Dyspepsiagord Nice Guideline2

DRAFT FOR CONSULTATION
Dyspepsia and gastro-oesophageal reflux

disease: investigation and management of
dyspepsia, symptoms suggestive of
gastro-oesophageal reflux disease, or both
NICE guideline
Draft for consultation, April 2014
If you wish to comment on this version of the guideline, please be aware that
all the supporting information and evidence is contained in the full version.
Dyspepsia and GORD: NICE guideline DRAFT (April 2014) 1 of 42

Contents
Introduction ...................................................................................................... 3
Patient-centred care......................................................................................... 5
Strength of recommendations .......................................................................... 6
Update information........................................................................................... 8
Key priorities for implementation .................................................................... 10
1 Recommendations .................................................................................. 12
Terms used in this guideline ....................................................................... 12
1.1 The community pharmacist ............................................................... 12
1.2 Common elements of care ................................................................ 12
1.3 Referral guidance for endoscopy ...................................................... 13
1.4 Interventions for uninvestigated dyspepsia ....................................... 14
1.5 Reviewing patient care...................................................................... 14
1.6 Interventions for gastro-oesophageal reflux disease (GORD) .......... 15
1.7 Interventions for peptic ulcer disease................................................ 16
1.8 Interventions for functional dyspepsia ............................................... 18
1.9 Helicobacter pylori testing and eradication ....................................... 18
1.10 Laparoscopic fundoplication .......................................................... 21
1.11 Referral to a specialist service ....................................................... 21
1.12 Surveillance for people with Barrett’s oesophagus ........................ 21
2 Research recommendations.................................................................... 23
3 Other information..................................................................................... 25
4 The Guideline Development Group, NICE Internal Clinical Guidelines
Programme team and NICE project team ...................................................... 29
Appendix A: Dosage information on proton pump inhibitors .......................... 32
Appendix B: Recommendations from NICE clinical guideline 17 (2004) that
have been deleted or changed……………………………………………………34

Introduction
Dyspepsia describes a range of symptoms arising from the upper
gastrointestinal (GI) tract, but it has no universally accepted definition. The
British Society of Gastroenterology (BSG) defines dyspepsia as a group of
symptoms that alert doctors to consider disease of the upper GI tract, and
states that dyspepsia itself is not a diagnosis. These symptoms, which
typically are present for 4 weeks or more, include upper abdominal pain or
discomfort, heartburn, gastric reflux, nausea or vomiting.
Some of the costs associated with treating dyspepsia are decreasing, but the
overall use of treatments is increasing. As a result, the management of
dyspepsia continues to have potentially significant costs to the NHS.
The use of endoscopy has increased considerably over the past decade, as
awareness of its value in investigating dyspepsia and gastro-oesophageal
reflux disease (GORD) has grown.
The review of ‘Dyspepsia: management of dyspepsia in adults in primary care’

(NICE clinical guideline 17) highlighted some concerns about the drug
regimens that were recommended in the guideline for Helicobacter pylori
(hereafter referred to as H pylori) eradication, because some bacterial
resistance has developed. Overall, the review process concluded that some
guidance in this area should be updated and expanded to cover aspects of
specialist hospital care.
NICE clinical guideline 17 covered the management of several underlying

causes of dyspepsia in primary care, but there is a lack of comprehensive
national guidance about managing GORD (in particular, surgical
management) when pharmacological treatments fail. Because of this, and the
possible role of GORD (with the subsequent development of Barrett’s
oesophagus) as a risk factor for cancer, the scope of the guideline update was
extended to cover managing GORD in secondary care.
This guideline update covers adults (18 years and older) with symptoms of
dyspepsia, symptoms suggestive of GORD, or both. It also covers endoscopic

surveillance for adults with a diagnosis of Barrett's oesophagus, but it does

not cover the management of Barrett's oesophagus. It is important to note that
children and young people (younger than 18 years) and people with a
diagnosis of oesophagogastric cancer are not covered in this guideline
update.
In this guideline, specialist care is defined as treatment decisions made by a

consultant-led service in secondary or tertiary care.
Drug recommendations
The guideline will assume that prescribers will use a drug’s summary of
product characteristics to inform decisions made with individual patients.
This guideline recommends some drugs for indications for which they do not
have a UK marketing authorisation at the date of publication, if there is good
evidence to support that use. The prescriber should follow relevant
professional guidance, taking full responsibility for the decision. The patient
(or those with authority to give consent on their behalf) should provide
informed consent, which should be documented. See the General Medical
Council’s Good practice in prescribing and managing medicines and devices
for further information. Where recommendations have been made for the use
of drugs outside their licensed indications (‘off-label use’), these drugs are
marked with a footnote in the recommendations.
Specific dosage information on proton pump inhibitors (PPIs) is detailed in

appendix A.

Patient-centred care
This guideline offers best practice advice on the care of adults (18 years and
older) with symptoms of dyspepsia or symptoms suggestive of GORD, or
both.
Patients and healthcare professionals have rights and responsibilities as set

out in the NHS Constitution for England – all NICE guidance is written to
reflect these. Treatment and care should take into account individual needs
and preferences. Patients should have the opportunity to make informed
decisions about their care and treatment, in partnership with their healthcare
professionals. Healthcare professionals should follow the Department of
Health’s advice on consent. If someone does not have capacity to make
decisions, healthcare professionals should follow the code of practice that
accompanies the Mental Capacity Act and the supplementary code of practice
on deprivation of liberty safeguards.
NICE has produced guidance on the components of good patient experience

in adult NHS services. All healthcare professionals should follow the
recommendations in Patient experience in adult NHS services.

