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Who should be referred for endoscopy?
General Practitioner, Hampshire
Email: lesley.ritchie{at}cantab.net
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Abstract |
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 TOP Abstract The GP curriculum and...Who should be referred...Preparing the patient for...Patients not requiring urgent...Other reasons for referring...References |
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Dyspepsia is a very common condition affecting 40% of the adult population of the UK in any given year. Many of these will self-treat with over-the-counter (OTC) preparations including antacids and alginates. Only 2% of the population will present dyspepsia symptoms to their GP. Prescribed drugs and endoscopies cost the health service £600 million a year. A further £100 million is spent on OTC treatment for dyspepsia.
A GP in training needs to be able to recognize when a patient is acutely unwell and arrange referral to an appropriate unit (section 7, care of the acutely ill patient). Certain patients will need same-day referral for endoscopy if they are actively bleeding. Upper GI symptoms are extremely common in general practice; the GP in training needs to be able to recognize which patients are safe to treat empirically and which need investigation (section 15.2, digestive problems). Strategies to recognize cancer in its early stages have been developed. Awareness of which patients to refer will enable those patients who are most at risk of upper GI cancer to receive an early endoscopy (section 12, care of people with cancer and palliative care) while ensuring that the endoscopy services are not swamped with patients who are at very low risk of having an upper GI malignancy.
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Upper gastrointestinal (GI) endoscopy is a common outpatient procedure normally performed to investigate dyspepsia. In a year, 1% of the population of England undergoes an upper gastrointestinal endoscopy.
This article looks at which patients presenting with dyspepsia should be referred for investigation and which can be safely managed without further investigation. It is based on two sets of NICE guidelines covering referrals for suspected cancer and management of dyspepsia.
Patients presenting with dyspepsia want reassurance as to whether they have a serious illness as well as treatment for their symptoms. Because of the high incidence of dyspepsia symptoms, it would be logistically impossible to offer endoscopy to all of these patients. It would also put many patients with low-risk symptoms through an unnecessary procedure with the inherent attached risks associated with an invasive procedure.
Guidelines have been developed to ensure that patients with high-risk symptoms receive prompt endoscopy. For other patients, a more pragmatic approach is recommended with treatment of symptoms and a policy of test and treat for Helicobacter eradication.
Adherence to the guidelines allows the resources needed for endoscopy to be concentrated on those patients with the highest risk of abnormal findings. This policy also ensures harm minimization (from adverse effects of endoscopy) for low-risk individuals.
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Who should be referred for upper gastrointestinal endoscopy? |
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TOPAbstractThe GP curriculum and...Who should be referred...Preparing the patient for...Patients not requiring urgent...Other reasons for referring...References |
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When presented with a patient complaining of dyspepsia, the clinician needs to decide whether to treat the patient empirically, to test and treat for helicobacter or to refer for endoscopy. This article will address the question of referral for endoscopy. Other articles will address the management of dyspepsia that does not require referral.
The initial assessment should allow identification of ‘red flags’ or alarm symptoms which predict a higher probability of an underlying serious disorder such as gastric cancer or an ulcer. All patients in these groups will require endoscopy.
The following situation requires urgent referral for endoscopy:
- Dyspepsia with significant acute gastrointestinal bleeding. This should be referred on the same day to a specialist unit with facilities for emergency endoscopy.
The following situations should be referred under the 2-week rules for urgent endoscopy, whatever the age of the patient:
- Chronic gastrointestinal bleeding
- Iron deficiency anaemia
- Epigastric mass
- Dysphagia
- Unintentional weight loss
- Persistent vomiting
- Suspicious barium swallow or meal
In addition to this the Cancer guidelines recommend that patients over 55 who present with new and persistent dyspepsia should also be referred urgently
In practice this means that in older patients, obvious precipitants such as NSAID's should be stopped, the patient treated symptomatically and the patient referred urgently if no other obvious cause for the symptoms is found and the symptoms persist beyond 4–6 weeks. It would be appropriate to test all such patients for helicobacter and treat if present. Patients in whom the symptoms are a recurrence of previous symptoms do not need to be referred urgently unless there are other alarm features.
There is also a group of patients with previously diagnosed pathology who should be referred if they present with worsening dyspepsia as they are at increased risk of malignancy.
- Barrett's oesophagus
- Known dysplasia, atrophic gastritis or intestinal metaplasia
- Peptic ulcer surgery more than 20 years previously
These guidelines for urgent referral have been formulated to pick out those patients most at risk of serious disease. For patients with alarm symptoms, the risk of a gastric cancer is approximately 4%.
A retrospective analysis has shown that referral for dysphagia or significant unintentional weight loss at any age and referral of patients over 55 years with any alarm symptoms would detect over 99% of cancers. It is extremely rare for a cancer to present in the under 55 age group without alarm symptoms. In the very few in which it does, it is almost always found to be inoperable. This allows the clinician to strongly reassure younger patients who do not have alarm signs that the risk of them having an undiagnosed cancer is very small.
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Preparing the patient for endoscopy |
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TOPAbstractThe GP curriculum and...Who should be referred...Preparing the patient for...Patients not requiring urgent...Other reasons for referring...References |
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It is important to explain to those patients who are referred for endoscopy what the procedure entails. Patients who are already on treatment with a proton pump inhibitor (PPI) or H2 receptor agonist will need to stop these 2 weeks prior to the endoscopy and revert to symptomatic treatment with antacids or alginates. This is to reduce the probability of the treatment masking the appearances of a small cancer in the stomach or oesophagus. It is also important to stop use of NSAID in those who will be referred. It may be helpful to give the patient an information leaflet, such as that produced by Patient UK. This describes how the procedure is performed and the options for it to be done under local anaesthesia or with sedation.
