Gastro-oesophageal Reflux Disease and Dyspepsia in Adults: Investigation and Management

This Guidelines summary covers the investigation and management of dyspepsia and gastro-oesophageal reflux disease (GORD), including H pylori testing and eradication, and endoscopy referral. For a complete set of recommendations, refer to the full guideline.

Common Elements of Care

• Offer simple lifestyle advice, including advice on healthy eating, weight reduction, and smoking cessation
• Advise people to avoid known precipitants they associate with their dyspepsia where possible. These include smoking, alcohol, coffee, chocolate, fatty foods, and being overweight. Raising the head of the bed and having a main meal well before going to bed may help some people
• Provide people with access to educational materials to support the care they receive
• Recognise that psychological therapies, such as cognitive behavioural therapy and psychotherapy, may reduce dyspeptic symptoms in the short term in individual people
• Encourage people who need long-term management of dyspepsia symptoms to reduce their use of prescribed medication stepwise: by using the effective lowest dose, by trying ‘as-needed’ use when appropriate, and by returning to self-treatment with antacid and/or alginate therapy (unless there is an underlying condition or comedication that needs continuing treatment)

Referral Guidance for Endoscopy

Flowchart of Referral Criteria and Subsequent Management

• For people presenting with dyspepsia together with significant acute gastrointestinal bleeding, refer them immediately (on the same day) to a specialist (also see Acute upper gastrointestinal bleeding [NICE clinical guideline 141].)
• Review medications for possible causes of dyspepsia (for example, calcium antagonists, nitrates, theophyllines, bisphosphonates, corticosteroids and nonsteroidal anti-inflammatory drugs [NSAIDs]). In people needing referral, suspend NSAID use
• Think about the possibility of cardiac or biliary disease as part of the differential diagnosis
• If people have had a previous endoscopy and do not have any new alarm signs,^A consider continuing management according to previous endoscopic findings
• For more information about when to refer people to specialists when they present with symptoms that could be caused by cancer, see Referral for suspected cancer (NICE clinical guideline 27)

Interventions for Uninvestigated Dyspepsia

Flowchart for the Interventions for Uninvestigated Dyspepsia

• Be aware that dyspepsia in unselected people in primary care is defined broadly to include people with recurrent epigastric pain, heartburn or acid regurgitation, with or without bloating, nausea or vomiting (also see Common elements of care, above)
• Leave a 2-week washout period after proton pump inhibitor (PPI) use before testing for Helicobacter pylori with a breath test or a stool antigen test
• Offer empirical full-dose PPI therapy for 4 weeks to people with dyspepsia
• Offer H pylori ‘test and treat’ to people with dyspepsia
• If symptoms return after initial care strategies, step down PPI therapy to the lowest dose needed to control symptoms. Discuss using the treatment on an ‘as-needed’ basis with people to manage their own symptoms
• Offer H2 receptor antagonist (H₂ RA) therapy if there is an inadequate response to a PPI

Reviewing Patient Care

• Offer people who need long-term management of dyspepsia symptoms an annual review of their condition, and encourage them to try stepping down or stopping treatment (unless there is an underlying condition or comedication that needs continuing treatment)
• Advise people that it may be appropriate for them to return to self-treatment with antacid and/or alginate therapy (either prescribed or purchased over-the-counter and taken as needed)

