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Dyspepsia and gastro-oesophageal reflux disease
About
What is covered
In this interactive flowchart infants are defined as under 1 year, children 1 to under 12 years, young people 12 to under 18 years and adults 18 years and older.
Infants, children and young people
Gastro-oesophageal reflux is a normal physiological process that usually happens after eating in healthy infants, children, young people and adults. In contrast, gastro-oesophageal reflux disease occurs when the effect of gastro-oesophageal reflux leads to symptoms severe enough to merit medical treatment. Gastro-oesophageal reflux is more common in infants than in older children and young people, and it is noticeable by the effortless regurgitation of feeds in young babies.
The recommendations for infants, children and young people focus on signs and symptoms and interventions for gastro-oesophageal reflux disease. Commonly observed events, such as infant regurgitation, are covered as well as much rarer but potentially more serious problems, such as apnoea. Where appropriate, clear recommendations are given as to when and how reassurance should be offered. Advice is also offered for healthcare professionals about when to think about investigations, and what treatments to offer. Finally, it is emphasised that other, and on occasion more serious, conditions that need different management can be confused with some of the relatively common manifestations of gastro-oesophageal reflux or gastro-oesophageal reflux disease. These warning signs are defined under the headings of 'red flags' along with recommended initial actions.
Adults
Dyspepsia describes a range of symptoms arising from the upper gastrointestinal tract, but it has no universally accepted definition. The British Society of Gastroenterology defines dyspepsia as a group of symptoms that alert doctors to consider disease of the upper gastrointestinal tract, and states that dyspepsia itself is not a diagnosis. These symptoms, which typically are present for 4 weeks or more, include upper abdominal pain or discomfort, heartburn, gastric reflux, nausea or vomiting. In these recommendations, gastro-oesophageal reflux disease in adults refers to endoscopically determined oesophagitis or endoscopy-negative reflux disease.
The recommendations for adults, cover adults with symptoms of dyspepsia, symptoms suggestive of gastro-oesophageal reflux disease, or both. They also cover endoscopic surveillance for adults with a diagnosis of Barrett's oesophagus, but not the management of Barrett's oesophagus.
Updates
Updates to this interactive flowchart
25 July 2017 Laparoscopic insertion of a magnetic titanium ring for gastro-oesophageal reflux disease (NICE interventional procedures guidance 585) added to surgical options.
27 January 2016 Gastro-oesophageal reflux in children and young people (NICE quality standard 112) added.
15 December 2015 Electrical stimulation of the lower oesophageal sphincter for treating gastro-oesophageal reflux disease (NICE interventional procedures guidance 540) added to surgical options.
22 July 2015 Dyspepsia and gastro-oesophageal reflux disease in adults (NICE quality standard 96) added.
13 January 2015 Major update on publication of gastro-oesophageal reflux disease in children and young people: diagnosis and management (NICE guideline NG1).
28 November 2014 Continued non-steroidal anti-inflammatory drug use amended to clarify the type of non-steroidal anti-inflammatory drug to be used and that a proton pump inhibitor should also be prescribed.
Person-centred care
People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.
Your responsibility
Guidelines
The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.
Technology appraisals
The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.
Medical technologies guidance, diagnostics guidance and interventional procedures guidance
The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.
Short Text
What is covered
In this interactive flowchart infants are defined as under 1 year, children 1 to under 12 years, young people 12 to under 18 years and adults 18 years and older.
Infants, children and young people
Gastro-oesophageal reflux is a normal physiological process that usually happens after eating in healthy infants, children, young people and adults. In contrast, gastro-oesophageal reflux disease occurs when the effect of gastro-oesophageal reflux leads to symptoms severe enough to merit medical treatment. Gastro-oesophageal reflux is more common in infants than in older children and young people, and it is noticeable by the effortless regurgitation of feeds in young babies.
The recommendations for infants, children and young people focus on signs and symptoms and interventions for gastro-oesophageal reflux disease. Commonly observed events, such as infant regurgitation, are covered as well as much rarer but potentially more serious problems, such as apnoea. Where appropriate, clear recommendations are given as to when and how reassurance should be offered. Advice is also offered for healthcare professionals about when to think about investigations, and what treatments to offer. Finally, it is emphasised that other, and on occasion more serious, conditions that need different management can be confused with some of the relatively common manifestations of gastro-oesophageal reflux or gastro-oesophageal reflux disease. These warning signs are defined under the headings of 'red flags' along with recommended initial actions.
Adults
Dyspepsia describes a range of symptoms arising from the upper gastrointestinal tract, but it has no universally accepted definition. The British Society of Gastroenterology defines dyspepsia as a group of symptoms that alert doctors to consider disease of the upper gastrointestinal tract, and states that dyspepsia itself is not a diagnosis. These symptoms, which typically are present for 4 weeks or more, include upper abdominal pain or discomfort, heartburn, gastric reflux, nausea or vomiting. In these recommendations, gastro-oesophageal reflux disease in adults refers to endoscopically determined oesophagitis or endoscopy-negative reflux disease.
The recommendations for adults, cover adults with symptoms of dyspepsia, symptoms suggestive of gastro-oesophageal reflux disease, or both. They also cover endoscopic surveillance for adults with a diagnosis of Barrett's oesophagus, but not the management of Barrett's oesophagus.
Updates
Updates to this interactive flowchart
25 July 2017 Laparoscopic insertion of a magnetic titanium ring for gastro-oesophageal reflux disease (NICE interventional procedures guidance 585) added to surgical options.
27 January 2016 Gastro-oesophageal reflux in children and young people (NICE quality standard 112) added.
15 December 2015 Electrical stimulation of the lower oesophageal sphincter for treating gastro-oesophageal reflux disease (NICE interventional procedures guidance 540) added to surgical options.
22 July 2015 Dyspepsia and gastro-oesophageal reflux disease in adults (NICE quality standard 96) added.
13 January 2015 Major update on publication of gastro-oesophageal reflux disease in children and young people: diagnosis and management (NICE guideline NG1).
28 November 2014 Continued non-steroidal anti-inflammatory drug use amended to clarify the type of non-steroidal anti-inflammatory drug to be used and that a proton pump inhibitor should also be prescribed.
Sources
NICE guidance and other sources used to create this interactive flowchart.
Gastro-oesophageal reflux disease in children and young people: diagnosis and management (2015) NICE guideline NG1
Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management (2014) NICE guideline CG184
Laparoscopic insertion of a magnetic titanium ring for gastro-oesophageal reflux disease (2017) NICE interventional procedures guidance 585
Electrical stimulation of the lower oesophageal sphincter for treating gastro-oesophageal reflux disease (2015) NICE interventional procedures guidance 540
Endoscopic radiofrequency ablation for gastro-oesophageal reflux disease (2013) NICE interventional procedures guidance 461
Endoluminal gastroplication for gastro-oesophageal reflux disease (2011) NICE interventional procedures guidance 404
Endoscopic augmentation of the lower oesophageal sphincter using hydrogel implants for the treatment of gastro-oesophageal reflux disease (2007) NICE interventional procedures guidance 222
Catheterless oesophageal pH monitoring (2006) NICE interventional procedures guidance 187
Endoscopic injection of bulking agents for gastro-oesophageal reflux disease (2004) NICE interventional procedures guidance 55
Gastro-oesophageal reflux in children and young people (2016) NICE quality standard 112
Dyspepsia and gastro-oesophageal reflux disease in adults (2015) NICE quality standard 96
Stretta System for gastro-oesophageal reflux disease (2016) NICE medtech innovation briefing 74
Peptest for diagnosing gastro-oesophageal reflux (2015) NICE medtech innovation briefing 31
Quality standards
Gastro-oesophageal reflux in children and young people
These quality statements are taken from the gastro-oesophageal reflux in children and young people quality standard. The quality standard defines clinical best practice for gastro-oesophageal reflux in children and young people and should be read in full.
Dyspepsia and gastro-oesophageal reflux disease in adults
These quality statements are taken from the dyspepsia and gastro-oesophageal reflux disease in adults quality standard. The quality standard defines clinical best practice for dyspepsia and gastro-oesophageal reflux disease in adults and should be read in full.
Quality statements
Information about gastro oesophageal reflux (GOR) in infants
This quality statement is taken from the gastro-oesophageal reflux in children and young people quality standard. The quality standard defines clinical best practice for gastro-oesophageal reflux in children and young people and should be read in full.
