
The practice has not always operated in this way and that is why we have made an effort to facilitate change by dedicating time to a subject, working on maintaining good relationships within the group and promoting a willingness to accept change.
Initiating change has been facilitated by the success of previous innovations. It also helps to choose a topic on which there is a desire to formulate a management strategy, i.e. a problem that is pertinent, about which some concern has been raised, and which is dealt with in timely fashion.
During the meeting, uncertainty was voiced regarding:
- How to manage patients with a previous diagnosis of peptic ulcer disease who were on maintenance therapy
- The appropriate care of newly consulting dyspeptic patients
- Whether to test for H. pylori and offer eradication therapy without further investigation or to test for H. pylori and refer positive cases for endoscopy
- Which eradication therapy to use
- Whether it is necessary to determine H. pylori status after cessation of therapy.
Two of the partners are members of the Primary Care Society for Gastroenterology (PCSG), and brought along the society's management guidelines for discussion. The group agreed that what was required was a GP approach to the problem.
|Page from the PCSG guidelines on the management of Helicobacter pylori in primary care|
The PCSG guidelines had been created by Dr Greg Rubin, Senior Lecturer in Primary Care at the University of Teesside and Secretary of the PCSG.
We were particularly impressed with the methodology used to create the guidelines. A panel of GPs and specialists had met to consider the management of H. pylori.
Their meetings were aided by the provision of workbooks with clinical situations. Using these workbooks they identified management points that required clarification or evidence of support from the literature.
A systematic review of the literature that addressed these points was carried out and the results were presented to the panel, who reviewed their management strategy. The recommendations from the literature were graded in standard fashion in order to describe the strength of evidence from the literature.
Dr Rubin's team also identified where there was insufficient evidence in the literature to make a categorical statement regarding management.
The resulting guidelines were agreed by the panel and have since been circulated to all members of the RCGP and presented at a number of specialist conferences.
The guidelines certainly facilitated agreement during our meeting as they addressed our more pressing concerns.
We were also impressed with their layout and presentation on one A4 card, which would be readily accessible in a surgery setting. Copies were given to each of the GPs present and to the practice nurses.
The main messages of the guidelines were that:
- Eradication therapy worked well, as long as it was triple therapy
- Eradication therapy was indicated for H. pylori-associated peptic ulcer disease
- It was important to carry out H. pylori testing before deciding how to manage patients with significant dyspepsia
- It was not acceptable to offer blind eradication therapy without prior H. pylori testing.
There was also helpful advice on the use of investigative tests and whether or not there was sufficient evidence for or against test-and-treat strategies. We decided not to use near-patient finger-prick serology tests because of concern regarding their sensitivity and specificity.
The partners agreed to use the guidelines and to identify patients on the register with known peptic ulcer disease and, where appropriate, to offer them eradication therapy.
We asked our two computer data administrators to identify patients with a history of peptic ulcer disease as well as patients who were on maintenance acid suppressants. The partners then checked paper and computer records to determine the accuracy of the patients' diagnosis (endoscopy or barium meal-confirmed ulcer) and whether or not eradication therapy had already been offered.
It was at this point that we had some uncertainties:
- What was the best strategy for a patient with a diagnosed peptic ulcer who has not had eradication therapy but who is asymptomatic and not on maintenance therapy?
- What does one do for the patient who has a malignant ulcer due to gastric carcinoma?
The guidelines do not address these problems. Some of the partners decided to offer eradication therapy to patients who had a definite diagnosis of (non-NSAID) peptic ulcer disease in the past, whereas others offered eradication therapy only to patients who had recently (within the previous 5 years) been diagnosed or were on maintenance therapy.
We are still unsure about what to do with patients who have had a malignant ulcer, and this uncertainty is also experienced in secondary care. There appears to be a dearth of information on whether treating H. pylori has any effect on the progression of gastric carcinoma.
Partners differed in how they introduced the issue of eradication therapy to patients: some asked patients to consult before their next repeat prescription for acid suppressants, whereas others invited patients to attend, and still others raised the subject opportunistically.
Unless there was a previous history of perforation or haemorrhage, we did not conduct a post-eradication breath test, although some patients did have this at their GP's discretion.
The partners continue to vary in their approach to this management problem. The use of serology testing has rocketed in our area, with some difficulty for the local laboratories, but access to endoscopy has improved, with reduced waiting time.
It is also now possible to refer patients to the local hospital laboratory for H. pylori breath testing, but it is not yet possible to collect the breath sample in the practice surgery for forwarding to the laboratory.
The ease of investigation and improvement in access to endoscopy has influenced the partners in different ways: some conduct a test-and-treat approach and others refer H. pylori-positive patients for endoscopy. Concern regarding antimicrobial resistance may also be influencing whether we test and treat or test and refer.
Either way there is less uncertainty regarding overall management of newly diagnosed dyspeptics, and there is a certain satisfaction among the partners in having dealt with our existing known peptic ulcer patients.
Uuring this process, concern was raised about whether or not the association between H. pylori and adenocarcinoma of the stomach had implications for the management of patients with known adenocarcinoma. We also wondered whether the relatives of patients with gastric cancer should be tested for H. pylori and offered eradication therapy, and what was the benefit of eradication therapy for patients with H. pylori-positive functional dyspepsia.
At the moment these questions seem unanswered and await the outcome of ongoing clinical trials.
The PCSG guidelines cover the main points of concern and offer acceptable and pragmatic evidence-based advice. This has allowed us to formulate a management strategy in our practice that covers the majority of patients with dyspepsia and/or peptic ulcer disease and has met with the approval of the practice partners.
- Copies of the PCSG guidelines may be obtained from the Primary Care Society for Gastroenterology
- Farthing M (Ed). Br Med Bull 1998; 54(1): 17-30. The entire issue is dedicated to H. pylori and provides a comprehensive review.