These guidelines were last updated in 2019 and cover the management of dyspepsia in general practice, criteria of when to be referred for further investigation and the management of H. pylori infection.
Each of these guidelines has serious flaws.
In the guidance for the initial management of dyspepsia in general practice, the definition of dyspepsia is inadequate and should be divided into reflux and non-reflux type dyspepsia. There is also no clear indication of how dyspepsia differs from abdominal pain. Abdominal pain for instance is considered a possible symptom of pancreatic cancer whereas dyspepsia is not. Pain or discomfort in the upper abdomen is not a reliable indicator of gastro-duodenal pathology a point which I elaborate further in another blog. It was a reliable indicator 20 years ago when peptic ulcer was common, but it is not now. Heartburn and reflux remain reasonably reliable indicators of finding oesophageal pathology and are generally responsive to management with acid suppressive treatment. This is not the case with upper abdominal symptoms who have been shown in studies to have much poorer responses to such treatment. In-fact the arbitrary division of abdominal pain into upper or lower with upper abdominal pain dictating investigation of the stomach and lower abdominal pain investigation of the colon is very unreliable. The body does not work like this. A study published over 20 years ago showed that people with pain in the upper abdomen were just as likely to have pathology discovered in the lower gastrointestinal tract or elsewhere. Hence patients with upper abdominal symptoms are not well served by being driven down the dyspepsia line of management and upper GI endoscopy which are really designed for the management of reflux symptoms and increasingly non-existent peptic ulcer.
The suggested management strategy for dyspepsia is a trial of full dose proton pump inhibitors. Many of the suggested regimes are once daily. Full dose has to be twice daily, once daily only acting for 12-14 hours. In the late 20th century when erosive gastro-oesophageal reflux was present once daily treatment would work to heal. However in the era of non-erosive disease and acid sensitive oesophagus a higher level of suppression is required to alleviate symptoms. A high dose means Lanzoprazole 30mg bd, Omeprazole 40mg bd or Esomeprazole 20mg bd, although some patients only respond to Esomperazole 40mg bd which is equivalent to Lanzoprazole 60mg bd or Omeprazole 60mg bd.
Helicobacter pylori is an important world-wide though rapidly diminishing problem in the developed world. H. Pylori causes gastric and duodenal ulcers and is responsible for most gastric cancers and hence is an important public health problem. In London and most parts of the UK it probably only affects about 5% of the adult population down from more than 50% 30 years ago. Symptoms from gastric and duodenal ulcers are virtually abolished within a few days of treatment with proton pump inhibitors. There is no good evidence on the other hand that Helicobacter pylori causes non ulcer dyspepsia. As a general rule, if symptoms do not respond to proton pump inhibitors then they will not be improved by eradicating Helicobacter pylori. Hence the relevance of testing for Helicobacter pylori in patients who have not responded to proton pump inhibitors is questionable. In low prevalence areas the people who should be tested for Helicobacter pylori are those with non-reflux type symptoms who have responded promptly to proton pump inhibitors.
As regards Helicobacter eradication, the guidelines are dangerous and risk resulting in large numbers of people in whom it is not possible to eradicate owing to prior sub-optimal treatment causing multi-drug resistance . One-week regimens are recommended for first line and second line and do not include treatment with bismuth salts which are essential to lift eradication rates from 50-60% to 80-90%. The International Helicobacter Society recommends 10 days to 2-week quadruple therapy including bismuth. These guidelines need urgently changing as I see more and more patients with resistant Helicobacter infections.
The problem with the NICE guidelines stems from their over-reliance on evidence-based medicine which bear little relation to the real world which has changed dramatically since the evidence on which the guidelines are based was acquired. The evidence should be seen as an assistance rather than slavishly followed. Evidence will always be out of date. I also suspect that it is medical politicians rather than doctors who actually see patients who draw up these guidelines.