Strength of recommendations
Some recommendations can be made with more certainty than others. The
Guideline Development Group makes a recommendation based on the trade-
off between the benefits and harms of an intervention, taking into account the
quality of the underpinning evidence. For some interventions, the Guideline
Development Group is confident that, given the information it has looked at,
most patients would choose the intervention. The wording used in the
recommendations in this guideline denotes the certainty with which the
recommendation is made (the strength of the recommendation).
For all recommendations, NICE expects that there is discussion with the
patient about the risks and benefits of the interventions, and their values and
preferences. This discussion aims to help them to reach a fully informed
decision (see also ‘Patient-centred care’).
Interventions that must (or must not) be used

We usually use ‘must’ or ‘must not’ only if there is a legal duty to apply the
recommendation. Occasionally we use ‘must’ (or ‘must not’) if the
consequences of not following the recommendation could be extremely
serious or potentially life threatening.
Interventions that should (or should not) be used – a ‘strong’

recommendation
We use ‘offer’ (and similar words such as ‘refer’ or ‘advise’) when we are
confident that, for the vast majority of patients, an intervention will do more
good than harm, and be cost effective. We use similar forms of words (for
example, ‘Do not offer…’) when we are confident that an intervention will not
be of benefit for most patients.
Interventions that could be used

We use ‘consider’ when we are confident that an intervention will do more
good than harm for most patients, and be cost effective, but other options may
be similarly cost effective. The choice of intervention, and whether or not to
have the intervention at all, is more likely to depend on the patient’s values

and preferences than for a strong recommendation, and so the healthcare

professional should spend more time considering and discussing the options
with the patient.
Recommendation wording in guideline updates

NICE began using this approach to denote the strength of recommendations
in guidelines that started development after publication of the 2009 version of
‘The guidelines manual’ (January 2009). This does not apply to any
recommendations shaded in grey and ending [2004] (see ‘Update information’
box below for details about how recommendations are labelled). In particular,
for recommendations labelled [2004], the word ‘consider’ may not necessarily
be used to denote the strength of the recommendation.

Update information
This guidance is an update of NICE clinical guideline 17 (published in
April 2004) and will replace it.
New recommendations have been added about investigation and referral,

H pylori eradication therapy, specialist management, and surveillance of
Barrett’s oesophagus in people with dyspepsia.
You are invited to comment on the new and updated recommendations in this
guideline. These are marked as:
 [new 2014] if the evidence has been reviewed and the recommendation
has been added or updated
 [2014] if the evidence has been reviewed but no change has been made to
the recommended action.
You are also invited to comment on recommendations that NICE proposes to

delete from the [2004] guideline, because either the evidence has been
reviewed and the recommendations have been updated, or NICE has updated
other relevant guidance and has replaced the original recommendations.
Appendix A sets out these recommendations and includes details of
replacement recommendations. Where there is no replacement
recommendation, an explanation for the proposed deletion is given.
Where recommendations are shaded in grey and end [2004], the evidence
has not been reviewed since the original guideline. We will not be able to
accept comments on these recommendations. Yellow shading in these
recommendations indicates wording changes that have been made for the
purposes of clarification only.
Where recommendations are shaded in grey and end [2004, amended 2014],
the evidence has not been reviewed but changes have been made to the
recommendation wording that change the meaning (for example, because of
equalities duties or a change in the availability of drugs, or incorporated

guidance has been updated). These changes are marked with yellow shading,
and explanations of the reasons for the changes are given in appendix B for
information. We will not be able to accept comments on these
recommendations.
The original NICE guideline and supporting documents are available here.

Key priorities for implementation

The following recommendations have been identified as priorities for
implementation.
Referral guidance for endoscopy
 For people presenting with dyspepsia together with significant acute

gastrointestinal bleeding, refer them immediately (on the same day) to a
specialist. [2004] (Also see Acute upper gastrointestinal bleeding [NICE
clinical guideline 141].) [Recommendation 1.3.1]
Interventions for uninvestigated dyspepsia
 Leave a 2-week washout period after proton pump inhibitor (PPI) use
before testing for Helicobacter pylori (hereafter referred to as H pylori) with
a breath test or a stool antigen test. [2004, amended 2014]
[Recommendation 1.4.2]
Interventions for gastro-oesophageal reflux disease (GORD)
 Offer people a full-dose PPI (see table 2 in appendix A) 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). [new 2014] [Recommendation
1.6.7]
 Offer a full-dose PPI (see table 2 in appendix A) 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. [new 2014] [Recommendation
1.6.9]
 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).

[new 2014] [Recommendation 1.6.11]
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'. [2004] [Recommendation 1.7.1]
 For people using NSAIDs with diagnosed peptic ulcer, stop the use of
NSAIDs where possible. Offer full-dose PPI (see table 1 in appendix A) or
H2RA therapy for 8 weeks and, if H pylori is present, subsequently offer
eradication therapy. [2004] [Recommendation 1.7.2]
 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 lesion. [2004, amended 2014] [Recommendation 1.7.4]
Referral to a specialist service
 Consider referral to a specialist service for people:

 of any age with gastro-oesophageal symptoms that are persistent,
non-responsive to treatment or unexplained1
 with suspected GORD who are thinking about surgery
 with H pylori and persistent symptoms that have not responded to
second-line eradication therapy. [new 2014] [Recommendation 1.11.1]
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), after first talking to the person about their preferences and
risk factors (for example, male gender, older age and the length of the
Barrett’s oesophagus segment). [new 2014] [Recommendation 1.12.2]
1
In Referral guidelines for suspected cancer (NICE clinical guideline 27), ‘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)’. (Please note that an update is in progress; publication expected May
2015. For more information see http://guidance.nice.org.uk/CG/Wave0/618.)

1 Recommendations
The following guidance is based on the best available evidence. The full
guideline [hyperlink to be added for final publication] gives details of the
methods and the evidence used to develop the guidance.
Terms used in this guideline

In this guideline, gastro-oesophageal reflux disease (GORD) refers to
endoscopically determined oesophagitis or endoscopy-negative reflux
disease.
1.1 The community pharmacist

1.1.1 Community pharmacists should offer initial and ongoing help for
people with symptoms of dyspepsia. This includes advice about
lifestyle changes, using over-the-counter medication, help with
prescribed drugs and advice about when to consult a GP. [2004]
1.1.2 Community pharmacists should record adverse reactions to

treatment and may participate in primary care medication review
clinics. [2004]
1.2 Common elements of care

1.2.1 Offer simple lifestyle advice, including advice on healthy eating,
weight reduction and smoking cessation. [2004]
1.2.2 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. [2004]
1.2.3 Provide people with access to educational materials to support the

care they receive. [2004]
1.2.4 Recognise that psychological therapies, such as cognitive

behavioural therapy and psychotherapy, may reduce dyspeptic

symptoms in the short term in individual people. [2004, amended

2014]
1.2.5 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). [2004, amended
2014]
1.3 Referral guidance for endoscopy

1.3.1 For people presenting with dyspepsia together with significant
acute gastrointestinal bleeding, refer them immediately (on the
same day) to a specialist. [2004] (Also see Acute upper
gastrointestinal bleeding [NICE clinical guideline 141].)
1.3.2 Review medications for possible causes of dyspepsia (for example,

calcium antagonists, nitrates, theophyllines, bisphosphonates,
corticosteroids and non-steroidal anti-inflammatory drugs
[NSAIDs]). In people needing referral, suspend NSAID use. [2004]
1.3.3 Think about the possibility of cardiac or biliary disease as part of

the differential diagnosis. [2004, amended 2014]
1.3.4 If people have had a previous endoscopy and do not have any new
alarm signs2, consider continuing management according to
previous endoscopic findings. [2004]
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 [update in progress; publication
expected May 2015: http://guidance.nice.org.uk/CG/Wave0/618]).
2
For more information about alarm signs please see Referral for suspected cancer (NICE
clinical guideline 27 [update in progress; publication expected May 2015. For more
information see http://guidance.nice.org.uk/CG/Wave0/618]).

