LLR Policy for Endoscopy for Dyspepsia

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Category

Threshold Criteria

Endoscopy is the procedure of choice for the diagnostic evaluation of the UGI tract because of its ease, reliability, diagnostic superiority, and the ability it gives to perform biopsies and/or therapeutic interventions, especially true for patients presenting with dyspepsia.

Eligibility

LLR ICB will only fund this procedure for patients who have dyspepsia and referred for endoscopy if specific clinical criteria are met.

The aim of the referral criteria is to only select patients who may have significant pathology for endoscopic investigation and to ensure that all patients have appropriate investigation and management in primary care.

Referral Process for Dyspepsia

Patients who have dyspepsia may only be routinely referred for endoscopy if specific clinical criteria are met. The aim of the referral criteria is to only select patients who may have significant pathology for endoscopic investigation and to ensure that all patients have appropriate investigation and management in primary care.

1. Immediate (same day) Referrals

Evidence of significant acute gastrointestinal bleeding.

2. Urgent (two week wait) Referrals

• Patients of any age presenting with any of the following alarm symptoms:

• Chronic gastrointestinal bleeding

• Progressive unintentional weight loss

• Progressive difficulty swallowing

• Persistent vomiting

• Documented iron deficiency anaemia

• Epigastric mass

• Abnormal barium meal

3. Patients aged 55 years or over with new-onset dyspepsia that is either:

• Unexplained i.e. no diagnosis has been made for the dyspepsia or/and

Persistent i.e. symptoms for 4-6 weeks but may be shorter depending on severity

• Routine Referrals

Patients under the age of 55 years, who have no alarm symptoms, will not be routinely offered endoscopy unless specific interventions for un-investigated dyspepsia have first been undertaken in primary care.

The following interventions must be undertaken in primary care prior to making a referral for endoscopy and then documented in the GP referral letter. The referral will be assessed by a consultant gastroenterologist and if the GP letter does not contain this information it will be returned by UHL.

4. Primary care interventions for un-investigated dyspepsia:

Review of medication for possible causes of dyspepsia e.g. NSAID Suspend treatment and treat with PPI therapy at full dose for at least one month (e.g. Lansoprazole 30mg daily) Empirical treatment with both:

• a PPI at full dose for at least one month (e.g. Lansoprazole 30mg daily) and H. Pylori testing and treatment 2 (see notes below).

• There is currently inadequate evidence on whether full dose PPI for one month or H. Pylori ‘test and treat’ should be offered first. Either treatment may be tried first and the other then offered if symptoms persist or return. If PPI treatment is tried first, a two-week ‘washout’ period is required before H. Pylori testing.

• If symptoms recur after treatment, use PPI therapy at the lowest dose required to control symptoms (possibly on an as-required basis). Recurrence of symptoms is not an indication for referral for endoscopy.

If PPI are ineffective at controlling symptoms, treat with H2RA H2 recepter antagonist ( e.g Famotidine) and use the lowest dose required to control symptoms (possibly on an as-required basis).

Domperidone 10 mg three times a day can be tried when bloating/early satiety or nausea are prominent symptoms.

5. Exceptional Cases.

It is recognised that there may be individual clinical circumstances that may warrant an endoscopy but fall outside the guidelines above. In these cases, the GP should provide the relevant additional clinical information in their referral to the gastroenterologist who will then determine whether an endoscopy is clinically necessary.

ARP 36. Review Date: 2026

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