Clinical

Diagnosis

Dyspepsia and Dysphagia

Background

  • Indigestion, heartburn, upper abdominal pain related to eating are experienced by one-third of the population at least once a year.   The vast majority of the population self medicate with OTC remedies.
  • Associated conditions include peptic ulcer disease (related to H.pylori and use of NSAIDs / aspirin) and GastroOesphageal Reflux Disease (GORD).
  • Dyspepsia often triggers endoscopy but management yields are low and costly compared to testing for and treating H. pylori or empirical use of PPIs.
  • Difficulty swallowing (dysphagia) and significant weight loss are alarm symptoms which merit prompt investigation along Two Week Wait Pathway
  • The incidence of oesophageal cancer (>6000 cases pa in UK) is one of the highest in the world and rising and exceeds gastric cancer where rates continue to fall due to decreasing rate of H.pylori infection and use of Hp eradication therapy.
  • No robust evidence exists to support current strategies for managing patients with Barrett's oesophagus.

Patient View

  • Most patients see medical advice from their GP because of troublesome symptoms or anxiety about serious underlying disease, which can trigger health seeking behaviour (and make their symptoms worse)

Current Practice

  • Management should be based upon the age of patient and presence/absence of alarm symptoms.
  • Young patients <55 without alarm features should usually be managed in primary care using H. Pylori test and treat and empirical PPI strategies.
  • Young patients with GORD symptoms may warrant laparoscopic surgery to avoid long term drug use.
  • Patients with alarm symptoms (dysphagia, early satiety, weight loss, anaemia) need prompt investigation, as do those > 55 with genuinely new significant dyspepsia.

Opportunities For Integrated Working

  • With the decline of H. Pylori and the effectiveness of empirical treatment the dividend from endoscopy for dyspepsia has become limited.
  • Patients on NSAIDS or coxibs chronically require PPI prophylaxis : http://www.nice.org.uk/CG017
  • Diagnosis of upper GI malignancy at a stage sufficiently early to cure is rewarding but uncommon and often a chance finding and is seldom achieved by systematic endoscopy of symptomatic patients.
  • However, it will remain important for high risk groups to have rapid access through structured pathways even though the therapeutic gain is limited.

Opportunities For Savings

  • Endoscopy has little value in the modern management of simple dyspepsia and reflux
  • Devising and enforcing precise local algorithms based on but with greater specificity than national ones represents a major opportunity for primary and secondary care to work together to free resources for other more valuable activity.
  • Feedback on referral practice is commonly given in many primary care settings but joint primary / secondary care discussion may also help in rationalising activity.
  • Wherever possible outpatient clinics should be based on the principle of one stop investigation and management.

Quality Indicators / Outcome Measures

  • Referral rates of individual practitioners for uncomplicated dyspepsia compared to local norms, with feed back and self directed moderation of behaviour Rate of specialist referral for uncomplicated dyspepsia (i.e. not adequately managed in primary care)
  • Proportion of occasions where the management of patients undergoing endoscopy for dyspepsia is changed following the procedure.
  • Conversion rates of TWW compared to rate of cancer diagnosis with previous inappropriately un-investigated symptoms.

Social Policy & Understanding

  • Numerous different systems and pathways to access OGD and USS, with risk that limiting access will drive inappropriate referral along TWW pathways
  • N/A to majority of patients with dyspepsia. Natural history of gastric cancer predicts that patients may only be diagnosed after attending A Long term management of GORD and appropriate consideration for surgical management

References