Quality statement
Parents and carers attending postnatal appointments are given information about gastro-oesophageal reflux (GOR) in infants.
Rationale
Regurgitation of feeds in infants can cause anxiety for parents and carers. Providing information about GOR can reassure parents and carers that, in well infants, effortless regurgitation of feeds is a common and normal occurrence that affects at least 40% of infants and is likely to resolve before the infant is 1.
Quality measures
Structure
Evidence of local arrangements to ensure that parents and carers attending postnatal appointments are given information about GOR in infants.
Data source: Local data collection.
Process
Proportion of infants aged 8 weeks and under whose parents or carers received information about GOR during 1 of the postnatal appointments.
Numerator – the number in the denominator whose parents received information about GOR during 1 of the postnatal appointments.
Denominator – the number of infants aged 8 weeks and under who had at least 1 postnatal appointment.
Data source: Local data collection.
Outcome
a) Parental anxiety around infant GOR.
Data source: Local data collection.
b) GP visits regarding GOR.
Data source: Local data collection.
What the quality statement means for service providers, healthcare professionals and commissioners
Service providers (community care trusts, secondary care trusts, specialised women’s/maternity providers) ensure that postnatal appointments include providing information about GOR in infants.
Healthcare professionals (health visitors, midwives, paediatric nurses or GPs) give information to parents and carers attending postnatal appointments about GOR in infants.
Commissioners (clinical commissioning groups, local authorities) ensure that postnatal appointments are commissioned to provide information about GOR in infants.
What the quality statement means for parents and carers attending antenatal and postnatal appointments
Parents and carers attending postnatal appointments receive information about reflux (regurgitating, bringing up or vomiting feeds) in babies.
Source guidance
- Gastro-oesophageal reflux disease in children and young people (2015) NICE guideline NG1, recommendation 1.1.3 (key priority for implementation) and 1.1.4
Definitions of terms used in this quality statement
Gastro-oesophageal reflux (GOR)
GOR is the passage of gastric contents into the oesophagus. It is a common physiological event that can happen at all ages from infancy to old age, and is often asymptomatic. It occurs more frequently after feeds/meals. In many infants, reflux is associated with a tendency to ‘overt regurgitation’ – the visible regurgitation of feeds.
[Gastro-oesophageal reflux disease in children and young people (2015) NICE guideline NG1]
Information for people attending postnatal appointments
Information should explain that in well infants, effortless regurgitation of feeds:
- is very common (it affects at least 40% of infants)
- usually begins before the infant is 8 weeks old
- may be frequent (5% of infants affected have 6 or more episodes each day)
- usually becomes less frequent with time (it resolves in 90% of affected infants before they are 1 year old)
- does not usually need further investigation or treatment.
[Gastro-oesophageal reflux disease in children and young people (2015) NICE guideline NG1, recommendation 1.1.3 (key priority for implementation) and 1.1.4]
Equality and diversity considerations
This statement relies on parents and carers understanding the information given to them. Healthcare professionals may need to provide support for people who have difficulties understanding the information.
Breast-fed infants – feeding assessment
This quality statement is taken from the gastro-oesophageal reflux in children and young people quality standard. The quality standard defines clinical best practice for gastro-oesophageal reflux in children and young people and should be read in full.
Quality statement
Breast-fed infants with frequent regurgitation associated with marked distress have their feeding assessed.
Rationale
A breastfeeding assessment should be the first step in supporting parents and carers with managing frequent regurgitation of feeds associated with marked distress. Correcting the breastfeeding technique for breast-fed infants (for example, positioning and attachment) can improve or eliminate the symptoms.
Quality measures
Structure
Evidence of local arrangements to ensure that breast-fed infants with frequent regurgitation associated with marked distress have their feeding assessed before other treatments are offered.
Data source: Local data collection.
Process
Proportion of breast-fed infants with frequent regurgitation associated with marked distress who have a breastfeeding assessment.
Numerator – number in the denominator who have a breastfeeding assessment.
Denominator – number of breast-fed infants presenting with frequent regurgitation associated with marked distress.
Data source: Local data collection.
Outcome
Breast-fed infants with frequent regurgitation associated with marked distress presenting in healthcare settings.
Data source: Local data collection.
What the quality statement means for service providers, healthcare professionals and commissioners
Service providers (community care providers, secondary care, women’s trusts) ensure that healthcare professionals carry out a breastfeeding assessment and offer advice if breast-fed infants have frequent regurgitation associated with marked distress, before other treatments are offered.
Healthcare professionals (health visitors, midwives, paediatric nurses or GPs) carry out a breastfeeding assessment and offer advice if breast-fed infants have frequent regurgitation associated with marked distress, before they offer any other treatments.
Commissioners (clinical commissioning groups, local authorities) ensure that services they commission support parents and carers with guidance and assessments on infant feeding technique.
What the quality statement means for breastfeeding mothers
Breastfeeding mothers receive support and advice about correct breastfeeding techniques for breast-fed babies with reflux (regurgitating, bringing up or vomiting feeds) who are very distressed, for example, if they cry inconsolably and seem to be in pain.
Source guidance
- Gastro-oesophageal reflux disease in children and young people (2015) NICE guideline NG1, recommendation 1.2.2
Definitions of terms used in this quality statement
Breastfeeding assessment
Breastfeeding assessments should be carried out by a health professional with appropriate expertise and training, for example a midwife, health visitor, breastfeeding specialist or paediatric nurse.
[Gastro-oesophageal reflux disease in children and young people (2015) NICE guideline NG1, recommendation 1.2.2]
Marked distress
There is very limited evidence, and no objective or widely accepted clinical definition, for what constitutes ‘marked distress’ in infants and children who are unable to adequately communicate (expressively) their sensory emotions. NICE guideline NG1 describes ‘marked distress’ as an outward demonstration of pain or unhappiness that is outside what is considered to be the normal range by an appropriately trained, competent healthcare professional, based on a thorough assessment. This assessment should include a careful analysis of the description offered by the parents or carers in the clinical context of the individual child.
[Gastro-oesophageal reflux disease in children and young people (2015) NICE guideline NG1]
Regurgitation
The voluntary or involuntary movement of part or all of the stomach contents up the oesophagus at least as far as the mouth, and often emerging from the mouth. Regurgitation is, in principle, clinically observable, so is an overt phenomenon, although lesser degrees of regurgitation into the mouth might be overlooked.
[Gastro-oesophageal reflux disease in children and young people (2015) NICE full guideline NG1]
Equality and diversity considerations
Breastfeeding assessments should be carried out in a culturally appropriate manner and any messages communicated in a sensitive way.
Formula-fed infants – stepped-care approach
This quality statement is taken from the gastro-oesophageal reflux in children and young people quality standard. The quality standard defines clinical best practice for gastro-oesophageal reflux in children and young people and should be read in full.
Quality statement
Formula-fed infants with frequent regurgitation associated with marked distress have their symptoms managed using a stepped-care approach.
Rationale
A stepped-care approach enables parents and carers of formula-fed infants to try a sequence of easy modifications to the feeding practice that can help them manage frequent regurgitation with marked distress.
Quality measures
Structure
Evidence of local arrangements to ensure that formula-fed infants with frequent regurgitation associated with marked distress have their symptoms managed using a stepped-care approach.
Data source: Local data collection.
Process
a) Proportion of formula-fed infants with frequent regurgitation associated with marked distress that have their feeding history reviewed.
Numerator – number in the denominator who have their feeding history reviewed.
Denominator – number of formula-fed infants presenting with frequent regurgitation associated with marked distress.
Data source: Local data collection.
b) Proportion of formula-fed infants with frequent regurgitation associated with marked distress that had excessive feed volumes reduced.
Numerator – number in the denominator whose excessive feed volumes were reduced.
Denominator – number of formula-fed infants presenting with frequent regurgitation associated with marked distress who receive excessive feed volumes.
Data source: Local data collection.
a) Proportion of formula-fed infants with frequent regurgitation associated with marked distress who received a trial of smaller and more frequent feeds.
Numerator – number in the denominator who received a trial of smaller and more frequent feeds.
Denominator – number of formula-fed infants presenting with frequent regurgitation associated with marked distress receiving appropriate total daily amount of milk.
Data source: Local data collection.
b) Proportion of formula-fed infants with frequent regurgitation associated with marked distress given a trial of thickened formula.
Numerator – number in the denominator given a trial of thickened formula.