Interventions for GORD

Flowchart for Interventions for GORD

• Manage uninvestigated ‘reflux-like’ symptoms as uninvestigated dyspepsia
• Offer people with GORD a full-dose PPI for 4 or 8 weeks
• If symptoms recur after initial treatment, offer a PPI at the lowest dose possible to control symptoms
• Discuss with people how they can manage their own symptoms by using the treatment when they need it
• Offer H₂ RA therapy if there is an inadequate response to a PPI
• People who have had dilatation of an oesophageal stricture should remain on long-term full-dose PPI therapy
• Offer people a full-dose PPI for 8 weeks to heal severe oesophagitis, taking into account the person’s preference and clinical circumstances (for example, underlying health conditions and possible interactions with other drugs)
• If initial treatment for healing severe oesophagitis fails, consider a high dose of the initial PPI, switching to another full-dose PPI or switching to another high-dose PPI, taking into account the person’s preference and clinical circumstances (for example, tolerability of the initial PPI, underlying health conditions and possible interactions with other drugs)
• Offer a full-dose PPI long-term as maintenance treatment for people with severe oesophagitis, taking into account the person’s preference and clinical circumstances (for example, tolerability of the PPI, underlying health conditions and possible interactions with other drugs), and the acquisition cost of the PPI
• If the person’s severe oesophagitis fails to respond to maintenance treatment, carry out a clinical review. Consider switching to another PPI at full dose or high dose taking into account the person’s preference and clinical circumstances, and/or seeking specialist advice
• Do not routinely offer endoscopy to diagnose Barrett’s oesophagus, but consider it if the person has GORD. Discuss the person’s preferences and their individual risk factors (for example, long duration of symptoms, increased frequency of symptoms, previous oesophagitis, previous hiatus hernia, oesophageal stricture or oesophageal ulcers, or male gender)

Interventions for Peptic Ulcer Disease

• Offer H pylori eradication therapy to people who have tested positive for H pylori and who have peptic ulcer disease. Also see H pylori testing and eradication, below
• For people using NSAIDs with diagnosed peptic ulcer, stop the use of NSAIDs where possible. Offer full-dose PPI or H₂ RA therapy for 8 weeks and, if H pylori is present, subsequently offer eradication therapy
• Offer people with gastric ulcer and H pylori repeat endoscopy 6 to 8 weeks after beginning treatment, depending on the size of the lesion
• Offer people with peptic ulcer (gastric or duodenal) and H pylori retesting for H pylori 6 to 8 weeks after beginning treatment, depending on the size of the lesion
• Offer full-dose PPI or H₂ RA therapy for 4 to 8 weeks to people who have tested negative for H pylori who are not taking NSAIDs
• For people continuing to take NSAIDs after a peptic ulcer has healed, discuss the potential harm from NSAID treatment. Review the need for NSAID use regularly (at least every 6 months) and offer a trial of use on a limited, ‘as-needed’ basis. Consider reducing the dose, substituting an NSAID with paracetamol, or using an alternative analgesic or low-dose ibuprofen (1.2 g daily)
• In people at high risk (previous ulceration) and for whom NSAID continuation is necessary, consider a COX-2 selective NSAID instead of a standard NSAID. In either case, prescribe with a PPI
• In people with an unhealed ulcer, exclude non-adherence, malignancy, failure to detect H pylori, inadvertent NSAID use, other ulcer-inducing medication and rare causes such as Zollinger–Ellison syndrome or Crohn’s disease
• If symptoms recur after initial treatment, offer a PPI to be taken at the lowest dose possible to control symptoms. Discuss using the treatment on an ‘as-needed’ basis with people to manage their own symptoms
• Offer H₂ RA therapy if there is an inadequate response to a PPI

Interventions for Functional Dyspepsia

• Manage endoscopically determined functional dyspepsia using initial treatment for H pylori if present, followed by symptomatic management and periodic monitoring
• Offer eradication therapy to people testing positive for H pylori
• Do not routinely offer re-testing after eradication, although the information it provides may be valued by individual people
• If H pylori has been excluded and symptoms persist, offer either a low-dose PPI or an H₂ RA for 4 weeks
• If symptoms continue or recur after initial treatment, offer a PPI or H₂ RA to be taken at the lowest dose possible to control symptoms
• Discuss using PPI treatment on an ‘as-needed’ basis with people to manage their own symptoms
• Avoid long-term, frequent dose, continuous antacid therapy (it only relieves symptoms in the short term rather than preventing them)