1.4 Interventions for uninvestigated dyspepsia

1.4.1 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’. [2004, amended
2014]
1.4.2 Leave a 2-week washout period after proton pump inhibitor (PPI)
use before testing for Helicobacter pylori (hereafter referred to as
H pylori) with a breath test or a stool antigen test. [2004, amended
2014]
1.4.3 Offer empirical full-dose PPI therapy (see table 1 in appendix A) for
4 weeks to people with dyspepsia. [2004]
1.4.4 Offer H pylori 'test and treat' to people with dyspepsia. [2004]
1.4.5 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. [2004]
1.4.6 Offer H2 receptor antagonist (H2RA) therapy if there is an

inadequate response to a PPI. [2004, amended 2014]
1.5 Reviewing patient care

1.5.1 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). [2004, amended 2014]
1.5.2 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).
[2004, amended 2014]

1.6 Interventions for gastro-oesophageal reflux disease

(GORD)
1.6.1 Manage uninvestigated 'reflux-like' symptoms as uninvestigated
dyspepsia. [2004, amended 2014]
1.6.2 Offer people with GORD a full-dose PPI (see table 1 in appendix A)
for 4 or 8 weeks. [2004]
1.6.3 If symptoms recur after initial treatment, offer a PPI at the lowest
dose possible to control symptoms. [2004, amended 2014]
1.6.4 Discuss with people how they can manage their own symptoms by
using the treatment when they need it. [2004]
1.6.5 Offer H2RA therapy if there is an inadequate response to a PPI.

[2004, amended 2014]
1.6.6 People who have had dilatation of an oesophageal stricture should

remain on long-term full-dose PPI (see table 1 in appendix A)
therapy. [2004]
1.6.7 Offer people a full-dose PPI (see table 2 in appendix A) 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). [new
2014]
1.6.8 If initial treatment for healing severe oesophagitis fails, consider a

high dose of the initial PPI, switching to another full-dose PPI (see
table 2) or switching to another high-dose PPI (see table 2 in
appendix A), 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). [new 2014]

1.6.9 Offer a full-dose PPI (see table 2 in appendix A) 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. [new 2014]
1.6.10 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 (see table 2 in appendix A), taking into
account the person’s preference and clinical circumstances, and/or
seeking specialist advice. [new 2014]
1.6.11 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). [new 2014]
1.7 Interventions for peptic ulcer disease

1.7.1 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'. [2004]
1.7.2 For people using NSAIDs with diagnosed peptic ulcer, stop the use
of NSAIDs where possible. Offer full-dose PPI (see table 1 in
appendix A) or H2RA therapy for 8 weeks and, if H pylori is present,
subsequently offer eradication therapy. [2004]
1.7.3 Offer people with gastric ulcer and H pylori repeat endoscopy 6 to
8 weeks after beginning treatment, depending on the size of lesion.
[2004, amended 2014]

1.7.4 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 lesion. [2004, amended 2014]
1.7.5 Offer full-dose PPI (see table 1 in appendix A) or H2RA therapy for
4 to 8 weeks to people who have tested negative for H pylori who
are not taking NSAIDs. [2004]
1.7.6 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).
[2004]
1.7.7 In people at high risk (previous ulceration) and for whom NSAID
continuation is necessary, offer gastric protection or consider
substitution with a cyclooxygenase (COX)-2-selective NSAID.
[2004]
1.7.8 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. [2004]
1.7.9 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. [2004, amended 2014]
1.7.10 Offer H2RA therapy if there is an inadequate response to a PPI.

[2004]

1.8 Interventions for functional dyspepsia

1.8.1 Manage endoscopically determined functional dyspepsia using
initial treatment for H pylori if present, followed by symptomatic
management and periodic monitoring. [2004]
1.8.2 Offer eradication therapy to people testing positive for H pylori.

[2004]
1.8.3 Do not routinely offer re-testing after eradication, although the

information it provides may be valued by individual people. [2004]
1.8.4 If H pylori has been excluded and symptoms persist, offer either a
low-dose PPI (see table 1 in appendix A) or an H2RA for 4 weeks.
[2004, amended 2014]
1.8.5 If symptoms continue or recur after initial treatment offer a PPI or

H2RA to be taken at the lowest dose possible to control symptoms.
[2004, amended 2014]
1.8.6 Discuss using PPI treatment on an as-needed basis with people to

manage their own symptoms. [2004]
1.8.7 Avoid long-term, frequent dose, continuous antacid therapy (it only
relieves symptoms in the short term rather than preventing them).
[2004, amended 2014]
1.9 Helicobacter pylori testing and eradication
Testing
1.9.1 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. [2004, amended 2014]

1.9.2 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 eradication3.) [2004]
1.9.3 Do not use office-based serological tests for H pylori because of

their inadequate performance. [2004, amended 2014]]
Eradication
First-line treatment
1.9.4 Offer people who test positive for H pylori a 7-day, twice-daily
course of treatment with:
 a PPI (see table 3 in appendix A) and

 amoxicillin and
 either clarithromycin or metronidazole.
Choose the treatment regimen with the lowest acquisition cost,

and take into account previous exposure to clarithromycin or
metronidazole. [new 2014]
1.9.5 Offer people who are allergic to penicillin and who have had
previous exposure to clarithromycin and a quinolone a 7-day,
twice-daily course of treatment with:

 clarithromycin and
 metronidazole. [new 2014]
previous exposure to clarithromycin a 7-day, twice-daily course of
treatment with:

 bismuth and
3
This refers to evidence reviewed in 2004.

