SIGNIFICANT EVENT MEETINGSIGNIFICANT EVENT MEETING

– – 2 PATIENTS WITH CANCER2 PATIENTS WITH CANCER

Dr Stephen NewellDr Stephen Newell

8/10/048/10/04

DOUGLASDOUGLAS

Presentation & course of illnessPresentation & course of illness

• Age 76

• Male

• Ex-smoker

• 14 units alcohol/week

• 6/03 heartburn

• 7/03 weight loss

• 7/03 2 week referral

• Missed initial apptmt

• 1/9/03 endoscopy showed oesophageal cancer

• Referred for consideration of surgery

• 11/03 adjuvant chemotherapy

• 26/11/03 seen for review – coping with diagnosis and treatment

• 12/03 intra-abdominal nodes found

• 12/03 oesophagectomy

• 8/12/03 discharged after surgery

• 17/1/04 further surgery for intrathoracic anastomotic leak

• 27/1/04 death from multiple organ failure

WEIGHT READINGS

20/4/98 75 kg02/7/03 69 kg20/7/03 68 kg

PAMELAPAMELA

Presentation & course of illnessPresentation & course of illness

• Age 71

• Female

• Smoker

• Lifelong teetotaller

• 2/03 heartburn / wind upwards

• FH bowel cancer

• 2/03 FBC and abdo USS

• 2/03 anaemia found

• 31/3/03 referred for open access endoscopy

• 22/5/03 endoscopy showed carcinoma stomach

• 14/7/03 admitted for consideration of gastrectomy but tumour fixed to pancreas with peritoneal metastases and palliative gastrojejunostomy only done

• 19/7/03 discharged from hospital

• Went to stay with relative elsewhere and not seen again in the practice

• 27/9/03 admitted with abdo pain which settled

• 28/9/03 readmitted with bowel obstruction

• 3/10/03 death from carcinomatosis

HAEMOGLOBIN LEVELS

26/2/03 9.3 g/dl18/3/03 9.2 g/dl04/4/03 9.5 g/dl

NEW NICE GUIDELINES NEW NICE GUIDELINES

ON DYSPEPSIAON DYSPEPSIA

8/20048/2004

NICE Clinical Guideline 17NICE Clinical Guideline 17August 2004August 2004Developed by the Newcastle Developed by the Newcastle

Guideline Development and Guideline Development and

Research UnitResearch UnitManagement of dyspepsia in Management of dyspepsia in

adults in primary careadults in primary carewww.nice.org.uk/CG017NICEguidelinewww.nice.org.uk/CG017NICEguideline

© Copyright National Institute for © Copyright National Institute for Clinical Excellence, August 2004. All Clinical Excellence, August 2004. All rights reserved. This material may be rights reserved. This material may be freely reproduced for educational and freely reproduced for educational and not-for-profit purposes within the NHS. not-for-profit purposes within the NHS. No reproduction by or for commercial No reproduction by or for commercial organisations is allowed without the organisations is allowed without the express written permission of the express written permission of the National Institute for Clinical National Institute for Clinical Excellence. Excellence.

This guidance is written in the following This guidance is written in the following context:context:

It represents the view of the Institute, arrived It represents the view of the Institute, arrived at after careful consideration of the evidence at after careful consideration of the evidence available. Health professionals are expected to available. Health professionals are expected to take it fully into account when exercising their take it fully into account when exercising their clinical judgement.clinical judgement.

However , it does not override the individual However , it does not override the individual responsibility of health professionals to make responsibility of health professionals to make decisions appropriate to the circumstances of decisions appropriate to the circumstances of the individual patient, in consultation with the the individual patient, in consultation with the patient and/or their guardian or carer.patient and/or their guardian or carer.

Key priorities for implementationKey priorities for implementation

1: Referral for endoscopy:1: Referral for endoscopy: • • Review medications for possible causes of dyspepsia (e.g. Review medications for possible causes of dyspepsia (e.g.

calcium antagonists, nitrates, theophyllines, bisphosphonates, calcium antagonists, nitrates, theophyllines, bisphosphonates, corticosteroids and NSAIDs). In patients requiring referral, corticosteroids and NSAIDs). In patients requiring referral, suspend NSAID use. suspend NSAID use.

• • Urgent specialist referral for endoscopic investigation (within Urgent specialist referral for endoscopic investigation (within 2 weeks) is indicated for patients of any age with dyspepsia 2 weeks) is indicated for patients of any age with dyspepsia when presenting with any of the following: chronic when presenting with any of the following: chronic gastrointestinal bleeding, progressive unintentional weight gastrointestinal bleeding, progressive unintentional weight loss, progressive difficulty swallowing, persistent vomiting, iron loss, progressive difficulty swallowing, persistent vomiting, iron deficiency anaemia, epigastric mass or suspicious barium meal.deficiency anaemia, epigastric mass or suspicious barium meal.