Helicobacter pylori Testing and Eradication

• Testing:
  • test for H pylori using a carbon-13 urea breath test or a stool antigen test, or laboratory-based serology where its performance has been locally validated
  • perform re-testing for H pylori using a carbon-13 urea breath test. (There is currently insufficient evidence to recommend the stool antigen test as a test of eradication)^B
  • do not use office-based serological tests for H pylori because of their inadequate performance
• Eradication:
  • first-line treatment:
    • offer people who test positive for H pylori a 7-day, twice-daily course of treatment with:
      • a PPI and
      • amoxicillin and
      • either clarithromycin or metronidazolechoose the treatment regimen with the lowest acquisition cost, and take into account previous exposure to clarithromycin or metronidazole
    • offer people who are allergic to penicillin^C a 7-day, twice-daily course of treatment with:
      • a PPI and
      • clarithromycin and
      • metronidazole
    • offer people who are allergic to penicillin^C and who have had previous exposure to clarithromycin a 7-day course of treatment with:
      • a PPI and
      • bismuth and
      • metronidazole and
      • tetracycline
  • discuss treatment adherence with the person and emphasise its importance. For more information about supporting adherence, see Medicines adherence (NICE clinical guideline 76)
• second-line treatment:
  • offer people who still have symptoms after first-line eradication treatment a 7-day, twice-daily course of treatment with:
    • a PPI and
    • amoxicillin and
    • either clarithromycin or metronidazole (whichever was not used first-line)
  • offer people who have had previous exposure to clarithromycin and metronidazole a 7-day course of treatment with:
    • a PPI and
    • amoxicillin and
    • tetracycline (or, if tetracycline cannot be used, levofloxacin)
  • offer people who are allergic to penicillin^C (and who have not had previous exposure to a fluoroquinolone antibiotic) a 7-day, twice-daily course of treatment with:
    • a PPI and
    • metronidazole and
    • levofloxacin^D
  • offer people who are allergic to penicillin^C and who have had previous exposure to a fluoroquinolone antibiotic a 7-day course of:
    • a PPI and
    • bismuth and
    • metronidazole and
    • tetracycline
  • seek advice from a gastroenterologist if eradication of H pylori is not successful with second-line treatment

Laparoscopic Fundoplication

• Consider laparoscopic fundoplication for people who have:
  • a confirmed diagnosis of acid reflux and adequate symptom control with acid suppression therapy, but who do not wish to continue with this therapy long term
  • a confirmed diagnosis of acid reflux and symptoms that are responding to a PPI, but who cannot tolerate acid suppression therapy

Referral to a Specialist Service

• Consider referral to a specialist service for people:
  • of any age with gastro-oesophageal symptoms that are non-responsive to treatment or unexplained^E
  • with suspected GORD who are thinking about surgery
  • with H pylori that has not responded to second-line eradication therapy

Surveillance for People With Barrett’s Oesophagus

• Consider surveillance to check progression to cancer for people who have a diagnosis of Barrett’s oesophagus (confirmed by endoscopy and histopathology), taking into account:
  • the presence of dysplasia (also see Barrett’s oesophagus­—ablative therapy [NICE clinical guideline 106])
  • the person’s individual preference
  • the person’s risk factors (for example, male gender, older age, and the length of the Barrett’s oesophagus segment)
• Emphasise that the harms of endoscopic surveillance may outweigh the benefits in people who are at low risk of progression to cancer (for example, people with stable non-dysplastic Barrett’s oesophagus)

Footnotes

[A] For more information about alarm signs please see Referral for suspected cancer (NICE clinical guideline 27).

[B] This refers to evidence reviewed in 2004.

[C] For the assessment of allergy to beta-lactam antibiotics and referral to specialist care, please see Drug allergy (NICE clinical guideline 183).

[D] See MHRA advice for restrictions and precautions for using fluoroquinolone antibiotics due to very rare reports of disabling and potentially long-lasting or irreversible side effects affecting musculoskeletal and nervous systems. Warnings include: stopping treatment at first signs of a serious adverse reaction (such as tendonitis), prescribing with special caution in people over 60 years and avoiding coadministration with a corticosteroid (March 2019).

[E] In the NICE guideline on Suspected cancer: recognition and referral, ‘unexplained’ is defined as ‘a symptom(s) and/or sign(s) that has not led to a diagnosis being made by the primary care professional after initial assessment of the history, examination and primary care investigations (if any)’.