 metronidazole and
 tetracycline. [new 2014]
1.9.7 Discuss treatment adherence with the person and emphasise its
importance. For more information about supporting adherence, see
Medicines adherence (NICE clinical guideline 76). [new 2014]
Second-line treatment
1.9.8 Offer people who still have symptoms after first-line eradication
treatment a 7-day, twice-daily course of treatment with:

 amoxicillin and
 either clarithromycin or metronidazole (whichever was not used
first-line). [new 2014]
1.9.9 Offer people who have had previous exposure to clarithromycin

and metronidazole a 7-day, twice-daily course of treatment with:

 amoxicillin and
 a quinolone or tetracycline (whichever has the lowest acquisition
cost). [new 2014]
1.9.10 Offer people who are allergic to penicillin (or who have had
previous exposure to clarithromycin but not a quinolone) a 7-day,

 levofloxacin. [new 2014]
previous exposure to clarithromycin and a quinolone:

 bismuth and

 a tetracycline. [new 2014]
1.9.12 Seek advice from a gastroenterologist if eradication of H pylori is

not successful with second-line treatment. [new 2014]
1.10 Laparoscopic fundoplication

1.10.1 Consider laparoscopic fundoplication for people who have:
 adequate symptom control with acid suppression therapy but do

not wish to continue with this therapy long term
 a confirmed diagnosis of acid reflux but cannot tolerate acid
suppression therapy. [new 2014]
1.11 Referral to a specialist service

1.11.1 Consider referral to a specialist service for people:
 of any age with gastro-oesophageal symptoms that are

persistent, non-responsive to treatment or unexplained4
 with suspected GORD who are thinking about surgery
 with H pylori and persistent symptoms that have not responded
to second-line eradication therapy. [new 2014]
1.12 Surveillance for people with Barrett’s oesophagus

1.12.1 Do not routinely offer surveillance for people with Barrett’s
oesophagus. [new 2014]
1.12.2 Consider surveillance to check progression to cancer for people

who have a diagnosis of Barrett’s oesophagus (confirmed by
endoscopy and histopathology), after first talking to the person
about their preferences and risk factors (for example, male gender,
4
In Referral guidelines for suspected cancer (NICE clinical guideline 27), ‘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)’. (Please note that an update is in progress; publication expected May
2015. For more information, see http://guidance.nice.org.uk/CG/Wave0/618.)

older age and the length of the Barrett’s oesophagus segment).

[new 2014]

2 Research recommendations
The Guideline Development Group has made the following recommendations
for research, based on its review of evidence, to improve NICE guidance and
patient care in the future.
2.1 Patient characteristics, risk factors and predictors

that indicate endoscopy for excluding Barrett’s
oesophagus
In people who experience symptoms of gastro-oesophageal reflux disease
(GORD) or symptoms suggestive of GORD, what patient characteristics, risk
factors, and predictors indicate when endoscopy is needed to exclude
Barrett’s oesophagus?
Why this is important
The aim is to identify adults with symptoms of GORD or symptoms suggestive

of GORD who may benefit from having an endoscopy for the purpose of early
identification of Barrett’s oesophagus (or to exclude Barrett’s oesophagus).
2.2 Laparoscopic fundoplication compared with medical

management
What is the effectiveness of laparoscopic fundoplication compared with
medical management in people with GORD that does not respond to optimal
proton pump inhibitor (PPI) treatment?
Current evidence on the clinical and cost effectiveness of laparoscopic

fundoplication compared with medical management involves people who had
relatively good treatment control with PPIs at baseline. The driver was the
people’s desire to be free from medication rather than their GORD being
non-responsive to PPIs.

2.3 Effective proton pump inhibitor dosage for severe

erosive reflux disease
What is the clinical effectiveness of double-dose PPIs in people with severe
erosive reflux disease (Los Angeles classification grade C/D or Savary–Miller
grade 3/4):
 to reduce severe oesophagitis

 to control symptoms
 as maintenance therapy?
People with severe erosive reflux disease or severe oesophagitis (Los

Angeles classification grade C/D or Savary–Miller grade 3/4) experience
severe heartburn, and prolonged acid and pepsin exposure in the lower
oesophagus, which can affect their day-to-day wellbeing. It would substantially
improve people’s quality of life if an optimal treatment regimen could be
identified. Currently, there is a lack of evidence on the efficacy of
‘double-dose’ PPIs in treating severe erosive reflux disease.
2.4 Other specialist management

What other specialist management is effective for people whose symptoms do
not respond to PPIs despite optimum primary care, or for people whose
symptoms return after surgery?
There is a small group of people whose symptoms do not resolve, despite

medical management and/or surgery for reflux. The group should be divided
into people with proven (by pH monitoring) GORD and people with symptoms
but no diagnosed reflux. The first group should have a trial of a twice-daily,
high-dose PPI versus a standard or full-dose PPI. The second group should
have a trial of tricyclic antidepressants (for example, amitriptyline) versus
standard or full-dose PPI. The purpose of any treatment should focus on
improving quality of life.

2.5 Specialist investigation

What specialist investigations should be conducted to exclude a diagnosis of
functional dyspepsia in people with uninvestigated dyspepsia that does not
respond to PPIs or H2 receptor antagonists (H2RAs) despite optimum primary
care?
People with uninvestigated dyspepsia that fails to respond to PPI or H2RA

therapy despite optimum primary care can have a poor quality of life. It is
important to ensure that appropriate investigations are carried out to make an
appropriate diagnosis or to correct misdiagnosis, so that appropriate
treatments can be provided.
3 Other information
3.1 Scope and how this guideline was developed

NICE guidelines are developed in accordance with a scope that defines what
the guideline will and will not cover.
How this guideline was developed
NICE commissioned the Internal Clinical Guidelines Programme to develop

the [2014] recommendations this guideline. The Centre established a
Guideline Development Group (see section 4), which reviewed the evidence
and developed the recommendations.
The methods and processes for developing NICE clinical guidelines are
described in The guidelines manual.
3.2 Related NICE guidance

Details are correct at the time of consultation on the guideline (March 2014).
Further information is available on the NICE website.

Published
General
 Patient experience in adult NHS services. NICE clinical guidance 138

(2012).
 Medicines adherence. NICE clinical guidance 76 (2009).
Condition-specific
 Endoscopic radiofrequency ablation for gastro-oesophageal reflux disease.