Denominator – number of formula-fed infants with frequent regurgitation associated with marked distress receiving appropriate total daily amount of milk and receiving trial of small and frequent feeds.
Data source: Local data collection.
Outcome
Infants with frequent regurgitation associated with marked distress presenting in healthcare settings.
Data source: Local data collection.
What the quality statement means for service providers, healthcare professionals and commissioners
Service providers (community care providers, secondary care and specialised women’s trusts) ensure that healthcare professionals offer a stepped-care approach to managing frequent regurgitation associated with marked distress for formula-fed infants.
Healthcare professionals (health visitors, midwives, paediatric nurses or GPs) use a stepped-care approach to manage frequent regurgitation associated with marked distress for formula-fed infants.
Commissioners (clinical commissioning groups, local authorities, NHS England) ensure that the services they commission use a stepped-care approach to managing frequent regurgitation associated with marked distress for formula-fed infants.
What the quality statement means for parents and carers
Parents and carers of formula-fed babies with reflux (regurgitating, bringing up or vomiting feeds) who are very distressed, for example, if they cry inconsolably and seem to be in pain, are told about small changes they can make to feeding that are likely to improve their baby’s symptoms, such as reducing the amount or frequency of feeds.
Source guidance
- Gastro-oesophageal reflux disease in children and young people (2015) NICE guideline NG1, recommendations 1.2.3
Definitions of terms used in this quality statement
Stepped-care approach
In formula-fed infants with frequent regurgitation associated with marked distress, use the following stepped-care approach:
- review the feeding history, then
- reduce the feed volumes only if excessive for the infant’s weight, then
- offer a trial of smaller, more frequent feeds (while maintaining an appropriate total daily amount of milk) unless the feeds are already small and frequent, then
- offer a trial of thickened formula (for example, containing rice starch, cornstarch, locust bean gum or carob bean gum).
[Gastro-oesophageal reflux disease in children and young people (2015) NICE guideline NG1, recommendation 1.2.3]
Alginate therapy
This quality statement is taken from the gastro-oesophageal reflux in children and young people quality standard. The quality standard defines clinical best practice for gastro-oesophageal reflux in children and young people and should be read in full.
Quality statement
Infants with frequent regurgitation associated with marked distress have a trial of alginate therapy if first-line management is unsuccessful.
Rationale
By reacting with acidic gastric contents, the alginate forms a viscous gel that stabilises stomach activity, which can be effective in reducing gastro-oesophageal reflux (GOR) in some infants. Alginate therapy should only be tried if first-line management (feeding assessment and advice for breast-fed infants or a stepped-care approach for formula-fed infants) is unsuccessful. In formula-fed infants, thickened formula should be stopped before alginate therapy is offered.
Quality measures
Structure
Evidence of local arrangements to ensure that infants with frequent regurgitation associated with marked distress have a trial of alginate therapy if first-line management is unsuccessful.
Data source: Local data collection.
Process
a) Proportion of breast-fed infants with frequent regurgitation associated with marked distress that continues despite a feeding assessment and advice who have a trial of alginate therapy.
Numerator – number in the denominator who have a trial of alginate therapy.
Denominator – number of breast-fed infants presenting with frequent regurgitation associated with marked distress that continues despite a feeding assessment and advice.
Data source: Local data collection.
b) Proportion of formula-fed infants with frequent regurgitation associated with marked distress that continues despite a feeding assessment and advice who have a trial of alginate therapy.
Numerator – number in the denominator who have a trial of alginate therapy.
Denominator – number of formula-fed infants with frequent regurgitation associated with marked distress that continues despite a stepped-care approach.
Data source: Local data collection.
Outcome
Infants with frequent regurgitation associated with marked distress presenting in healthcare settings.
Data source: Local data collection.
What the quality statement means for service providers, healthcare professionals and commissioners
Service providers (community care providers, secondary care and specialised women’s trusts) ensure that healthcare professionals offer a trial of alginate therapy for infants with frequent regurgitation associated with marked distress if first-line management is unsuccessful.
Healthcare professionals (health visitors, midwives, paediatric nurses or GPs) offer a trial of alginate therapy for infants with frequent regurgitation associated with marked distress if first-line management is unsuccessful.
Commissioners (clinical commissioning groups, local authorities, NHS England) ensure that the services they commission offer a trial of alginate therapy for infants with frequent regurgitation associated with marked distress if first-line management is unsuccessful.
What the quality statement means for parents and carers
Parents and carers who have had support and advice about correct breastfeeding techniques (for breast-fed babies) or tried using smaller and more frequent feeds followed by thickened formula (for formula-fed babies), but whose baby’s symptoms haven’t improved are offered a medicine called an alginate for a trial period of 1 to 2 weeks. Alginates may help to reduce reflux.
Source guidance
- Gastro-oesophageal reflux disease in children and young people (2015) NICE guideline NG1, recommendations 1.2.3, 1.2.4 and 1.2.5 (key priority for implementation)
Definitions of terms used in this quality statement
Trial of alginate therapy
By reacting with acidic gastric contents the alginate forms a viscous gel that stabilises stomach activity which results in reducing the incidence of GOR.
Infants have alginate therapy for a period of 1–2 weeks to assess if GOR improves. After the trial period, the approach needs to be reviewed by the healthcare professional.
[Gastro-oesophageal reflux disease in children and young people (2015) NICE full guideline NG1 and expert opinion]
First-line management
In breast-fed infants with frequent regurgitation associated with marked distress, first-line management is a breastfeeding assessment carried out by a person with appropriate expertise and training.
In formula-fed infants with frequent regurgitation associated with marked distress, first-line management is a stepped-care approach, as follows:
- review the feeding history, then
- reduce the feed volumes only if excessive for the infant’s weight, then
- offer a trial of smaller, more frequent feeds (while maintaining an appropriate total daily amount of milk) unless the feeds are already small and frequent, then
- offer a trial of thickened formula (for example, containing rice starch, cornstarch, locust bean gum or carob bean gum).
In formula-fed infants, if the stepped-care approach is unsuccessful stop the thickened formula and offer alginate therapy for a trial period of 1–2 weeks.
[Adapted from gastro-oesophageal reflux disease in children and young people (2015) NICE guideline NG1, recommendations 1.2.2, 1.2.3 and 1.2.5 (key priority for implementation)].
Symptoms that do not need investigation or treatment
This quality statement is taken from the gastro-oesophageal reflux in children and young people quality standard. The quality standard defines clinical best practice for gastro-oesophageal reflux in children and young people and should be read in full.
Quality statement
Infants and children are not investigated or treated for gastro-oesophageal reflux disease (GORD) if they have no visible regurgitation and only 1 associated symptom.
Rationale
Although a combination of symptoms, such as unexplained feeding difficulties (for example, refusing to feed, gagging or choking), distressed behaviour, faltering growth, chronic cough, hoarseness or a single episode of pneumonia can be associated with GORD, having no visible regurgitation and only 1 of these symptoms does not indicate GORD. Unnecessary investigations cause distress for infants and children, as well as costs to the NHS that can be avoided.
Quality measures
Structure
Evidence of local arrangements to ensure that infants and children are not investigated or treated for GORD if they have no visible regurgitation and only 1 associated symptom.
Data source: Local data collection.
Process
Proportion of infants and children with no visible regurgitation and only 1 associated symptom investigated or treated for GORD.
Numerator – number in the denominator who had no visible regurgitation and only 1 associated symptom.
Denominator – number of infants and children investigated or treated for GORD.
Data source: Local data collection.
What the quality statement means for service providers, healthcare professionals and commissioners
Service providers (GP practices, community care providers, secondary care) ensure that there are practice arrangements and written clinical protocols to ensure that infants and children are not investigated or treated for GORD if they have no visible regurgitation and only 1 associated symptom.
Healthcare professionals (health visitors, midwives, paediatric nurses or GPs) ensure that they do not investigate or treat infants and children for GORD if they have only 1 associated symptom and no visible regurgitation.
Commissioners (clinical commissioning groups, NHS England, local authorities) ensure that the services they commission do not investigate or treat infants and children for GORD if they have only 1 associated symptom and no visible regurgitation.
What the quality statement means for infants and children
Infants and children do not undergo tests or treatments for GORD if they are not regurgitating their feeds and if they only have 1 of the following symptoms: feeding problems such as refusing to feed, gagging or choking, discomfort or pain on a regular basis, poor growth, cough that does not go away, hoarseness or pneumonia.
