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What not to do - gastroenterology

Sometimes being up to date means knowing what you can stop doing. Dr Adam Haycock outlines what has fallen out of fashion in gastroenterology

Investigations

Do not send patients who meet the criteria for IBS for ultrasound, colonic transit studies, rigid or flexible sigmoidoscopy, colonoscopy, faecal ova and parasites, faecal occult blood test or hydrogen breath testing.1

Patients who meet IBS criteria should have an ESR, CRP and coeliac serology to exclude other diagnoses. NICE has recommended the use of faecal calprotectin as a cost-effective investigation to distinguish IBS from inflammatory bowel disease in primary care in presentations that are not possible cancer. Estimated cost was £22.79 per patient, while a colonoscopy was estimated to cost £741.68 per person.

Treatment

Do not treat patients who have ongoing dyspepsia symptoms with a long-term, frequent-dose continuous prescription of antacid therapy.2

This is not recommended by NICE as it only relieves symptoms in the short term. Prevention by lifestyle changes such as dietary manipulation, smoking cessation and weight loss is more effective long term. Patients should also be encouraged to self-treat with a step-down approach to medical management using a PPI, H2 antagonist, prokinetic or alginates, with an annual review of medication.

Do not use dietary interventions alone as first-line treatment for constipation.1

Although dietary interventions alone should not be used first line, patients should be discouraged from taking excessive insoluble fibre and advised to increase their fluid and soluble fibre intake, and they should be given dietary and lifestyle advice, including the importance of physical activity.

The use of acupuncture or reflexology should not be encouraged for the treatment of IBS.3

Low-dose (5-10mg nocte) tricyclic antidepressants (TCAs) can be considered as second-line therapy, with SSRIs for patients who are intolerant of, or have poor response to, TCAs. NICE has recommended prucalopride as an option for the treatment of chronic constipation in women, in whom at least two laxatives and lifestyle changes over six months have failed to provide adequate relief.

Referral

Do not refer patients with globus for routine pH testing if you have no concerns over the symptoms.4

Routine pH testing is not recommended in this subset of patients with gastro-oesophageal reflux (GORD) or laryngopharyngeal reflux that has globus as the only symptom. If you have no concerns – true dysphagia and odynophagia have been excluded, and there were no findings on neurological examination – then there is no need for testing.

Patients with intractable unresponsive globus can be considered for referral to ENT for exclusion of laryngeal oedema with flexible nasal endoscopy. A barium swallow may also be reasonable to rule out co-existent oesophageal dysmotility or achalasia, which can be present in up to 25% of patients with persistent symptoms.

Do not refer patients with simple dyspepsia for gastroscopy without testing and treating for Helicobacter pylori.2

NICE recommends that patients (of any age) with dyspepsia but no alarm symptoms should be either given a one-month course of a PPI or tested for H. pylori, and those testing positive offered eradication therapy. Re-testing after eradication should not be offered routinely, but may be reasonable in patients who remain dependent on PPIs or other antacids. This should be with carbon-13 urea breath testing rather than a stool antigen test, which can remain persistently positive despite successful eradication.

Do not refer patients with dyspeptic symptoms for psychological therapies.2

Referral for psychological therapies, such as CBT and psychotherapy, may reduce dyspeptic symptoms in the short term in individual patients. However, given the intensive and costly nature of such interventions, routine provision by primary care is not recommended.

Do not refer patients with dyspeptic symptoms for surgery.2

Surgery is not recommended for the routine management of reflux, as only a minority of patients will benefit.

Do not use a family history of colorectal cancer as a criterion for referral in symptomatic patients with symptoms of rectal bleeding.5

Patients older than 40 years with a change in bowel habit with rectal bleeding, or patients over 60 with rectal bleeding alone, should be referred for urgent endoscopic evaluation. There is insufficient evidence that a family history of colorectal cancer can be used as a criterion for referral in symptomatic patients.

Dr Adam Haycock is a consultant gastroenterologist at The London Clinic and St Mark’s Hospital, Harrow

References

  1. NICE. CG99: Constipation in children and young people: diagnosis and management of idiopathic childhood constipation in primary and secondary care. London: NICE; 2010
  2. NICE. CG17: Dyspepsia: managing dyspepsia in adults in primary care. London: NICE; 2004
  3. NICE. CG61: Irritable bowel syndrome in adults: diagnosis and management of irritable bowel syndrome in primary care. London: NICE; 2008
  4. Globus sensation, pharyngoesophageal function, psychometric and psychiatric findings, and follow-up in 88 patients. Moser G et al. Arch Intern Med 1998;158:1365.
  5. NICE. CG27: Referral guidelines for suspected cancer. London: NICE; 2005

Readers' comments (4)

  • Let common sense prevail

    Prokinetics?
    The goalposts have moved again!

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  • Pipin Singh

    Useful thanks. No mention of safety issues with domperidone? Lots of recent MHRA alerts

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  • Really useful series; I'm certainly trying to review patients on long term PPI more as not such a "safe drug" anymore, c diff etc. Would be very harsh not to refer a patient for Investigation if they have FH of bowel ca in a young relative and are getting rectal bleeding...they would be so anxious.

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  • Thanks! An excellent and useful addition to a great series of articles.

    I would be interested to see credible trial evidence that weight loss actually improves pre-existing dyspepsia before recommending that patients lose weight.

    And I live in dread of the day when the local prescribing committee starts using financial thumbscrews to "encourage" GPs to get our patients off long-term PPIs. I'm old enough to remember the days of cimetidine-induced gynaecomastia and of telling patients to raise the head of their bed by at least 12 inches to prevent nocturnal reflux and I don't want to go back there.

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