NICE interventional procedure guidance 461 (2013).
 Laparoscopic insertion of a magnetic bead band for gastro-oesophageal
reflux disease. NICE interventional procedure guidance 431 (2012).
 Acute upper gastrointestinal bleeding. NICE clinical guideline 141 (2012).
 Minimally invasive oesophagectomy. NICE interventional procedure
guidance 407 (2011).
 Endoluminal gastroplication for gastro-oesophageal reflux disease. NICE
interventional procedure guidance 404 (2011).
 Barrett’s oesophagus – ablative therapy. NICE clinical guideline 106
(2010).
 Chest pain of recent onset. NICE clinical guideline 95 (2010).
 Endoscopic submucosal dissection of gastric lesions. NICE interventional
procedure guidance 360 (2010).
 Endoscopic mucosal resection and endoscopic submucosal dissection of
non-ampullary duodenal lesions. NICE interventional procedure guidance
359 (2010).
 Endoscopic submucosal dissection (ESD) of oesophageal dysplasia and
neoplasia. NICE interventional procedure guidance 355 (2010).
 Photodynamic therapy for Barrett's oesophagus. NICE interventional
 Epithelial radiofrequency ablation for Barrett's oesophagus. NICE
interventional procedure guidance 344 (2010).
 Photodynamic therapy for early oesophageal cancer. NICE interventional

 Catheterless oeosophageal pH monitoring. NICE interventional procedure

guidance 187 (2006).
 Endoscopic injection of bulking agents for gastro-oesophageal reflux
disease. NICE interventional procedure guidance 55 (2004).
 Dyspepsia. NICE clinical guideline 17 (2004).
Under development
NICE is developing the following guidance (details available from the NICE
website):
 GORD in children. NICE clinical guideline. Publication expected January

2015.
 Suspected cancer (update of CG27). NICE clinical guideline. Publication
expected May 2015.

4 The Guideline Development Group, NICE

Internal Clinical Guidelines Programme team
and NICE project team
4.1 Guideline Development Group

The Guideline Development Group members listed are those for the 2014
update. For the composition of (the) previous Guideline Development
Group(s), see the full guideline [hyperlink to be added for final publication].
Peter Barry
Chair, Consultant in Paediatric Intensive Care, Leicester Royal Infirmary
Hugh Barr
Consultant General and Upper Gastrointestinal Surgeon, Gloucestershire
Royal Hospital
John de Caestecker
Consultant Gastroenterologist, University Hospitals of Leicester
Mark Follows
Freelance GP, Yorkshire
Alex Ford
Consultant Gastroenterologist, Leeds Teaching Hospitals NHS Trust
Janusz Jankowski
Consultant Gastroenterologist, Leicester Royal Infirmary
Ann Harding
Patient and carer member
Mimi McCord
Patient and carer member

4.2 Expert advisers to the group

Clionda McNulty
Head of Primary Care Unit, Public Health England, Gloucestershire Royal
Hospital
Marco Novelli
Consultant Histopathology, University College Hospitals NHS Trust
Sui Man Tin

Senior Pharmacist Gastroenterology, Royal Liverpool and Broadgreen
University Hospitals NHS Trust
4.3 NICE Internal Clinical Guidelines Programme team

Lynda Ayiku
Information Specialist (until January 2013)
Mark Baker
Clinical Adviser (until March 2012)
Emma Banks
Project Manager
Steven Barnes
Technical Analyst (until December 2012)
Jenny Craven
Information Specialist (from January 2013)
Susan Ellerby
Clinical Adviser (from October 2012)
Nicole Elliott
Associate Director
Ruth Garnett
Medicines Evidence Senior Adviser

Kathryn Harrisson
Technical Analyst
Michael Heath
Programme Manager
Rachel Houten
Health Economist (from April 2013)
Emma McFarlane
Technical Analyst
Gabriel Rogers
Technical Adviser (Health Economist)
Claire Stevens
Medicines Evaluation Scientist
Lisa Stone
Medicines Evidence Senior Adviser
Toni Tan
Technical Adviser
Jonathan Underhill
Medicines Evidence Associate Director
Thomas Wilkinson
Health Economist (until February 2013)
4.4 NICE project team

Sharon Summers-Ma
Guideline Lead
Martin Allaby
Clinical Adviser

Ben Doak
Guideline Commissioning Manager
Joy Carvill
Guideline Coordinator
Beth Shaw
Technical Lead
Jasdeep Hayre
Technical Lead (Health Economics)
Sarah Palombella
Editor

Appendix A: Dosage information on proton pump

inhibitors
In 2004, when the original guideline was developed (CG17), doses of PPIs
were based on the British National Formulary (BNF) at the time, as in table 1
below.
During the update of this guideline (2014), the GDG have further defined the
PPI doses specifically for severe oesophagitis and H pylori eradication
therapy, in tables 2 and 3 below.
Table 1 PPI doses relating to evidence synthesis and recommendations

in the original guideline (CG17; 2004)
PPI Full/standard Low dose (on- Double dose
dose demand dose)
Esomeprazole 20 mg1 once a day Not available 40 mg3 once a day
Lansoprazole 30 mg once a day 15 mg once a day 30 mg2 twice a day
Omeprazole 20 mg once a day 10 mg2 once a day 40 mg once a day
Pantoprazole 40 mg once a day 20 mg once a day 40 mg2 twice a day
Rabeprazole 20 mg once a day 10 mg once a day 20 mg2 twice a day
1
Lower than the licensed starting dose for esomeprazole in GORD, which is 40 mg, but
considered to be dose-equivalent to other PPIs. When undertaking meta-analysis of
dose-related effects, NICE classed esomeprazole 20 mg as a full-dose equivalent to
omeprazole 20 mg.
2
Off-label dose for GORD.
3
40 mg is recommended as a double dose of esomeprazole because the 20-mg dose is
considered equivalent to omeprazole 20 mg.
Table 2 PPI doses for severe oesophagitis in this guideline update (2014)
PPI Full/standard dose Low dose High/double dose
(on-demand dose)
Esomeprazole (40 mg1 once a day) (20 mg1once a day) (40 mg1 twice a day)
Lansoprazole 30 mg once a day 15 mg once a day 30 mg2 twice a day
Omeprazole (40 mg1 once a day) (20 mg1 once a day) (40 mg1 twice a day)
Pantoprazole 40 mg once a day 20 mg once a day 40 mg2 twice a day
Rabeprazole 20 mg once a day 10 mg once a day 20 mg2 twice a day
1
Change from the 2004 dose, specifically for severe oesophagitis, agreed by the GDG
during the update of CG17.
2
Off-label dose for GORD.

