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GPs should refer patients for persistent gastric reflux, says NICE

GPs should refer patients with persistent gastro-oesophageal symptoms for specialist care, recommend new draft NICE guidelines.

The guidance, published this week, says GPs should consider referring people of any age who have gastro-oesophageal reflux symptoms that are persistent, unresponsive to treatment or unexplained, or who are thinking about undergoing surgery.

But it advises against routinely referring patients for endoscopy to check for Barrett’s oesophagus, unless they have specific risk factors such as long duration or increased frequency of symptoms, or a history of strictures, ulcers, or hiatus hernia.

Current NICE guidance advises GPs on how to manage patients with uninvestigated dyspepsia or confirmed gastro-oesophageal reflux disease (GORD) who do not respond to initial treatment approaches, but leaves it to the GP when they should refer to a specialist.

The draft guidance also proposes GPs consider targeted surveillance for signs of cancer in some patients diagnosed with Barrett’s oesophagus, depending on the patient’s risk factors and personal preferences. But it advises against routine surveillance of these patients.

Other new recommendations include putting patients diagnosed with severe oesophagitis onto proton-pump inhibitor (PPI) maintenance treatment at the maximum dose if needed, if initial treatment for eight weeks fails.

The guidance, which will replace previous recommendations made in 2004, will also include some changes to first- and second-line therapy for peptic ulcer disease.

Professor Gillian Leng, deputy chief executive at NICE, said: ‘Since the last guideline was published, new evidence has come to light regarding the cost and most effective use of treatments and diagnostic equipment.

‘By updating our guideline and extending it to cover both primary and secondary care, we will continue to support the NHS to provide the highest possible quality of care in the most effective manner.’

Dr John O’Malley, a GPSI in gastroenterology in Manchester, said the proposals were ‘level-headed’ and reflected what many GPs were doing already, and should help to encourage more rational use of endoscopy.

Dr O’Malley said: ‘This is a level-headed set of proposals which say, offer people with GORD a full-dose PPI and see how things go -  but don’t jump into an endoscopy.

‘There is a worry about checking for Barrett’s oesophagus and if the patient is having lots of problems, with stricture or ulcers, or worsening symptoms despite higher doses of treatment, then weigh it up. But just because someone has got GORD does not mean they need endoscopy – you can diagnose it without and try to treat it with a PPI.’

Dr O’Malley added: ‘More rational use of upper GI endoscopy would mean we could redirect endoscopy facilities to screening for colon cancer, where we can improve outcomes through earlier diagnosis.’

NICE draft guidance on dyspepsia  key new recommendations

Offer a full-dose PPI for eight weeks to heal severe oesophagitis, taking into account patient’s preference and clinical circumstances such as PPI tolerance, underlying health conditions and any potential drug interactions .

Offer a full-dose PPI as long-term maintenance treatment for people with severe oesophagitis, taking into account patient’s preference and clinical circumstances such as PPI tolerance, underlying health conditions and any potential drug interactions, as well as the cost of the PPI.

Consider referral to a specialist service for people:

- of any age with gastro-oesophageal symptoms that are persistent, non‑responsive to treatment or unexplained

- with suspected GORD who are thinking about surgery

- with H pylori and persistent symptoms that have not responded to second-line eradication therapy.

Do not routinely offer endoscopy to diagnose Barrett’s oesophagus, but consider it if the person has GORD. Discuss the person’s preferences and their individual risk factors (for example, long duration of symptoms, increased frequency of symptoms, previous oesophagitis, previous hiatus hernia, oesophageal stricture or oesophageal ulcers, or male gender).

Consider surveillance to check progression to cancer for people who have a diagnosis of Barrett’s oesophagus (confirmed by endoscopy and histopathology), after first talking to the person about their preferences and risk factors (for example, male gender, older age and the length of the Barrett’s oesophagus segment).

Source: NICE draft guideline on dyspepsia, April 2014

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