• • Routine endoscopic investigation of patients of any age, Routine endoscopic investigation of patients of any age,

presenting with dyspepsia and without alarm signs, is not presenting with dyspepsia and without alarm signs, is not necessary. However, for patients over 55, consider endoscopy necessary. However, for patients over 55, consider endoscopy when symptoms persist despite H. pylori testing and acid when symptoms persist despite H. pylori testing and acid suppression therapy, and when patients have one or more of suppression therapy, and when patients have one or more of the following: previous gastric ulcer or surgery, continuing the following: previous gastric ulcer or surgery, continuing need for NSAID treatment, or raised risk of gastric cancer or need for NSAID treatment, or raised risk of gastric cancer or anxiety about cancer. anxiety about cancer.

2: Interventions for uninvestigated dyspepsia 2: Interventions for uninvestigated dyspepsia • • Initial therapeutic strategies for dyspepsia are empirical Initial therapeutic strategies for dyspepsia are empirical treatment with a proton pump inhibitor (PPI) or testing for treatment with a proton pump inhibitor (PPI) or testing for and treating H. pylori. There is currently insufficient and treating H. pylori. There is currently insufficient evidence to guide which should be offered first. A 2-week evidence to guide which should be offered first. A 2-week washout period following PPI use is necessary before washout period following PPI use is necessary before testing for H. pylori with a breath test or a stool antigen test. testing for H. pylori with a breath test or a stool antigen test.

3: Interventions for gastro-oesophageal reflux disease 3: Interventions for gastro-oesophageal reflux disease (GORD) (GORD) • • Offer patients who have GORD a full-dose PPI for 1 or 2 Offer patients who have GORD a full-dose PPI for 1 or 2 months. months. • • If symptoms recur following initial treatment, offer a PPI If symptoms recur following initial treatment, offer a PPI at the lowest dose possible to control symptoms, with a at the lowest dose possible to control symptoms, with a limited number of repeat prescriptions. limited number of repeat prescriptions.

4: Interventions for peptic ulcer disease 4: Interventions for peptic ulcer disease • • Offer H. pylori eradication therapy to H. pylori-positive Offer H. pylori eradication therapy to H. pylori-positive patients who have peptic ulcer disease. patients who have peptic ulcer disease. • • For patients using NSAIDs with diagnosed peptic ulcer, For patients using NSAIDs with diagnosed peptic ulcer, stop the use of NSAIDs where possible. Offer full-dose PPI stop the use of NSAIDs where possible. Offer full-dose PPI or H2 receptor antagonist (H2RA) therapy for 2 months to or H2 receptor antagonist (H2RA) therapy for 2 months to these patients and, if H. pylori is present, subsequently offer these patients and, if H. pylori is present, subsequently offer eradication therapy. eradication therapy.

5: Interventions for non-ulcer dyspepsia 5: Interventions for non-ulcer dyspepsia • • Management of endoscopically determined non-ulcer Management of endoscopically determined non-ulcer dyspepsia involves initial treatment for H. pylori if present, dyspepsia involves initial treatment for H. pylori if present, followed by symptomatic management and periodic followed by symptomatic management and periodic monitoring. monitoring. • • Re-testing after eradication should not be offered Re-testing after eradication should not be offered routinely, although the information it provides may be routinely, although the information it provides may be valued by individual patients.valued by individual patients.

6: Reviewing patient care 6: Reviewing patient care • • Offer patients requiring long-term management of dyspepsia Offer patients requiring long-term management of dyspepsia symptoms an annual review of their condition, encouraging them to try symptoms an annual review of their condition, encouraging them to try stepping down or stopping treatment. stepping down or stopping treatment. • • A return to self-treatment with antacid and/or alginate therapy A return to self-treatment with antacid and/or alginate therapy (either prescribed or purchased over-the-counter and taken as (either prescribed or purchased over-the-counter and taken as required) may be appropriate. required) may be appropriate.