Table 3 PPI doses for H pylori eradication therapy in this guideline

update (2014)
PPI Dose
Esomeprazole 20 mg
Lansoprazole 30 mg
Omeprazole 20–40 mg
Pantoprazole 40 mg
Rabeprazole 20 mg

Appendix B: Recommendations from NICE clinical

guideline 17 (2004) that have been deleted or changed
Recommendations to be deleted
The table shows recommendations from 2004 that NICE proposes deleting in
the 2014 update. The right-hand column gives the replacement
recommendation, or explains the reason for the deletion if there is no
replacement recommendation
Recommendation in 2004 guideline Comment

1.2.4 Urgent specialist referral or This recommendation has been deleted
endoscopic investigations indicated for as it was felt more appropriate to cross-
patients of any age with dyspepsia when refer to the relevant recommendations
presenting with any of the following: from CG27 and its update.
chronic gastrointestinal bleeding;
progressive unintentional weight loss;
progressive difficulty swallowing;
persistent vomiting; iron deficiency
anaemia; epigastric mass or suspicious
barium meal.
1.2.5 and 1.5.5 Routine endoscopic This recommendation has been deleted
investigation of patients of any age as it was felt more appropriate to cross-
presenting with dyspepsia and without refer to the relevant recommendations
alarm signs is not necessary. However, from CG27 and its update.
in patients aged 55 years and older with
unexplained and persistent recent-onset
dyspepsia alone, an urgent referral for
endoscopy should be made.
1.2.6 Patients undergoing endoscopy This recommendation has been deleted
should be free from medication with as it was felt more appropriate to cross-
either a proton pump inhibitor (PPI) or an refer to the relevant recommendations
H2 receptor antagonist (H 2RA) for a from CG27 and its update.
minimum of 2 weeks beforehand
1.3.1 For many patients, self-treatment This recommendation is now considered
with antacid and/or alginate therapy background information and not in line
(either prescribed or purchased over-the- with The guidelines manual 2012 and
counter and taken 'as required') may current editorial guidance.
continue to be appropriate for immediate
symptom relief. However, additional
therapy is appropriate to manage
symptoms that persistently affect
patients' quality of life.
1.3.2 Offer older patients (over 80 years This recommendation has been deleted
of age) the same treatment as younger because it was considered that an age
patients, taking account of any limit is no longer appropriate.
comorbidity and their existing use of
medication.

1.5.3 Offer simple lifestyle advice, This recommendation has been deleted
including healthy eating, weight reduction as it is a duplicate of recommendation
and smoking cessation. 1.2.2.
1.5.4 Advise patients to avoid known This recommendation has been deleted
precipitants they associate with their as it is a duplicate of recommendation
dyspepsia where possible. These include 1.2.3.
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.
1.6.6 Surgery cannot be recommended Replaced by:
for the routine management of persistent 1.11.1 Consider referral to a specialist
GORD although individual patients service for people:
whose quality of life remains significantly
 of any age with gastro-oesophageal
impaired may value this form of
symptoms that are persistent, non-
treatment.
responsive to treatment or
unexplained1
 with suspected GORD who are
thinking about surgery
 with H pylori and persistent
symptoms that have not responded to
second-line eradication therapy. [new
2014]
1
In Referral guidelines for suspected cancer
(NICE clinical guideline 27), ‘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)’. (Please note that an update
is in progress; publication expected May 2015. For
more information, see
http://guidance.nice.org.uk/CG/Wave0/618).
1.9.4 For patients who test positive, Replaced by:
provide a 7-day, twice-daily course of 1.9.4 Offer people who test positive for
treatment consisting of a full-dose PPI, H pylori a 7-day, twice-daily course of
with either metronidazole 400 mg and treatment with:
clarithromycin 250 mg or amoxicillin 1 g
and clarithromycin 500 mg.
 amoxicillin and
 either clarithromycin or
metronidazole.
Choose the treatment regimen with the

lowest acquisition cost, and take into
account previous exposure to
clarithromycin or metronidazole. [new
2014]
1.9.5 Offer people who are allergic to

penicillin a 7-day, twice-daily course of
treatment with:


 clarithromycin and
 metronidazole. [new 2014]
1.9.6 Offer people who have had

previous exposure to clarithromycin and
who are allergic to penicillin a 7-day,
 bismuth and
 tetracycline. [new 2014]
1.9.7 Discuss treatment adherence with

the person and emphasise its
importance. For more information about
supporting adherence, see Medicines
adherence (NICE clinical guideline 76).
[new 2014]
1.9.5 For patients requiring a second Replaced by:
course of eradication therapy, a regimen 1.9.8 For people who still have symptoms
should be chosen that does not include after first-line eradication treatment, offer
antibiotics given previously (see the a 7-day, twice-daily course of treatment
British National Formulary for guidance). with:
 amoxicillin and
 either clarithromycin or metronidazole
(whichever was not used first-line).
[new 2014]

previous exposure to clarithromycin and
metronidazole a 7-day, twice-daily course
of treatment with:
 amoxicillin and
 a quinolone or tetracycline
(whichever has the lowest acquisition
cost). [new 2014]
1.9.10 Offer people who are allergic to

penicillin (or who have had previous
exposure to clarithromycin) a 7-day,
 levofloxacin. [new 2014]


previous exposure to clarithromycin,
quinolones and who are allergic to
penicillin:
 bismuth and
 a tetracycline. [new 2014]

Amended recommendation wording (change to meaning)

Recommendations are labelled [2004, amended 2014] if the evidence has
not been reviewed but changes have been made to the recommendation
wording (indicated by highlighted text) that change the meaning.
Recommendation in Recommendation in Reason for

