NICE guidance - management of new episode of dyspepsia in primary care

Last edited 03/2019

Management of New Episode of Dyspepsia in Primary Care

Consider referral criteria

• immediate referral is indicated for significant acute gastrointestinal bleeding. Consider the possibility of cardiac or biliary disease as part of the differential diagnosis (1)
• NICE urgent cancer referral guidance states (2)

  • Suspected Oesophageal cancer

    • offer urgent direct access upper gastrointestinal endoscopy (to be performed within 2 weeks) to assess for oesophageal cancer n people:
      • with dysphagia or
      • aged 55 and over with weight loss and any of the following:
        • upper abdominal pain
        • reflux
        • dyspepsia

    Suspected Stomach cancer

    • consider a suspected cancer pathway referral (for an appointment within 2 weeks) for people with an upper abdominal mass consistent with stomach cancer
    • offer urgent direct access upper gastrointestinal endoscopy (to be performed within 2 weeks) to assess for stomach cancer in people:
      • with dysphagia or
      • aged 55 and over with weight loss and any of the following:
        • upper abdominal pain
        • reflux
        • dyspepsia

    Non Urgent Referral guidance:

    Suspected stomach cancer/oesophageal cancer:

    • consider non-urgent direct access upper gastrointestinal endoscopy to assess for stomach cancer/oesophageal cancer in people with haematemesis
      
      
    • consider non-urgent direct access upper gastrointestinal endoscopy to assess for stomach cancer/oesophageal cancer in people aged 55 or over with:
      • treatment-resistant dyspepsia or
        
        
      • upper abdominal pain with low haemoglobin levels or
        
        
      • raised platelet count with any of the following:
        • nausea
        • vomiting
        • weight loss
        • reflux
        • dyspepsia
        • upper abdominal pain, or
          
          
      • nausea or vomiting with any of the following:
        • weight loss
        • reflux
        • dyspepsia
        • upper abdominal pain
          
          
• routine endoscopic investigation of patients of any age, presenting with dyspepsia and without alarm signs, is not necessary (1)

If referral criteria met then:

1. review medications for possible causes of dyspepsia, for example, calcium antagonists, nitrates, theophyllines, bisphosphonates, steroids and NSAIDs. Patients undergoing endoscopy should be free from medication with either a proton pump inhibitor (PPI) or an H2 receptor (H2RA) for a minimum of 2 weeks
2. undertake endoscopy
   1. if upper GI malignancy then refer to specialist
   2. if gastro-oesophageal reflux disease see linked item
   3. if peptic ulcer disease then see linked items gastric ulcer or duodenal ulcer as appropriate
   4. if non-ulcer dyspepsia then see linked item

If referral criteria not met then treat as univestigated dyspepsia (see linked item)

For full details then refer to the full guideline (1).

Reference:

• NICE (2014). Dyspepsia - management of dyspepsia in adults in primary care.
• NICE (June 2015). Referral Guidelines for Suspected Cancer.
• NPC. Dyspepsia. MeReC Briefing 2006;32:1-8.