First and second line as per antimicrobial guidelines: helicobacter eradication therapy

While it is possible to refer for gastroscopy to culture helicobacter and treat based on sensitivities, it may be helpful to be aware that this strategy is not always successful, as it can be difficult to culture H pylori in the lab.

Helicobacter eradication therapy

First and second line, see antimicrobial guidance: eradication of helicobacter pylori
While it is possible to refer for gastroscopy to culture helicobacter and treat based on sensitivities, it may be helpful to be aware that this strategy is not always successful, as it can be difficult to culture H pylori in the lab.

Confirm eradication

13C-urea breath test – prescribed on GP10

The patient must omit anti-secretory therapy for 2 weeks and antibiotics for 4 weeks before testing

Lifestyle factors

• Weight
• Smoking
• Diet eg caffeine, spicy food, alcohol intake, fatty foods
• Timing of meals ie taking small, regular meals and avoid eating late at night
• Raise head of bed for those with nocturnal reflux symptoms

Review medication:

• NSAIDs, steroids, bisphosphonates, calcium antagonists, nitrites and theophyllines are among the drugs associated with upper GI side-effects and should be reduced, stopped or substituted if possible

Consider recommending use of simple antacid therapy such as Peptac

Risk factors for Upper GI Malignancy

Patients with new onset upper GI pain or discomfort and any of the following risk factors for upper GI malignancy should be considered for routine referral

• Family history of oesophago-gastric cancer in a first degree relative
• Barrett’s oesophagus
• Pernicious anaemia
• Previous gastric surgery
• Achalasia
• Known dysplasia, atrophic gastritis, intestinal metaplasia

Lifestyle factors

• Weight
• Smoking
• Diet, eg: caffeine, spicy food, alcohol intake, fatty foods
• Timing of meals ie taking small, regular meals and avoid eating late at night
• Raise head of bed for those with nocturnal reflux symptoms

Review medication

• NSAIDs, steroids, bisphosphonates, calcium antagonists, nitrites and theophyllines are among the drugs associated with upper GI side-effects and should be reduced, stopped or substituted if possible.

Consider recommending use of simple antacid therapy such as Peptac

Risk factors Barrett's oesophagus

Routine endoscopy to look for Barrett’s oesophagus is not recommended for all patients with longstanding GORD but it should be considered in those with additional risk factors for the condition such as:

• male gender
• increased frequency of symptoms
• history of oesophageal stricture or oesophageal ulcers

Guidelines are based on the most recent Scottish Guidelines for Suspected Cancer  www.cancerreferral.scot.nhs.uk/oesophago-gastric-hepatobiliary-and-pancreatic-cancers/?alttemplate=guideline and the 2014 NICE document https://www.nice.org.uk/guidance/cg184/resources/gastrooesophageal-reflux-disease-and-dyspepsia-in-adults-investigation-and-management-pdf-35109812699845 for management of gastro-oesophageal reflux and dyspepsia

Neither guideline sets out a specific age at which simple dyspepsia or reflux requires to be investigated and it should be noted that gastroscopy does not feature significantly in the guidelines. This is because in the vast majority of patients with dyspepsia or GORD and in the absence of alarm symptoms, the findings at gastroscopy do not alter the management already outlined in the guidelines.

Many patients with upper GI symptoms who do not require to be referred for specialist assessment benefit from reassurance and the use of resources such as patient information leaflets for non-ulcer dyspepsia may be useful in primary care, for example:

https://gutscharity.org.uk/wp-content/uploads/2018/08/Guts-UK-Non-ulcer-Dyspepsia-Leaflet.pdf