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Patient profile
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Dave Clark is 59 years old and has been a truck driver for the last 20 years. He is a heavy smoker and drinker and is recently divorced.

First appointment

Dave has come to see Dr Roberts to discuss his persistent indigestion.


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Summary of symptoms

  • Indigestion and heartburn
  • Pain in stomach
  • Bloating
  • Nausea
  • Unexplained weight loss

Proton pump inhibitors (PPI)

At this point in the consultation, Dr Roberts has a choice to make. He could offer Dave some advice on lifestyle changes, based on the fact that many gastric problems discussed in primary care are lifestyle related, and a prescription for omeprazole (PPI).

Proton pump inhibitors (PPIs) reduce the production of acid by blocking the enzyme in the wall of the stomach that produces acid. Acid is necessary for the formation of most ulcers in the oesophagus, stomach, and duodenum, and the reduction of acid with
PPIs prevents ulcers and can allow any ulcers that exist to heal.

Dr Sarah Taylor, GatewayC GP Lead, explores some of the issues surrounding PPIs and diagnosing stomach cancer with Dr Was Mansoor, Consultant in Medical Oncology.

Key points

  • Stomach cancer is often diagnosed late as a result of prescribed PPIs masking or altering symptoms
  • Patients who have been prescribed proton pump inhibitors may:
    • No longer experience symptoms of indigestion
    • Have their red flag symptoms masked by increasing the dosage of PPIs
    • Experience a change in symptoms as a result of the PPI (i.e. change from a burning sensation to pain)

Results from the National Cancer Diagnosis Audit in 2018 found that stomach cancer has the highest percentage of avoidable delays (34%) out of all cancer sites.

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Although Dave was not referred for a gastroscopy, it is a further option for patients who fit the criteria outlined below.

See the table below for NICE NG12 Guidance on when to offer or consider a gastrointestinal endoscopy.

Symptoms and specific features Recommendation
Dyspepsia or upper abdominal pain with weight loss, 55 and over Offer urgent direct access upper gastrointestinal endoscopy (to be performed within 2 weeks) [1.2.7]

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Additional resources

Link: Risks and causes of stomach cancer, Cancer Research UK (2019)
Link: Interventions for functional dyspepsia – Clinical guidelines [CG184], NICE (2019)
Link: BSG Position Statement – Proton pump inhibitors (PPIs) and the risk of gastric cancer, British Society of Gastroenterology (2018)
Link: Diagnosing cancer in primary care: results from the National Cancer Diagnosis Audit, British Journal of General Practice (2018)

NEW: GPs Talk Cancer podcast. Listen to our first episode.