2004 guideline 2014 guideline change
1.2.3 Consider the possibility 1.3.3 Think about the Changed to make
of cardiac or biliary disease possibility of cardiac or biliary recommendation
as part of the differential disease as part of the active.
diagnosis. differential diagnosis.
1.3.6 Psychological 1.2.4 Recognise that Changed to make
therapies, such as cognitive psychological therapies, recommendation
behavioural therapy and such as cognitive active and to bring in
psychotherapy, may reduce behavioural therapy and line with The
dyspeptic symptoms in the psychotherapy, may reduce guideline manual
short term in individual dyspeptic symptoms in the 2012 and editorial
patients. Given the intensive short term in individual guidance.
and relatively costly nature of people.
such interventions, routine
provision by primary care
teams is not currently
recommended.
1.3.7 Patients requiring long- 1.2.5 Encourage people Changed to make
term management of who need long-term this recommendation
dyspepsia symptoms should management of dyspepsia active and for clarity
be encouraged to reduce symptoms to reduce their as this
their use of prescribed use of prescribed medication recommendation
medication stepwise: by stepwise: by using the now only applies to
using the effective lowest effective lowest dose, by people without an
dose, by trying as-required trying ‘as-needed’ use when underlying condition
use when appropriate, and appropriate, and by returning or comedication that
by returning to self-treatment to self-treatment with antacid needs continuing
with antacid and/or alginate and/or alginate therapy treatment.
therapy. (unless there is an
underlying condition or
comedication that needs
continuing treatment).
1.4.1 Dyspepsia in 1.4.1 Be aware that Changed to make
unselected patients in dyspepsia in unselected recommendation
primary care is defined people in primary care is active and for clarity.
broadly to include patients defined broadly to include
with recurrent epigastric people with recurrent
pain, heartburn, or acid epigastric pain, heartburn or
regurgitation, with or without acid regurgitation, with or
bloating, nausea or vomiting. without bloating, nausea or
Review common elements of vomiting. Also see ‘Common
care for managing dyspepsia elements of care’.
(section 1.3).
1.4.2 Initial therapeutic 1.4.2 Leave a 2-week Changed to make

strategies for dyspepsia are washout period after proton recommendation

empirical treatment with a pump inhibitor (PPI) use active and for clarity.
PPI or testing for and treating before testing for
H pylori. There is currently Helicobacter pylori (hereafter
insufficient evidence to guide referred to as H pylori) with a
which should be offered first. breath test or a stool antigen
A 2-week washout period test.
following PPI use is
necessary before testing for
H pylori with a breath test or
a stool antigen test.
1.4.6 Offer H2RA or 1.4.6 Offer H2 receptor Reference to
prokinetic therapy if there is antagonist (H2RA) therapy if prokinetic therapy
an inadequate response to a there is an inadequate has been removed
PPI. response to a PPI. as the original
guideline only
reviewed the
evidence for
cisapride, not
domperidone or
metoclopramine.
Cisapride has been
suspended in the UK
since the publication
of CG17.
1.5.1 Offer people requiring 1.5.1 Offer people who need Changed for clarity.
long-term management of long-term management of
symptoms for dyspepsia an dyspepsia symptoms an
annual review of their annual review of their
condition, encouraging them condition, and encourage
to try stepping down or them to try stepping down or
stopping treatment. stopping treatment (unless
there is an underlying
condition or comedication
that needs continuing
treatment).
1.5.2 A return to self- 1.5.2 Advise people that it Changed to make
treatment with antacid and/or may be appropriate for them recommendation
alginate therapy (either to return to self-treatment active.
prescribed or purchased with antacid and/or alginate
over-the-counter and taken therapy (either prescribed or
as-required) may be purchased over-the-counter
appropriate. and taken as needed).
1.6.1 Gastro-oesophageal 1.6.1 Manage uninvestigated Changed to make

reflux disease (GORD) refers 'reflux-like' symptoms as recommendation
to endoscopically determined uninvestigated dyspepsia. active.
oesophagitis or endoscopy-
negative reflux disease.
Patients with uninvestigated
'reflux-like' symptoms should
be managed as patients with
uninvestigated dyspepsia.

1.6.3 If symptoms recur 1.6.3 If symptoms recur after Removed ‘with a

following initial treatment, initial treatment, offer a PPI limited number of
offer a PPI at the lowest at the lowest dose possible repeat prescriptions’
dose possible to control to control symptoms. as the GDG felt this
symptoms, with a limited was included due to
number of repeat the costs of PPI at
prescriptions. the time of original
publication. Costs
have since fallen and
therefore limiting
repeat prescriptions
due to costs is not a
factor in current
practice.
1.6.5 Offer H2RA or 1.6.5 Offer H2RA therapy if Reference to
prokinetic therapy if there is there is an inadequate prokinetic therapy
an inadequate response to a response to a PPI. has been removed
PPI. as the original
guideline only
reviewed the
evidence for
cisapride, not
domperidone or
metoclopramine.
Cisapride has been
suspended in the UK
since the publication
of CG17.
1.7.3 Patients with gastric 1.7.3 Offer people with The GDG felt the
ulcer and H pylori should gastric ulcer and H pylori original
receive repeat endoscopy, repeat endoscopy 6 to 8 recommendation
retesting for H pylori 6–8 weeks after beginning needed to be split to
weeks after beginning treatment, depending on the reflect the different
treatment, depending on the size of lesion. actions taken in each
size of the lesion. flowchart within the
Full guideline.
People with gastric
ulcers needed an
endoscopy and
retesting, however
just retesting for H
pylori was necessary
for people with
duodenal ulcers.
1.7.3 Patients with gastric 1.7.4 Offer people with peptic The GDG felt the
ulcer and H pylori should ulcer (gastric or duodenal) original
receive repeat endoscopy, and H pylori retesting for recommendation
retesting for H pylori 6–8 H pylori 6 to 8 weeks after needed to be split to
weeks after beginning beginning treatment, reflect the different
treatment, depending on the depending on the size of actions taken in each
size of the lesion. lesion. flowchart within the
Full guideline.
People with gastric
ulcers needed an

endoscopy and
retesting, however
just retesting for H
pylori was necessary
for people with
duodenal ulcers.
The GDG felt peptic