Source guidance
- Gastro-oesophageal reflux disease in children and young people (2015) NICE guideline NG1, recommendation 1.1.6 (key priority for implementation)
Definitions of terms used in this quality statement
Symptoms associated with GORD
Symptoms that infants may present with include:
- unexplained feeding difficulties (for example, refusing to feed, gagging or choking)
- distressed behaviour
- faltering growth
- chronic cough
- hoarseness
- a single episode of pneumonia.
[Gastro-oesophageal reflux disease in children and young people NICE guideline NG1, recommendation 1.1.6 (key priority for implementation)]
Acid-suppressing drugs
This quality statement is taken from the gastro-oesophageal reflux in children and young people quality standard. The quality standard defines clinical best practice for gastro-oesophageal reflux in children and young people and should be read in full.
Quality statement
Infants and children are not prescribed acid-suppressing drugs if visible regurgitation is an isolated symptom.
Rationale
There is no evidence that acid-suppressing drugs such as proton pump inhibitors (PPIs) or H2 receptor antagonists (H2RAs) are effective in reducing regurgitation in infants and children. They are generally well tolerated but do have potential adverse effects, and unnecessary use should be avoided.
Quality measures
Structure
Evidence of local arrangements to ensure that infants and children with regurgitation as an isolated symptom are not prescribed acid-suppressing drugs.
Data source: Local data collection.
Process
Proportion of infants and children presenting with regurgitation as an isolated symptom prescribed acid-suppressing drugs.
Numerator – number in the denominator prescribed acid-suppressing drugs.
Denominator – number of infants and children presenting with regurgitation as an isolated symptom.
Data source: Local data collection.
Outcome
PPI and H2RA prescribing rates among infants and children.
Data source: Local data collection.
What the quality statement means for service providers, healthcare professionals and commissioners
Service providers (secondary care, community care providers, GP practices) ensure that there are practice arrangements and written clinical protocols to ensure that infants and children with regurgitation as an isolated symptom are not prescribed acid-suppressing drugs.
Healthcare professionals (midwives, paediatric nurses or GPs) do not prescribe acid-suppressing drugs to infants and children with regurgitation as an isolated symptom.
Commissioners (clinical commissioning groups and NHS England) ensure that services they commission do not prescribe acid-suppressing drugs to infants and children with regurgitation as an isolated symptom.
What the quality statement means for infants and children
Infants and children who regurgitate food but have no other symptoms are not prescribed medicines that reduce acid production in the stomach.
Source guidance
- Gastro-oesophageal reflux disease in children and young people (2015) NICE guideline NG1, recommendation 1.3.1 (key priority for implementation)
Definitions of terms used in this quality statement
Acid-suppressing drugs
Acid-suppressing drugs are a group of medications that reduce gastric acid secretion. They include H2RAs and PPIs.
[Gastro-oesophageal reflux disease in children and young people (2015) NICE full guideline NG1]
Upper gastrointestinal (GI) contrast study
This quality statement is taken from the gastro-oesophageal reflux in children and young people quality standard. The quality standard defines clinical best practice for gastro-oesophageal reflux in children and young people and should be read in full.
Quality statement
Infants, children and young people do not have an upper gastrointestinal (GI) contrast study to diagnose or assess the severity of gastro-oesophageal reflux disease (GORD).
Rationale
Upper GI contrast studies are neither sensitive nor specific enough to diagnose or assess the severity of GORD, and they unnecessarily expose infants, children and young people to radiation.
Quality measures
Structure
Evidence of local arrangements to ensure that upper GI contrast studies are not used to diagnose or assess the severity of GORD in infants, children and young people.
Data source: Local data collection.
Process
Proportion of infants, children and young people referred for upper GI contrast study to diagnose or assess the severity of GORD.
Numerator – number in the denominator referred to diagnose or assess the severity of GORD.
Denominator – number of infants, children and young people referred for upper GI contrast study.
Data source: Local data collection.
What the quality statement means for service providers, healthcare professionals and commissioners
Service providers (secondary care providers) ensure that there are practice arrangements to ensure that upper GI contrast studies are not carried out to diagnose or assess the severity of GORD in infants, children and young people.
Healthcare professionals (midwives, paediatric nurses or GPs) do not refer infants, children and young people for upper GI contrast studies to diagnose or assess the severity of GORD.
Commissioners (clinical commissioning groups) ensure that services they commission have protocols that do not allow healthcare professionals to carry out upper GI contrast studies to diagnose or assess the severity of GORD in infants, children and young people.
What the quality statement means for infants, children and young people
Infants, children and young people do not have a type of scan called an upper gastrointestinal contrast study to assess how serious their reflux is.
Source guidance
- Gastro-oesophageal reflux disease in children and young people (2015) NICE guideline NG1, recommendation 1.1.15 (key priority for implementation)
Domperidone, metoclopramide and erythromycin
This quality statement is taken from the gastro-oesophageal reflux in children and young people quality standard. The quality standard defines clinical best practice for gastro-oesophageal reflux in children and young people and should be read in full.
Quality statement
Infants, children and young people are not prescribed domperidone, metoclopramide or erythromycin to manage gastro-oesophageal reflux (GOR) or gastro-oesophageal reflux disease (GORD) without specialist paediatric advice.
Rationale
Prokinetics such as domperidone and metoclopramide are associated with a range of risks such as neurological and cardiac adverse events. Domperidone, metoclopramide and erythromycin (which is used in GOR and GORD for its prokinetic properties) should only be prescribed for infants, children and young people if there is an agreement for its use by a specialist paediatric healthcare professional.
Quality measures
Structure
Evidence of local arrangements to ensure that infants, children and young people are not prescribed domperidone, metoclopramide or erythromycin to manage GOR or GORD without specialist paediatric advice.
Data source: Local data collection.
Process
Proportion of infants, children and young people prescribed domperidone, metoclopramide or erythromycin to manage GOR or GORD on the basis of specialist paediatric advice.
Numerator – number in the denominator who were prescribed domperidone, metoclopramide or erythromycin on the basis of specialist paediatric advice.
Denominator – number of infants, children and young people prescribed domperidone, metoclopramide or erythromycin to manage GOR or GORD.
Data source: Local data collection.
Outcome
Domperidone, metoclopramide and erythromycin prescribing among infants, children and young people.
Data source: Local data collection.
What the quality statement means for service providers, healthcare professionals and commissioners
Service providers (secondary care, community care providers, GP practices) ensure that there are practice arrangements and written clinical protocols to ensure that infants, children and young people are not prescribed domperidone, metoclopramide or erythromycin to manage GOR or GORD without specialist paediatric advice.
Healthcare professionals (midwives, paediatric nurses or GPs) do not prescribe domperidone, metoclopramide or erythromycin to manage GOR or GORD in infants, children and young people without specialist paediatric advice.
Commissioners (clinical commissioning groups and NHS England) ensure that services they commission do not prescribe domperidone, metoclopramide or erythromycin to manage GOR or GORD in infants, children and young people without specialist paediatric advice.
What the quality statement means for infants, children and young people
Infants, children and young people are not prescribed medicines called domperidone, metoclopramide or erythromycin to manage reflux unless a specialist advises it.
Source guidance
- Gastro-oesophageal reflux disease in children and young people (2015) NICE guideline NG1, recommendation 1.3.7 (key priority for implementation)
Definitions of terms used in this quality statement
Specialist
Specialist refers to a paediatrician with the skills, experience and competency necessary to deal with the particular clinical concern that has been identified by the referring healthcare professional. In this guideline this is most likely to be a consultant general paediatrician. Depending on the clinical circumstances, ‘specialist’ may also refer to a paediatric surgeon, paediatric gastroenterologist or a doctor with the equivalent skills and competency.
[Gastro-oesophageal reflux disease in children and young people (2015) NICE guideline NG1, definitions section]
'Red flag' symptoms and suggested actions
This quality statement is taken from the gastro-oesophageal reflux in children and young people quality standard. The quality standard defines clinical best practice for gastro-oesophageal reflux in children and young people and should be read in full.
Quality statement
Infants, children and young people with vomiting or regurgitation and any ‘red flag’ symptoms are referred to specialist care with investigations as appropriate.
Rationale
Some symptoms that are commonly mistaken for gastro-oesophageal reflux disease (GORD) may be ‘red flag’ symptoms for other problems. These problems need action to be taken, such as further investigations or specialist referral.
