Tuesday, August 7, 2012

Guidelines for Investigation of Reflux by PCP

I was recently contacted by a local Pittsburgh resident upset with his primary care doctor's refusal to consider his symptoms anything other than gastroesophageal reflux disease (GERD). For a couple of years, the man presented with complaints of persistent indigestion and trouble swallowing. A couple years after his complaints were first documented, he was diagnosed, by a different doctor, with esophageal cancer. As a result, he had to undergo a myriad of treatment including multiple rounds of chemotherapy and radiation.

We are in the process of investigating whether this unfortunate situation may have been the result of medical malpractice. As a precursor to the requisite certificate of merit from a another doctor in the same area of practice I always do as much research as possible to see if I can determine whether malpractice likely occurred and, just as important, whether the negligence could be said to have caused or increased the risk of the patient's end condition.

 As often happens, I found myself at guidelines.gov where I found the article "Gastrointestinal cancer. In: Suspected cancer in primary care: guidelines for investigation and referral" This article set forth the following guidelines for a primary care doctor's duty to respond to a patient with certain reflux symptoms.

The following symptoms should result in an Urgent Referral (within Two Weeks).

A person of any age with dyspepsia (reflux/indigestion) should be referred urgently for endoscopy or to a specialist if they have any of the following:

Gastrointestinal bleeding
Dysphagia (trouble swallowing)
Progressive unexplained weight loss
Persistent vomiting
Iron deficiency anaemia
Epigastric mass

A person aged 55 years or older with unexplained and persistent recent-onset dyspepsia solely, should be referred urgently for endoscopy.

A person with dysphagia (specifically, interference with the swallowing mechanism that occurs within 5 seconds of having commenced the swallowing process) should be referred urgently.

For a person with unexplained weight loss or iron deficiency anaemia, without dyspepsia, the possibility of upper gastrointestinal cancer and need for urgent referral for investigation should be considered.

For a person with persistent vomiting and weight loss, without dyspepsia, the possibility of upper gastrointestinal cancer and need for urgent referral for investigation should be considered.

For a person with unexplained worsening of their dyspepsia, the need for urgent referral to a specialist should be considered if they have any of the following known risk factors:

Barrett's oesophagus
Known dysplasia,
atrophic gastritis or
intestinal metaplasia

These are the standards for primary care practice at this time.  Failure to adhere to these guidelines may amount to malpractice.

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