ulcer was the more
appropriate term to
use and included
gastric and duodenal
for further
clarification.
1.7.8 If symptoms recur 1.7.9 If symptoms recur after Removed ‘with a
following initial treatment, initial treatment, offer a PPI limited number of
offer a PPI to be taken at the to be taken at the lowest repeat prescriptions’
lowest dose possible to dose possible to control as the GDG felt this
control symptoms, with a symptoms. Discuss using the was included due to
limited number of repeat treatment on an ‘as-needed’ the costs of PPI at
prescriptions. Discuss using basis with people to manage the time of original
the treatment on an as- their own symptoms. publication. Costs
required basis with patients have since fallen and
to manage their own therefore limiting
symptoms. repeat prescriptions
factor in current
practice.
1.8.4 If H pylori has been 1.8.4 If H pylori has been Treatment has been
excluded or treated and excluded and symptoms removed from this
symptoms persist, offer persist, offer either a low- recommendation and
either a low-dose PPI or an dose PPI (see table 1 in this is now covered
H2RA for 1 month. appendix A) or an H2RA for by recommendations
4 weeks. on H pylori
eradication.
1.8.5 If symptoms continue 1.8.5 If symptoms continue Removed ‘with a
or recur following initial or recur after initial treatment limited number of
treatment offer a PPI or offer a PPI or H 2RA to be repeat prescriptions’
H2RA to be taken at the taken at the lowest dose as the GDG felt this
lowest dose possible to possible to control was included due to
control symptoms, with a symptoms. the costs of PPI at
limited number of repeat the time of original
prescriptions. publication. Costs
have since fallen and
therefore limiting
repeat prescriptions
factor in current
practice.
1.8.7 Long-term, frequent 1.8.7 Avoid long-term, Changed to make
dose, continuous prescription frequent dose, continuous recommendation
of antacid therapy is antacid therapy (it only active and for clarity
inappropriate and only relieves symptoms in the

relieves symptoms in the short term rather than

short term rather than preventing them).
preventing them.
1.9.1 H pylori can be initially 1.9.1 Test for H pylori using Changed to make
detected using a carbon-13 a carbon-13 urea breath test recommendation
urea breath test or a stool or a stool antigen test, or active.
antigen test, or laboratory- laboratory-based serology
based serology where its where its performance has
performance has been been locally validated.
locally validated
1.9.3 Office-based 1.9.3 Do not use office- Changed to make
serological tests for H pylori based serological tests for recommendation
cannot be recommended H pylori because of their active.
because of their inadequate inadequate performance.
performance.
Changes to recommendation wording for clarification only (no

change to meaning)
Recommendation numbers in Comment
current guideline
All recommendations except those Recommendations have been edited into the
labelled [new 2014] direct style (in line with current NICE style for
recommendations in clinical guidelines)
where possible. Yellow highlighting has not
1.1.1, 1.1.2, 1.2.1,1.2.2, 1.2.3, 1.3.1,
been applied to these changes.
1.3.2, 1.3.4, 1.4.3, 1.4.4, 1.4.5, 1.6.2,
1.6.4, 1.6.6, 1.7.1, 1.7.2, 1.7.5, 1.7.6,
1.7.7, 1.7.8, 1.7.10,1.8.1, 1.8.2, 1.8.3,
1.8.6, 1.9.2

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DRAFT FOR CONSULTATION

Dyspepsia and gastro-oesophageal reflux

Dyspepsia and GORD: NICE guideline DRAFT (April 2014) 1 of 42

Dyspepsia and GORD: NICE guideline DRAFT (April 2014) 2 of 42

The review of ‘Dyspepsia: management of dyspepsia in adults in primary care’

NICE clinical guideline 17 covered the management of several underlying

Dyspepsia and GORD: NICE guideline DRAFT (April 2014) 3 of 42

surveillance for adults with a diagnosis of Barrett's oesophagus, but it does

In this guideline, specialist care is defined as treatment decisions made by a

Specific dosage information on proton pump inhibitors (PPIs) is detailed in

Dyspepsia and GORD: NICE guideline DRAFT (April 2014) 4 of 42

Patients and healthcare professionals have rights and responsibilities as set

NICE has produced guidance on the components of good patient experience

Dyspepsia and GORD: NICE guideline DRAFT (April 2014) 5 of 42

Interventions that must (or must not) be used

Interventions that should (or should not) be used – a ‘strong’

Interventions that could be used

Dyspepsia and GORD: NICE guideline DRAFT (April 2014) 6 of 42

and preferences than for a strong recommendation, and so the healthcare

Recommendation wording in guideline updates

Dyspepsia and GORD: NICE guideline DRAFT (April 2014) 7 of 42

New recommendations have been added about investigation and referral,

You are also invited to comment on recommendations that NICE proposes to

Dyspepsia and GORD: NICE guideline DRAFT (April 2014) 8 of 42

Dyspepsia and GORD: NICE guideline DRAFT (April 2014) 9 of 42

Key priorities for implementation

Referral guidance for endoscopy

 For people presenting with dyspepsia together with significant acute

Interventions for uninvestigated dyspepsia

Interventions for gastro-oesophageal reflux disease (GORD)

 Offer a full-dose PPI (see table 2 in appendix A) long-term as maintenance

 Do not routinely offer endoscopy to diagnose Barrett’s oesophagus, but

Dyspepsia and GORD: NICE guideline DRAFT (April 2014) 10 of 42

hernia, oesophageal stricture or oesophageal ulcers, or male gender).

Interventions for peptic ulcer disease

Referral to a specialist service

 Consider referral to a specialist service for people:

Surveillance for people with Barrett’s oesophagus

 Consider surveillance to check progression to cancer for people who have

Dyspepsia and GORD: NICE guideline DRAFT (April 2014) 11 of 42

Terms used in this guideline

1.1 The community pharmacist

1.1.2 Community pharmacists should record adverse reactions to

1.2 Common elements of care

1.2.3 Provide people with access to educational materials to support the

1.2.4 Recognise that psychological therapies, such as cognitive

Dyspepsia and GORD: NICE guideline DRAFT (April 2014) 12 of 42

symptoms in the short term in individual people. [2004, amended

1.2.5 Encourage people who need long-term management of dyspepsia

1.3 Referral guidance for endoscopy

1.3.2 Review medications for possible causes of dyspepsia (for example,

1.3.3 Think about the possibility of cardiac or biliary disease as part of

Dyspepsia and GORD: NICE guideline DRAFT (April 2014) 13 of 42

1.4 Interventions for uninvestigated dyspepsia

1.4.6 Offer H2 receptor antagonist (H2RA) therapy if there is an

1.5 Reviewing patient care

1.5.2 Advise people that it may be appropriate for them to return to

Dyspepsia and GORD: NICE guideline DRAFT (April 2014) 14 of 42

1.6 Interventions for gastro-oesophageal reflux disease

1.6.5 Offer H2RA therapy if there is an inadequate response to a PPI.