Quality measures
Structure
Evidence of local arrangements to ensure that infants, children and young people with vomiting or regurgitation and any ‘red flag’ symptoms are further investigated or referred to specialist care with investigations as appropriate.
Data source: Local data collection.
Process
a) Proportion of infants, children and young people with vomiting or regurgitation and any ‘red flag’ symptoms who had further investigations and specialist referral.
Numerator – number in the denominator who had further investigations and specialist referral.
Denominator – number of infants, children and young people presenting with vomiting or regurgitation and any ‘red flag’ symptoms.
Data source: Local data collection.
b) Proportion of infants, children and young people with vomiting or regurgitation and any ‘red flag’ symptoms who had appropriate investigations and specialist referral.
Numerator – number in the denominator who had appropriate investigations and specialist referral.
Denominator – number of infants, children and young people with vomiting or regurgitation and any ‘red flag’ symptoms who had further investigations and specialist referral.
Data source: Local data collection.
What the quality statement means for service providers, healthcare professionals and commissioners
Service providers ensure that there are practice arrangements and written clinical protocols to ensure that healthcare professionals look out for ‘red flag’ symptoms in infants, children and young people with vomiting or regurgitation, and carry out further investigations or arrange specialist referrals depending on the symptoms.
Healthcare professionals (midwives, paediatric nurses or GPs) look out for ‘red flag’ symptoms in infants, children and young people with vomiting or regurgitation and carry out further investigations or arrange specialist referrals depending on the symptoms.
Commissioners (clinical commissioning groups and NHS England) ensure that services they commission have pathways for healthcare professionals to carry out further investigations or arrange specialist referrals for infants, children and young people with vomiting or regurgitation and ‘red flag’ symptoms.
What the quality statement means for infants, children and young people
Infants, children and young people have tests or are referred to a specialist if their symptoms show that they might have another problem than reflux.
Source guidance
- Gastro-oesophageal reflux disease in children and young people (2015) NICE guideline NG1, recommendation 1.1.5 (key priority for implementation)
Definitions of terms used in this quality statement
'Red flag' symptoms and suggested actions
Symptoms and signs | Possible diagnostic implications | Suggested actions |
Gastrointestinal | ||
Frequent, forceful (projectile) vomiting | May suggest hypertrophic pyloric stenosis in infants up to 2 months old | Paediatric surgery referral |
Bile–stained (green or yellow–green) vomit | May suggest intestinal obstruction | Paediatric surgery referral |
Haematemesis (blood in vomit) with the exception of swallowed blood, for example, following a nose bleed or ingested blood from a cracked nipple in some breast-fed infants | May suggest an important and potentially serious bleed from the oesophagus, stomach or upper gut | Specialist referral |
Onset of regurgitation and/or vomiting after 6 months or persisting after 1 year | Late onset suggests a cause other than reflux, for example a urinary tract infection (also see the NICE guideline on urinary tract infection in under 16s) Persistence suggests an alternative diagnosis | Urine microbiology investigation Specialist referral |
Blood in stool | May suggest a variety of conditions, including bacterial gastroenteritis, infant cows’ milk protein allergy (also see the NICE guideline on food allergy in under 19s) or an acute surgical condition | Stool microbiology investigation Specialist referral |
Abdominal distension, tenderness or palpable mass | May suggest intestinal obstruction or another acute surgical condition | Paediatric surgery referral |
Chronic diarrhoea | May suggest cows’ milk protein allergy (also see the NICE guideline on food allergy in under 19s) | Specialist referral |
Systemic | ||
Appearing unwell Fever | May suggest infection (also see the NICE guideline on fever in under 5s) | Clinical assessment and urine microbiology investigation Specialist referral |
Dysuria | May suggest urinary tract infection (also see the NICE guideline on urinary tract infection in under 16s) | Clinical assessment and urine microbiology investigation Specialist referral |
Bulging fontanelle | May suggest raised intracranial pressure, for example, due to meningitis (also see the NICE guideline on meningitis (bacterial) and meningococcal septicaemia in under 16s) | Specialist referral |
Rapidly increasing head circumference (more than 1 cm per week) Persistent morning headache, and vomiting worse in the morning | May suggest raised intracranial pressure, for example, due to hydrocephalus or a brain tumour | Specialist referral |
Altered responsiveness, for example, lethargy or irritability | May suggest an illness such as meningitis (also see the NICE guideline on meningitis (bacterial) and meningococcal septicaemia in under 16s) | Specialist referral |
Infants and children with, or at high risk of, atopy | May suggest cows' milk protein allergy (also see the NICE guideline on food allergy in under 19s) | Specialist referral |
Advice to support self-management
This quality statement is taken from the dyspepsia and gastro-oesophageal reflux disease in adults quality standard. The quality standard defines clinical best practice for dyspepsia and gastro-oesophageal reflux disease in adults and should be read in full.
Quality statement
Adults with dyspepsia or reflux symptoms who present to community pharmacists are given advice about making lifestyle changes, using over-the-counter medicines and when to consult their GP.
Rationale
Adults with dyspepsia or reflux symptoms who present to their community pharmacist may be able to alleviate and manage their symptoms by making changes to their lifestyle (eating healthily, losing weight if they are overweight, not smoking) and using over-the-counter medicines. It is also important that adults receive advice about when they should consult their GP to ensure that symptoms are investigated and managed appropriately.
Quality measures
Structure
Evidence of local arrangements to ensure that adults with dyspepsia or reflux symptoms who present to their community pharmacist are given advice about making lifestyle changes, using over-the-counter medicines and when to consult their GP.
Data source: Local data collection.
Process
Proportion of presentations of adults with dyspepsia or reflux symptoms to community pharmacists in which advice is received about making lifestyle changes, using over-the-counter medicines and when to consult a GP.
Numerator – the number in the denominator in which advice is received about making lifestyle changes, using over-the-counter medicines and when to consult a GP.
Denominator – the number of presentations of adults with dyspepsia or reflux symptoms to community pharmacists.
Data source: Local data collection.
Outcome
Adults with dyspepsia or reflux symptoms are satisfied that they are able to self-manage their condition.
Data source: Local data collection.
Patient-reported health outcomes for adults with dyspepsia or gastro-oesophageal reflux disease.
Data source: Local data collection.
What the quality statement means for service providers, healthcare professionals and commissioners
Service providers (community pharmacists) ensure that processes are in place so that adults presenting with dyspepsia or reflux symptoms receive advice about making lifestyle changes, using over-the-counter medicines and when to consult their GP. This may include providing information leaflets when over-the-counter medicines are purchased.
Community pharmacists advise adults presenting with dyspepsia or reflux symptoms about making lifestyle changes, using over-the-counter medicines and when to consult their GP.
Commissioners (NHS England area teams and clinical commissioning groups) commission services that ensure community pharmacists advise people presenting with dyspepsia or reflux symptoms about making lifestyle changes, using over-the-counter medicines and when to consult their GP. Commissioners should work collaboratively with available minor ailment schemes to ensure that advice to adults with dyspepsia or reflux symptoms is included in any relevant service specifications.
What the quality statement means for patients, service users and carers
Adults with indigestion or heartburn receive advice from their pharmacist about what they can do to relieve their symptoms. This should include advice about eating healthily, losing weight if they are overweight and not smoking. They should also receive information about medicines that can be bought ‘over-the-counter’ without a prescription and when people should make an appointment to see their GP. This information will help adults with indigestion or heartburn to manage their condition themselves.
Source guidance
- Dyspepsia and gastro-oesophageal reflux disease (2014) NICE guideline CG184, recommendations 1.1.1, 1.2.1, 1.2.2, and 1.2.3.
Definitions of terms used in this quality statement
Advice about lifestyle changes
Adults presenting with dyspepsia or reflux symptoms should be given simple lifestyle advice including:
- Healthy eating, weight loss for people who are overweight and smoking cessation for people who smoke.
- Avoiding known causes that may be associated with symptoms, including smoking, alcohol, coffee, chocolate, fatty foods and being overweight.
- Other factors that might help, such as raising the head of the bed and having a main meal at least 3 hours before going to bed.
[Dyspepsia and gastro-oesophageal reflux disease (NICE guideline CG184) recommendations 1.2.1, 1.2.2 and information for the public]
Advice about using over-the-counter medication
Adults presenting with dyspepsia or reflux symptoms should be advised to avoid long-term, frequent dose, continuous antacid therapy, because it only relieves symptoms in the short-term rather than preventing them. Adults with these symptoms should also be advised that non-steroidal anti-inflammatory drugs (NSAIDs) can be a potential cause.
