PTH-005 Dyspepsia in 2017: are we adhering to guidelines?

Abstract

Dyspepsia in 2017: are we adhering to guidelines? Introduction Recent NICE guidance advocates a test-and-treat strategy for H. pylori in the management of dyspepsia without red-flag features (simple dyspepsia). In addition, NICE recommends trialling symptomatic management with proton pump inhibitors (PPI) or histamine receptor antagonists (H2RA). Upper gastrointestinal (UGI) endoscopy is recommended only if symptoms persist despite these strategies. The aim of this study was to assess degrees of adherence to current guidelines across various UGI endoscopy referral pathways (for example, GP direct access and gastroenterology clinics). Methods A single-centre, retrospective analysis was performed for patients who underwent endoscopy from 2016–2017, at a large district general hospital in North London. Data was obtained from Unisoft Endoscopy Reporting Tool software, alongside electronic patient records. Patient data was scrutinised for the following features prior to endoscopy: Presence of red–flag symptoms Endoscopy referral pathway type H. pylori investigations and treatment Management with PPI or H2RA Results Data was collected for 250 patients who underwent UGI endoscopy for dyspepsia. 53% were simple dyspepsia cases. 15% had clear red-flag symptoms warranting urgent endoscopy. 4% had symptoms warranting non-urgent endoscopy. 28% had no data available regarding red-flag symptoms. The majority of patients were referred for endoscopy either from gastroenterology clinics (47%) or GP direct access (43%). Other sources included surgical clinics and 1-stop clinics (10%). 60% of patients underwent H. pylori investigations prior to endoscopy. 35% had not been tested by the time of endoscopy. 5% had no data available regarding investigations. 33% of patients did not trial management prior to endoscopy. Of simple dyspepsia cases, 21/133 had not trialled management (11 had been referred from gastroenterology clinics, 6 from general surgery clinics, and 4 by GP direct access). Additionally, 51/133 of simple dyspepsia cases had not undergone H. pylori stool testing prior to endoscopy. The majority of these patients had been referred from gastroenterology clinics or GP direct access. Conclusions The majority of patients (53%) included in the study had no symptoms warranting urgent endoscopy. However, over 33% of patients had no H. pylori testing prior to endoscopy – furthermore, 15% had no trial of treatment. Lack of adherence to guidelines was present across all referral pathways. For an endoscopy service to function effectively, it must not be overloaded with inappropriate referrals; failure to follow guidelines increases this burden. Despite widespread availability of these guidelines, implementation remains poorly practised. Thus, NICE endoscopy referral guidance requires better implementation, by means such as increasing awareness in both primary and secondary care.