Dr Mark Cottrill discusses the key changes to the BSGÍs recommendations on investigating and treating dyspepsia
The revised dyspepsia guidelines from the British Society of Gastroenterology contain some important points for GPs and for commissioning groups.
The age at which endoscopy is recommended for patients with recent onset dyspepsia has been raised from 45 to 55 years in line with national cancer referral guidance. The working group concedes that the evidence for the change is weak. Identifying young patients with oesophagogastric cancer is difficult, and although most younger patients with this disease present with alarm symptoms, a smaller proportion present with uncomplicated dyspepsia.
The incidence of oesophageal cancer has increased dramatically in the past two decades, especially in younger patients. The working party recognises this phenomenon and recommends adjustments to the age for referral in areas with a high prevalence. The guidelines, of course, recommend that patients who present with alarm symptoms, such as dysphagia, anaemia, and weight loss, at any age should undergo early endoscopy.
The second main revision is the recommendation to treat patients under 55 years of age with dyspepsia if they test positive for Helicobacter pylori. The guidelines previously recommended a ïtest and scopeÍpolicy - to endoscope only those patients who tested positive for H. pylori. The new ïtest and treatÍ approach, is based on a number of studies and is cost effective and safe.
GPs should, however, be aware that although this strategy will cure most patients with peptic ulcer disease it may not alter symptoms in patients with non-ulcer dyspepsia. Meta-analyses suggest that only one in 15 H. pylori-positive patients with non-ulcer dyspepsia will benefit, so counselling before treatment is recommended.
The BSG acknowledges that ïtest and scopeÍ is still rational especially in areas with low H. pylori prevalence. Some patients still prefer investigation, and in my own practice I employ both strategies depending on the patientÍs preference.
The recommendations for H. pylori treatment have been simplified to a one-week course of ïtriple therapyÍ (a proton pump inhibitor with two of three antibiotics: amoxicillin, metronidazole and clarithromycin). ïQuadruple therapyÍ is suggested as second-line treatment. My own view is that metronidazole should be reserved for second line therapy.
A significant revision for GPs and those who commission services is the recommendation of a 13C urea breath test as the preferred test for identifying H. pylori and for confirming eradication.
The working group, along with the European Helicobacter Study Group, concedes that serology testing is not sufficiently sensitive to be recommended. GPs, therefore, should have easy access to urea breath testing. This is a logical development and PCTs should be aware of it and provide a testing service.
Although urea breath tests are available on an FP10 prescription, it is not reasonable for GPs to administer the test in view of the time involved.
The final main revision is the adoption of the NICE guidance on the use of proton pump inhibitors. NICE is also developing guidelines for the management of dyspepsia.
The BSG guideline developers admit that while many recommendations are evidence based, others that lack evidence are based on consensus. This is certainly the case for the management of functional dyspepsia. However, the document is well researched and well laid out, with useful flow diagrams for management. It provides valuable guidance for GPs and those involved with providing services at a local level.
Dyspepsia Management Guidelines can be downloaded from the BSG website: www.bsg.org.uk