[Adapted from Dyspepsia and gastro-oesophageal reflux disease (NICE guideline CG184) recommendations 1.3.2 and 1.8.7]
Advice about when to consult their GP
Adults presenting with dyspepsia or reflux symptoms should be advised to see their GP if their symptoms have persisted for several weeks, get worse over time, or do not improve with medication. They should be advised to see their GP urgently if they have dysphagia or if they are aged 55 and over with additional symptoms that may be a cause for concern including weight loss, haematemesis, nausea or vomiting, or upper abdominal pain.
[Adapted from Dyspepsia and gastro-oesophageal reflux disease (NICE full guideline CG184) section 4.1.2.1, Suspected cancer (NICE guideline NG12) recommendations 1.2.1, 1.2.2, 1.2.3, 1.2.7, 1.2.8, 1.2.9, and expert opinion]
Equality and diversity considerations
Healthcare professionals should offer prescriptions to socially disadvantaged adults for over-the-counter medicines for dyspepsia or reflux symptoms if needed.
Community pharmacists should take into account cultural and communication needs when providing advice and educational materials.
Not all adults will want to self-manage their dyspepsia or reflux symptoms, or be able to do so, and community pharmacists should identify any vulnerable people who may need additional support.
Urgent endoscopy
This quality statement is taken from the dyspepsia and gastro-oesophageal reflux disease in adults quality standard. The quality standard defines clinical best practice for dyspepsia and gastro-oesophageal reflux disease in adults and should be read in full.
Quality statement
Adults presenting with dyspepsia or reflux symptoms are referred for urgent direct access endoscopy to take place within 2 weeks if they have dysphagia, or are aged 55 and over with weight loss.
Rationale
There is currently wide geographical variation in referral rates for endoscopy for adults with dyspepsia or reflux symptoms. Although many adults presenting with dyspepsia or reflux symptoms will not need an endoscopy, it is important that those with additional symptoms that indicate a higher risk of oesophagogastric cancer are referred urgently for investigation. Direct access endoscopy will ensure that referrals from primary care to the suspected cancer pathway are focused on people with symptoms of suspected cancer.
Quality measures
Structure
Evidence of local arrangements to ensure that adults presenting with dyspepsia or reflux symptoms are referred for urgent direct access endoscopy to take place within 2 weeks if they have dysphagia, or are aged 55 and over with weight loss.
Data source: Local data collection.
Process
a) Proportion of adults presenting with dyspepsia or reflux symptoms and dysphagia who are referred for urgent direct access endoscopy.
Numerator – the number in the denominator who are referred for urgent direct access endoscopy.
Denominator – the number of adults presenting with dyspepsia or reflux symptoms and dysphagia.
Data source: Local data collection. Hospital Episode Statistics collects data on upper gastrointestinal endoscopies.
b) Proportion of referrals for adults presenting with dyspepsia or reflux symptoms and dysphagia who receive urgent direct access endoscopy within 2 weeks.
Numerator – the number in the denominator who receive endoscopy within 2 weeks.
Denominator – the number of referrals for urgent direct access endoscopy for adults presenting with dyspepsia or reflux symptoms and dysphagia.
Data source: Local data collection. Hospital Episode Statistics collects data on upper gastrointestinal endoscopies.
c) Proportion of adults aged 55 and over presenting with dyspepsia or reflux symptoms and weight loss who are referred for urgent direct access endoscopy.
Numerator – the number in the denominator who are referred for urgent direct access endoscopy.
Denominator – the number of adults aged 55 and over presenting with dyspepsia or reflux symptoms and weight loss.
Data source: Local data collection. Hospital Episode Statistics collects data on upper gastrointestinal endoscopies.
d) Proportion of referrals for adults aged 55 and over presenting with dyspepsia or reflux symptoms and weight loss who receive urgent direct access endoscopy within 2 weeks.
Numerator – the number in the denominator who receive endoscopy within 2 weeks.
Denominator – the number of referrals for urgent direct access endoscopy for adults aged 55 and over presenting with dyspepsia or reflux symptoms and weight loss.
Data source: Local data collection. Hospital Episode Statistics collects data on upper gastrointestinal endoscopies.
Outcome
a) Incidence of oesophagogastric cancer.
Data source: Local data collection. Cancer Registration Statistics collects data on the incidence of cancer.
b) Oesophagogastric cancer survival rates.
Data source: Local data collection. Geographic patterns of cancer survival in England provide data on 1- and 5-year survival rates.
c) Patient satisfaction with investigation of dyspepsia and reflux symptoms.
Data source: Local data collection.
What the quality statement means for service providers, healthcare professionals and commissioners
Service providers (general practices and community healthcare providers) ensure that processes and resources are in place so that adults presenting with dyspepsia or reflux symptoms are referred for urgent direct access endoscopy to take place within 2 weeks if they have dysphagia or are aged 55 and over with weight loss. Endoscopy services should record and report inappropriate urgent direct access referrals for adults with dyspepsia or reflux symptoms.
Healthcare professionals refer adults presenting with dyspepsia or reflux symptoms for urgent direct access endoscopy to take place within 2 weeks if they have dysphagia or are aged 55 and over with weight loss.
Commissioners (clinical commissioning groups and NHS England area teams) ensure that they commission services that refer adults presenting with dyspepsia or reflux symptoms for urgent direct access endoscopy to take place within 2 weeks if they have dysphagia or are aged 55 and over with weight loss. Commissioners should monitor inappropriate urgent direct access referrals for endoscopy for adults with dyspepsia or reflux symptoms as well as investigate particularly low rates of referral.
What the quality statement means for patients, service users and carers
Adults with indigestion or heartburn will be referred for an endoscopy if they have additional symptoms that need to be investigated, such as pain or difficulty swallowing or weight loss when they are over 55. An endoscopy is a procedure that is sometimes carried out to investigate indigestion symptoms and find out what is causing them. It involves using an endoscope (a narrow, flexible tube with a camera at its tip), to see inside the oesophagus and stomach. The person may be offered sedation before the procedure or given a local anaesthetic to numb the throat. The endoscope is then guided down the person's throat and into their stomach. Not everyone with indigestion or heartburn will need an endoscopy.
Source guidance
- Suspected cancer (2015) NICE guideline NG12, recommendations 1.2.1 and 1.2.7.
Definitions of terms used in this quality statement
Urgent direct access endoscopy
Primary care arranges for an endoscopy to be carried out within 2 weeks and retains clinical responsibility throughout, including acting on the result.
[Suspected cancer (NICE guideline NG12)]
Equality and diversity considerations
Healthcare professionals should take into account cultural and communication needs when arranging and explaining a referral for direct access endoscopy.
Healthcare professionals should respect an adult’s choice to refuse an endoscopy if they consider themselves to be too frail due to age.
Testing conditions for Helicobacter pylori
This quality statement is taken from the dyspepsia and gastro-oesophageal reflux disease in adults quality standard. The quality standard defines clinical best practice for dyspepsia and gastro-oesophageal reflux disease in adults and should be read in full.
Quality statement
Adults with dyspepsia or reflux symptoms have a 2-week washout period before a test for Helicobacter pylori if they are receiving proton pump inhibitor therapy.
Rationale
To improve the accuracy of Helicobacter pylori (H pylori) testing it is important to have a 2-week washout period after using a proton pump inhibitor (PPI). Improving the accuracy of the test will ensure that treatment for H pylori infection is given only if needed. Treatment for H pylori infection is complex and there is concern that treatment without an accurate diagnosis may lead to increasing antimicrobial resistance. In addition, treatment for H pylori can be unpleasant for the patient and has an increased risk of antibiotic-associated diarrhoea and enteric infections such as Clostridium difficile.
Quality measures
Structure
Evidence of local arrangements to ensure that adults with dyspepsia or reflux symptoms have a 2-week washout period before a test for H pylori if they are receiving PPI therapy.
Data source: Local data collection.
Process
Proportion of adults with dyspepsia or reflux symptoms receiving PPI therapy who are tested for H pylori who had a 2-week washout period before the test.
Numerator – the number in the denominator who had a 2-week washout period before the test.
Denominator – the number of adults with dyspepsia or reflux symptoms receiving PPI therapy who are tested for H pylori.