7: H. pylori testing and eradication 7: H. pylori testing and eradication • • H. pylori can be initially detected using either a Carbon-13 urea H. pylori can be initially detected using either a Carbon-13 urea breath test or a stool antigen test, or laboratory-based serology where breath test or a stool antigen test, or laboratory-based serology where its performance has been locally validated. its performance has been locally validated. • • Office-based serological tests for H. pylori cannot be recommended Office-based serological tests for H. pylori cannot be recommended because of their inadequate performance. because of their inadequate performance. • • For patients who test positive, provide a 7-day, twice-daily course For patients who test positive, provide a 7-day, twice-daily course of treatment consisting of a full-dose PPI with either metronidazole 400 of treatment consisting of a full-dose PPI with either metronidazole 400 mg and clarithromycin 250 mg or amoxicillin 1 g and clarithromycin mg and clarithromycin 250 mg or amoxicillin 1 g and clarithromycin

500 mg.500 mg.

How do these comments relate to the How do these comments relate to the

patients discussed?patients discussed?

Did they have any sinister features?Did they have any sinister features?

DouglasDouglas

- dyspepsia- dyspepsia

- age 76- age 76

- weight loss- weight loss

PamelaPamela

- dyspepsia- dyspepsia

- bowel disturbance- bowel disturbance

- age 69- age 69

- iron deficiency anaemia- iron deficiency anaemia

Translating NICE guidance into practice:Translating NICE guidance into practice:

Under 55, no endoscopy necessary unless alarm signsUnder 55, no endoscopy necessary unless alarm signs

Over 55, consider endoscopy when: Over 55, consider endoscopy when: symptoms persist despite H. pylori testing and symptoms persist despite H. pylori testing and acid acid

suppression therapysuppression therapyprevious gastric ulcer or surgeryprevious gastric ulcer or surgerycontinuing need for NSAID treatmentcontinuing need for NSAID treatmentraised risk of gastric cancerraised risk of gastric canceranxiety about cancer anxiety about cancer

Urgent specialist referral for patients of any age with dyspepsia with Urgent specialist referral for patients of any age with dyspepsia with any of the following:any of the following:

chronic gastrointestinal bleedingchronic gastrointestinal bleedingprogressive unintentional weight lossprogressive unintentional weight lossprogressive difficulty swallowingprogressive difficulty swallowingpersistent vomitingpersistent vomitingiron deficiency anaemiairon deficiency anaemiaepigastric massepigastric masssuspicious Barium mealsuspicious Barium meal

What have I learned and what will I do in the future?What have I learned and what will I do in the future?

Remember the alarm symptoms - GI bleeding; unintended weight Remember the alarm symptoms - GI bleeding; unintended weight loss – weigh everyone; dysphagia; persistent vomiting; iron loss – weigh everyone; dysphagia; persistent vomiting; iron deficiency anaemia – FBC on everyone; epigastric masses – examine deficiency anaemia – FBC on everyone; epigastric masses – examine everyone; (abnormal Ba meal – not likely to do this investigation) – everyone; (abnormal Ba meal – not likely to do this investigation) – urgent referral for all these patientsurgent referral for all these patients

Under 55, no endoscopy necessary unless alarm signsUnder 55, no endoscopy necessary unless alarm signs

Over 55, think about referral when: Over 55, think about referral when: symptoms persist despite empirical acid suppression therapy symptoms persist despite empirical acid suppression therapy – H. pylori testing not easy to do– H. pylori testing not easy to doprevious gastric ulcer or surgery - PMHprevious gastric ulcer or surgery - PMHcontinuing need for NSAID treatmentcontinuing need for NSAID treatmentraised risk of gastric cancer – ask about FH, smokingraised risk of gastric cancer – ask about FH, smokinganxiety about cancer - discuss with patientanxiety about cancer - discuss with patient

Current 2 week urgent referral form for upper GI symptoms indicates Current 2 week urgent referral form for upper GI symptoms indicates urgent referral for:urgent referral for:

• JaundiceJaundice• Palpable upper abdominal massPalpable upper abdominal mass• DysphagiaDysphagia• Dyspepsia (> 55) Dyspepsia (> 55)

onset < 1 year ago onset < 1 year ago continous symptoms sincecontinous symptoms since

• Dyspepsia (any age) with one or more ofDyspepsia (any age) with one or more ofweight lossweight lossproven anaemiaproven anaemiavomitingvomitingat least one high risk factorat least one high risk factor

FH of upper GI cancer in more than 2 first degree FH of upper GI cancer in more than 2 first degree relativesrelatives

Barrett’s oesophagusBarrett’s oesophaguspernicious anaemiapernicious anaemiaprevious ulcer surgery > 20 years agoprevious ulcer surgery > 20 years agoknown dysplasia, atrophic gastritis, intestinal known dysplasia, atrophic gastritis, intestinal

metaplasiametaplasia