NICE guidance on the management of many disorders is rigidly followed by many doctors in primary and secondary care and by commissioners, leading to sub-optimal outcomes for patients. The guidance on dyspepsia is a good example of this.
Dyspepsia otherwise known as indigestion has dramatically changed in nature over the past 20-30 years along with the principle underlying causes. Despite this, the guidance as to its management as issued by NICE in 2019 is very 20th century rather than fit for the 21st. To appreciate this one must first consider how the underlying causes of acid dyspeptic disorders have changed which guidelines have failed to take account of.
Peptic ulcer disease was first described in the 1840s in young women who developed gastric ulcers which perforated and lead to their demise. From what can be gathered gastric rather than duodenal ulcers became the dominant form of peptic ulcer disease before duodenal ulcers began to emerge in the 1920s initially amongst wealthier people. Duodenal ulcers then became the dominant form of peptic ulcer disease affecting the less affluent as well as the more affluent. Duodenal ulcer disease then began to disappear from the more affluent and finally towards the end of the 20th century from the less affluent as well. Then in the 1970s and 1980s acid reflux disease which affects the oesophagus rather than the duodenum became the dominant form of acid dyspeptic disorder although again the nature of this has changed. Initially when described severe erosive disease with ulceration and scarring of the oesophagus was the dominant form which has changed a form with less severe tissue damage but still symptomatic just the same. The final from of reflux disease which is emerging is acid sensitive oesophagus where people are sensitive to normal levels of acid reflux not noticed by others.
The major reasons for these changes are the improvements in living conditions which occurred from Victorian times. People became much healthier as evidenced by the progressive increase in height which continues to the present day, compensating for the loss of about 15cm or so in height which occurred when man changed from hunter gatherer to farming. These improvements in health led to increased gastric acid production, gastric acid secretion having been shown to be suppressed in the malnourished. Alongside this with improvements in living conditions Helicobacter pylori infection transmission was interrupted and infection rates declined rapidly after the second world war. Because H. pylori is mainly acquired in childhood and retained throughout life it has taken 40 or 50 years for peptic ulcer disease to more or less disappear, although ulcers are still seen predominantly in people born in the developing world.
NICE guidance belongs to the era when peptic ulcer disease was more of a problem and are ill equipped to deal with the growing problem of acid sensitive oesophagus which does not respond so well to standard doses of acid suppressant drugs. These deficiencies will be dealt with in another blog and are unlikely to be dealt with in the near future as the guidance was last updated in 2019.