It may be helpful to discuss the option of sedation prior to the patient attending. Although this may make the procedure better tolerated, it does require the patient to be driven home by someone else afterwards and to be accompanied for the following 24 hours. The patient is advised not to drive, operate machinery or sign important documents for 24 hours if they have had benzodiazepine sedation.
The small risk of morbidity and mortality associated with endoscopy may need to be mentioned. The rate of morbidity—that is of non-trivial adverse events—has been reported as approximately 1 in 200. Mortality rates may be as high as 1 in 2000. These rates were reported from a group of patients referred partially from secondary care who are more likely to have other co-morbidities and may therefore be higher than rates in otherwise uncomplicated primary care referrals.
In some patients, the procedure may be judged to have a much higher risk rate because of multiple co-morbidities. It is important to include all relevant information on the referral form to allow the endoscopy team to make a judgement as to risks. If the risk is considered too great, it may be more appropriate to consider an urgent double contrast barium meal. This gives good definition of gastric and duodenal ulcers and of all but very early gastric cancers. In particular, patients with severe kyphosis or respiratory failure may not tolerate endoscopy.
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Patients not requiring urgent endoscopy |
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TOPAbstractThe GP curriculum and...Who should be referred...Preparing the patient for...Patients not requiring urgent...Other reasons for referring...References |
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For patients without alarm symptoms, a more pragmatic approach should be taken. The possibility of drugs causing the dyspepsia should be considered and the drug stopped if at all possible. Drugs which may cause dyspepsia include: non-steroidal anti-inflammatory drugs, corticosteroids, calcium antagonists, theophyllines, nitrates and bisphosphonates. Alternative diagnoses should be considered including cardiac and biliary causes for the symptoms.
In the absence of alarm symptoms, the initial management of uninvestigated dyspepsia consists of either a 1-month trial of a PPI or a policy of test and treat for helicobacter. The evidence does not favour either of these options. There is no evidence to support early endoscopy in the absence of alarm symptoms. Empirical treatment has been shown to be safe, effective and cost effective. It is important to remember that there is a need for a 2-week wash out period following PPI treatment before testing for Helicobacter with a stool antigen test or a breath test. If the patient has previously had an endoscopy and presents with new symptoms but no alarm symptoms, it is appropriate to treat the patient based on the previous endoscopic findings.
Some patients without alarm symptoms will fail to improve on empirical treatment or will get a rapid return of symptoms when they try to step down their medication. These patients should be reassured that dyspepsia is a benign illness. In such situations, although there is no requirement to offer such patients an endoscopy, both the physician and the patient may find referral for a non-urgent endoscopy helpful. This may give a definitive diagnosis which will help in determining the best long-term treatment.
There is also difficulty in determining the best management of patients who relapse after initially effective treatment. These may well need a re-endoscopy to ensure that a new pathology has not developed. Unfortunately, there is no good guidance as to which need reinvestigating: the decision as to whom to refer will rely on the clinicians’ judgement and the views of the patient.
The patient may be more compliant with treatment if there is a definitive diagnosis. In many patients, there may be a continuing concern that they have a malignancy, despite reassurance that this is unlikely. Such concerns may only be resolved by a definitive investigation such as endoscopy or barium meal.
There should also be a lower threshold for referral in older patients when there is a history of previous gastric ulcer or surgery, continuing need for NSAID treatment or raised risk of gastric cancer or anxiety about cancer. In such cases, consideration should be made as to whether to refer for endoscopy or to secondary care for advice about diagnosis and management.
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Other reasons for referring for an endoscopy |
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TOPAbstractThe GP curriculum and...Who should be referred...Preparing the patient for...Patients not requiring urgent...Other reasons for referring...References |
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Patients with known benign oesophageal strictures may require recurring endoscopies for dilatation. Most will be under the regular care of the gastroenterologists but they may present to primary care with a worsening or recurrence of their symptoms. Prompt referral for endoscopy and dilatation should prevent the development of malnutrition.
Patients with a know diagnosis of Barrett's oesophagus require regular surveillance endoscopies. Such patients have a much higher risk of oesophageal cancer and adenocarcinoma than the general population. In such patients, worsening symptoms should be investigated.
| Key points Patients with the following symptoms and signs must be referred for urgent endoscopy under the 2-week rules:
Refer for same-day investigation
Upper GI endoscopy is not without risk. The risk of serious adverse effects is approximately 1 : 200 and the risk of death associated with the procedure is 1 : 2000. Patients without alarm signs do not need referral for endoscopy; they can safely be treated empirically with a PPI or a test and treat strategy for helicobacter can be used. Patients under the age of 55 who do not have any alarm signs can be reassured that the probability of a malignant cause for their symptoms is very small—less than 0.2%
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References |
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TOPAbstractThe GP curriculum and...Who should be referred...Preparing the patient for...Patients not requiring urgent...Other reasons for referring...References |
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NICE Guidance. Dyspepsia: managing dyspepsia in adults in primary care (2004) Accessed via www.nice.org.uk/nicemedia/pdf/CG017fullguideline.pdf [date last accessed 17.06.2008].
NICE Guidance. Referral guidelines for suspected cancer (2005) Accessed via www.nice.org.uk/nicemedia/pdf/cg027niceguideline.pdf [date last accessed 17.06.2008].
Patient UK information sheet on Gastroscopy (Endoscopy). (2005) Accessed via www.patient.co.uk/showdoc/27000331 [date last accessed 19.06.2008].
Quine MA, Bell GD, McCloy RF, Charlton JE, Devlin HB, Hopkins A. Prospective audit of upper gastrointestinal endoscopy in two regions of England: safety, staffing, and sedation methods. Gut (1995) 36:462–67.
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