Data source: Local data collection.
Outcome
H pylori antimicrobial resistance rate.
Data source: Local data collection.
What the quality statement means for service providers, healthcare professionals and commissioners
Service providers (general practices and hospitals) ensure that adults with dyspepsia or reflux symptoms have a 2-week washout period before a test for H pylori if they are receiving PPI therapy.
Healthcare professionals ensure that adults with dyspepsia or reflux symptoms have a 2-week washout period before testing for H pylori if they are receiving PPI therapy.
Commissioners (clinical commissioning groups and NHS England area teams) commission services that ensure that adults with dyspepsia or reflux symptoms have a 2-week washout period before a test for H pylori if they are receiving PPI therapy.
What the quality statement means for patients, service users and carers
Adults with indigestion or heartburn may need to have a test for an infection called Helicobacter pylori (H pylori for short), which can cause stomach and duodenal ulcers (the duodenum is the section of intestine immediately after the stomach). H pylori infection is detected using a breath or stool test, or sometimes a blood test. If the person is taking a medicine called a proton pump inhibitor (PPI) for their indigestion or heartburn symptoms, their GP will tell them if they need to stop taking the PPI or any other medicine before the H pylori test.
Source guidance
- Dyspepsia and gastro-oesophageal reflux disease (2014) NICE guideline CG184, recommendations 1.4.2 (key priority for implementation), 1.4.4 and 1.9.1.
Definitions of terms used in this quality statement
Proton pump inhibitor (PPI)
Proton pump inhibitors inhibit gastric acid secretion by blocking the hydrogen-potassium adenosine triphosphatase enzyme system (the ‘proton pump’) of the gastric parietal cell. PPIs include esomeprazole, lansoprazole, omeprazole, pantoprazole, and rabeprazole.
Test for H pylori
Use a carbon-13 urea breath test, a stool antigen test or laboratory-based serology where its performance has been locally validated to test for H pylori. Ensure that no antibiotics have been taken for any infection in the 4 weeks before the test.
If laboratory-based serology is to be used, its performance should be locally validated to test for H pylori. The serology test should have high positive predictive value in the intended population, or positives should be confirmed with a second test. Validation is an evidence-based assessment of how a test performs in the laboratory, and demonstrates suitability for intended purpose. Local validation will provide documentary evidence that a commercial serology kit is performing within the manufacturer’s specifications. This will include results of experiments to determine its accuracy, sensitivity, reliability and reproducibility. Local validation should meet the requirements set out in the UK Standards for Microbiology Investigations.
[Adapted from Dyspepsia and gastro-oesophageal reflux disease (2014) NICE guideline CG184 recommendations 1.4.2 and 1.9.1, UK Standards for Microbiology Investigations – SMI Q1: Commercial and in-house diagnostic tests: evaluations and validations (2014) Public Health England Quality Guidance, and expert opinion]
Equality and diversity considerations
Serological tests are less reliable in older people and therefore, where laboratory-based serology tests are used, their suitability for people over 65 should be carefully considered.
It is important to use an accurate test for H pylori for people from ethnic minority groups because resistance rates are higher than in the general population. Where laboratory-based serology tests are used, their suitability for people from ethnic minority groups should be carefully considered.
Discussion about referral for non-urgent endoscopy
This quality statement is taken from the dyspepsia and gastro-oesophageal reflux disease in adults quality standard. The quality standard defines clinical best practice for dyspepsia and gastro-oesophageal reflux disease in adults and should be read in full.
Quality statement
Adults aged 55 and over with dyspepsia or reflux symptoms that have not responded to treatment have a discussion with their GP about referral for non-urgent direct access endoscopy.
Rationale
There is currently wide geographical variation in referral rates for endoscopy for adults with dyspepsia or reflux symptoms. Although many adults with dyspepsia or reflux symptoms will not need an endoscopy, it is important that those with an increased risk of oesophagogastric cancer have a discussion with their GP about referral for endoscopy to investigate the cause.
Quality measures
Structure
Evidence of local arrangements to ensure that adults aged 55 and over with dyspepsia or reflux symptoms that have not responded to treatment have a discussion with their GP about referral for non-urgent direct access endoscopy.
Data source: Local data collection.
Process
Proportion of adults aged 55 and over with dyspepsia or reflux symptoms that have not responded to treatment who have a recorded discussion with their GP about referral for non-urgent direct access endoscopy.
Numerator – the number in the denominator who have a recorded discussion with their GP about referral for non-urgent direct access endoscopy.
Denominator – the number of adults aged 55 and over with dyspepsia or reflux symptoms that have not responded to treatment.
Data source: Local data collection.
Outcome
a) Incidence of oesophagogastric cancer.
Data source: Local data collection. Cancer Registration Statistics collect data on the incidence of cancer.
b) Oesophagogastric cancer survival rate.
Data source: Local data collection. Geographic patterns of cancer survival in England provide data on 1- and 5-year survival rates.
c) Patient satisfaction with investigation of dyspepsia and reflux symptoms.
Data source: Local data collection.
What the quality statement means for service providers, healthcare professionals and commissioners
Service providers (general practices) ensure that processes are in place so that adults aged 55 and over with dyspepsia or reflux symptoms that have not responded to treatment have a discussion with their GP about referral for non-urgent direct access endoscopy.
Healthcare professionals (GPs) discuss referral for non-urgent direct access endoscopy with adults aged 55 and over with dyspepsia or reflux symptoms that have not responded to treatment.
Commissioners (NHS England area teams) commission services that ensure adults aged 55 and over with dyspepsia or reflux symptoms that have not responded to treatment have a discussion with their GP about referral for non-urgent direct access endoscopy.
What the quality statement means for patients, service users and carers
Adults with indigestion or heartburn whose symptoms do not respond to treatment should have a discussion with their GP about referral for an endoscopy. An endoscopy is a procedure that is sometimes carried out to investigate indigestion symptoms and find out what is causing them. It involves using an endoscope (a narrow, flexible tube with a camera at its tip), to see inside the oesophagus and stomach. The person may be offered sedation before the procedure or given a local anaesthetic to numb the throat. The endoscope is then guided down the person's throat and into their stomach. Not everyone with indigestion or heartburn will need an endoscopy.
Source guidance
- Suspected cancer (2015) NICE guideline NG12, recommendations 1.2.3 and 1.2.9.
Definitions of terms used in this quality statement
Not responded to treatment
Adults with uninvestigated dyspepsia or reflux symptoms should try a full dose proton pump inhibitor (PPI) for a month and, if there is an inadequate response, H2 receptor antagonist (H2RA) therapy for a month, in order to manage their symptoms. If there is no improvement in symptoms after 8 weeks of treatment and testing for Helicobacter pylori is negative, it should be concluded that the condition has not responded to treatment.
[Adapted from Dyspepsia and gastro-oesophageal reflux disease (NICE guideline CG184) recommendations 1.4.3, 1.4.4 and 1.4.6]
Discussion about referral for endoscopy
Endoscopy should not routinely be offered to diagnose Barrett’s oesophagus. If endoscopy is considered, the discussion should focus on the person’s preferences and their individual risk factors (long duration of symptoms, increased frequency of symptoms, previous oesophagitis, previous hiatus hernia, oesophageal stricture or oesophageal ulcers, or male gender)BOB CAT: a large-scale review and Delphi consensus for management of Barrett’s Esophagus with no dysplasia, indefinite for, or low-grade dysplasia. Bennett et al, The American Journal of Gastronenterology 2015 . If people have had a previous endoscopy and there is no change in symptoms, discuss continuing management according to previous endoscopic findings.
[Dyspepsia and gastro-oesophageal reflux disease (NICE guideline CG184) recommendations 1.3.4 and 1.6.11]
Non-urgent direct access endoscopy
Primary care arranges for a non-urgent endoscopy to be carried out and retains clinical responsibility throughout, including acting on the result.
[Suspected cancer (NICE guideline NG12)]
Equality and diversity considerations
Healthcare professionals should take into account cultural and communication needs when discussing a referral for non-urgent direct access endoscopy.
Healthcare professionals should respect a person’s choice to refuse an endoscopy if they consider themselves to be too frail due to age.
Referral to a specialist service
This quality statement is taken from the dyspepsia and gastro-oesophageal reflux disease in adults quality standard. The quality standard defines clinical best practice for dyspepsia and gastro-oesophageal reflux disease in adults and should be read in full.
Quality statement
Adults with persistent, unexplained dyspepsia or reflux symptoms have a discussion with their GP about referral to a specialist service.
Rationale
Long-term symptoms can negatively affect an adult’s quality of life, so they should have a discussion with their healthcare professional about possible referral to a specialist service based on their individual risk factors and preferences. A referral to a specialist service will enable treatment and potential causes to be reviewed in order to reduce symptom burden. It could also reduce the risk of further complications developing, such as scarring of the oesophagus and pylorus, oesophageal stricture, pyloric stenosis and Barrett’s oesophagus, which is a risk factor for cancer.
Quality measures
Structure
Evidence of local arrangements to ensure that adults with persistent, unexplained dyspepsia or reflux symptoms have a discussion with their GP about referral to a specialist service.
Data source: Local data collection.
Process
Proportion of adults presenting with persistent, unexplained dyspepsia or reflux symptoms with a recorded discussion with their GP about referral to a specialist service.
Numerator – the number in the denominator with a recorded discussion with their GP about referral to a specialist service.
Denominator – the number of adults presenting with persistent, unexplained dyspepsia or reflux symptoms.
Data source: Local data collection.
Outcome
a) Incidence of Barrett’s oesophagus.
Data source: Local data collection.
b) Incidence of oesophageal stricture.
Data source: Local data collection.
c) Incidence of pyloric stenosis in adults.
Data source: Local data collection.
d) Patient-reported health outcomes for people with dyspepsia or reflux symptoms.
Data source: Local data collection.
What the quality statement means for service providers, healthcare professionals and commissioners
Service providers (general practices) ensure that processes are in place so that adults with persistent, unexplained dyspepsia or reflux symptoms discuss referral to a specialist service.
Healthcare professionals (GPs) discuss referral to a specialist service with adults with persistent, unexplained dyspepsia or reflux symptoms.
Commissioners (NHS England area teams) ensure that they commission services that ensure that GPs discuss referral to a specialist service with adults with persistent, unexplained dyspepsia or reflux symptoms. Commissioners should also ensure that a suitable specialist service is available.
What the quality statement means for patients, service users and carers
Adults with unexplained indigestion or heartburn that does not go away should talk to their GP about the possibility of being referred to see a specialist.
Source guidance
- Dyspepsia and gastro-oesophageal reflux disease (2014) NICE guideline CG184, recommendation 1.11.1 (key priority for implementation).
Definitions of terms used in this quality statement
Persistent unexplained dyspepsia or reflux symptoms
Symptoms that have not led to a diagnosis being made by the healthcare professional in primary care after initial assessment (including history, examination and any appropriate primary care investigations such as endoscopy or Helicobacter pylori test). Symptoms have continued beyond a period that would normally be associated with self-limiting problems.
[Suspected cancer (NICE guideline NG12) and expert opinion]
Discussion about referral to a specialist service
The discussion should focus on the person’s preferences and their individual risk factors (long duration of symptoms, increased frequency of symptoms, previous oesophagitis, previous hiatus hernia, oesophageal stricture or oesophageal ulcers, or male gender). If people have had a previous endoscopy and there is no change in symptoms, discuss continuing management according to previous endoscopic findings.
[Dyspepsia and gastro-oesophageal reflux disease (NICE guideline CG184) recommendations 1.3.4 and 1.6.11]
Specialist service
A consultant-led medical or surgical service. [Adapted from Dyspepsia and gastro-oesophageal reflux disease (NICE full guideline CG184) review question 4.9.1]
Equality and diversity considerations
Healthcare professionals should take into account cultural and communication needs when discussing referral to a specialist service.
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Effective interventions library
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Implementation
NICE has produced resources to help implement its guidance on:
Information for the public
NICE has written information for the public on each of the following topics.
Pathway information
Person-centred care
People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.
Your responsibility
Guidelines
The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.
Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.
Technology appraisals
The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.
Medical technologies guidance, diagnostics guidance and interventional procedures guidance
The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.
Supporting information
Proton pump inhibitor doses for H. pylori eradication therapy
Proton pump inhibitor | Dose |
|---|---|
Esomeprazole | 20 mg |
Lansoprazole | 30 mg |
Omeprazole | 20–40 mg |
Pantoprazole | 40 mg |
Rabeprazole | 20 mg |
Proton pump inhibitor doses for severe oesophagitis
Proton pump inhibitor | Full/standard dose | Low dose (on‑demand dose) | High/double dose |
|---|---|---|---|
Esomeprazole | |||
Lansoprazole | 30 mg once a day | 15 mg once a day | |
Omeprazole | |||
Pantoprazole | 40 mg once a day | 20 mg once a day | |
Rabeprazole | 20 mg once a day | 10 mg once a day |
Proton pump inhibitor doses relating to evidence synthesis and recommendations in NICE guideline CG17
If people have had a previous endoscopy and do not have any new alarm signs, consider continuing management according to previous endoscopic findings.
For more information about alarm signs and when to refer people to specialists when they present with symptoms that could be caused by cancer see what NICE says on suspected cancer recognition and referral.
Avoid long-term, frequent-dose, continuous antacid therapy (it only relieves symptoms in the short term rather than preventing them).
Perform re-testing for H. pylori using a carbon-13 urea breath test. (There is currently insufficient evidence to recommend the stool antigen test as a test of eradication.This refers to evidence reviewed in 2004.)
Symptoms and signs | Possible diagnostic implications | Suggested actions |
|---|---|---|
Gastrointestinal | ||
Frequent, forceful (projectile) vomiting | May suggest hypertrophic pyloric stenosis in infants up to 2 months old | Paediatric surgery referral |
Bile-stained (green or yellow-green) vomit | May suggest intestinal obstruction | Paediatric surgery referral |
Haematemesis (blood in vomit) with the exception of swallowed blood, for example, following a nose bleed or ingested blood from a cracked nipple in some breast-fed infants | May suggest an important and potentially serious bleed from the oesophagus, stomach or upper gut | Specialist referral |
Onset of regurgitation and/or vomiting after 6 months old or persisting after 1 year old | Late onset suggests a cause other than reflux, for example a urinary tract infection (also see what NICE says on urinary tract infection in children) Persistence suggests an alternative diagnosis | Urine microbiology investigation Specialist referral |
Blood in stool | May suggest a variety of conditions, including bacterial gastroenteritis, infant cows' milk protein allergy (also see what NICE says on food allergy in under 19s) or an acute surgical condition | Stool microbiology investigation Specialist referral |
Abdominal distension, tenderness or palpable mass | May suggest intestinal obstruction or another acute surgical condition | Paediatric surgery referral |
Chronic diarrhoea | May suggest cows' milk protein allergy (also see what NICE says on food allergy in under 19s) | Specialist referral |
Systemic | ||
Appearing unwell Fever | May suggest infection (also see what NICE says on fever in under 5s) | Clinical assessment and urine microbiology investigation Specialist referral |
Dysuria | May suggest urinary tract infection (also see what NICE says on urinary tract infection in under 16s) | Clinical assessment and urine microbiology investigation Specialist referral |
Bulging fontanelle | May suggest raised intracranial pressure, for example, due to meningitis (also see what NICE says on bacterial meningitis and meningococcal septicaemia) | Specialist referral |
Rapidly increasing head circumference (more than 1 cm per week) Persistent morning headache, and vomiting worse in the morning | May suggest raised intracranial pressure, for example, due to hydrocephalus or a brain tumour | Specialist referral |
Altered responsiveness, for example, lethargy or irritability | May suggest an illness such as meningitis (also see what NICE says on bacterial meningitis and meningococcal septicaemia) | Specialist referral |
Infants and children with, or at high risk of, atopy | May suggest cows' milk protein allergy (also see what NICE says on food allergy in under 19s) | Specialist referral |
Glossary
Helicobacter pylori
H2 receptor antagonist
non-steroidal anti-inflammatory drug
proton pump inhibitor
Paths in this pathway
- Managing gastro-oesophageal reflux and reflux disease in infants
- Managing gastro-oesophageal reflux and reflux disease in children and young people
- Dyspepsia and gastro-oesophageal reflux disease in adults
- Managing uninvestigated dyspepsia in adults
- Managing functional dyspepsia in adults
- Managing peptic ulcer disease in adults
- Managing gastro-oesophageal reflux disease in adults
- Helicobacter pylori testing and eradication in adults
Pathway created: September 2014 Last updated: October 2017
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