Dyspepsia Algorithm · Reasoning GP

The full reasoning pathway — screen ALARM red flags for urgent OGD, stop the culprit drugs, test-and-treat H. pylori before any empirical PPI, then step-wise treat, refer on NICE NG12 thresholds, and review long-term PPI use.StartDecisionInvestigateActionReferStop / Admit

PresentationDyspepsia

Epigastric pain/burning, fullness, early satiety, reflux. Review NSAIDs, aspirin, bisphosphonates, iron, alcohol and smoking. Screen ALARM features at the first visit; a positive H. pylori test or NSAID link is far more common than cancer — but never skip the red-flag check.

Step 1 · Safety — ALARM red flags (NICE NG12)Urgent OGD or admission needed?

Dysphagia — at ANY age → urgent OGD
Aged ≥55 + weight loss with upper abdominal pain / reflux / dyspepsia
Upper abdominal mass (stomach), iron-deficiency anaemia, persistent vomiting
Significant acute GI bleed — haematemesis / melaena → immediate admission

YES — red flag

Stop · refer / admitUrgent OGD — 2WW (or admit)

Suspected oesophago-gastric cancer → urgent direct-access endoscopy. Stop NSAIDs and, where possible, the PPI for 2 weeks before OGD (PPIs mask malignancy). Acute GI bleed → emergency admission.

NO — uncomplicated

Step 2 · InvestigateTest H. pylori + review meds

Stool antigen or urea breath test (off PPI 2 weeks, off antibiotics 4 weeks). Stop culprit drugs. Offer FIT if any colorectal features; coeliac serology if IBS overlap; USS if biliary picture.

Step 3 · subtype the uncomplicated patient

H. pylori positive

Peptic ulcer / infection

Drives ~80% of duodenal & 60% of gastric ulcers; eradication reduces gastric-cancer risk.

GORD-predominant

Heartburn / regurgitation

Acid reflux worse lying flat / post-prandial, relieved by antacids → full-dose PPI + lifestyle.

Functional / drug-induced

No alarm, normal tests

Rome IV functional dyspepsia (gut–brain), or a clear NSAID/aspirin/bisphosphonate link → stop the drug.

Step 7 · stepwise treatment

Step 7 · Action — NICE CKS stepwise pathwayDrugs off → eradicate → PPI → review

① Remove culprit drugs — stop NSAIDs/aspirin (if safe), bisphosphonates, iron; switch NSAID or add cover.
② H. pylori positive → 7-day triple therapy: omeprazole 20 mg BD + amoxicillin 1 g BD + clarithromycin 500 mg BD (metronidazole 400 mg BD if penicillin-allergic). Confirm eradication by UBT/HpSA 4 wks after, off PPI 2 wks. 2nd-line = quadruple bismuth therapy.
③ H. pylori negative / eradicated but symptomatic → empirical PPI (omeprazole 20–40 mg OD, 30 min before food) for 4–8 weeks; step down to lowest effective / PRN dose.
④ Adjuncts — alginate/antacid PRN (Gaviscon Advance); H₂RA (famotidine) if PPI not tolerated.

Step 6 · escalation thresholds

Step 6 · ReferEscalation thresholds

2WW · NICE NG12 dysphagia (any age); ≥55 + weight loss + upper-abdo pain / reflux / dyspepsia; upper-abdominal (stomach) mass → urgent direct-access OGD.
Direct-access OGD (non-urgent) ≥55 with treatment-resistant dyspepsia, or upper-abdo pain + low Hb, or raised platelets / nausea-vomiting with other features; ≥40 + family history or high-risk origin.
Urgent CT ≥60 + weight loss + back pain / new diabetes → suspected pancreatic cancer.
Gastroenterology symptoms persisting after 2 full treatment courses, diagnostic doubt, or H. pylori failing 1st+2nd-line.

Step 8 · lifestyle & deprescribe

Step 8 · Lifestyle & medication reviewReduce reflux, rationalise PPIs

Weight loss, smaller meals, avoid late eating, reduce alcohol, caffeine, fatty/spicy foods, raise bed-head, stop smoking. Add routine PPI gastroprotection for anyone needing ongoing NSAIDs (esp. ≥65 / PUD history / steroids / anticoagulants). Annual review of long-term PPIs — step down to lowest effective dose.

Step 9 · review & safety-net

Step 9 · Review & safety-netWhen to come back

Admit / 999 if vomiting blood, black tarry stools, collapse or new difficulty swallowing. Review: PPI response at 4 weeks; confirm H. pylori eradication at 4–6 weeks; reassess if symptoms recur after stopping. Safety-net: alarm features can appear de novo in someone previously labelled functional — document a red-flag return plan.

⚠️ Test-and-treat H. pylori before empirical PPI, and stop the PPI 2 weeks before any urea breath test or OGD or you'll get a false-negative and mask malignancy. Dysphagia is never functional — urgent OGD at any age.

Safety

Exclude alarm features — these patients must NOT wait

Done

Ask these questions BEFORE assuming simple dyspepsia. Alarm features mandate urgent investigation — most are 2WW upper GI cancer referrals.

Dysphagia Difficulty swallowing solids or liquids → 2WW UGI (oesophageal/gastric cancer)

Progressive unintentional weight loss >5% body weight unexplained → 2WW UGI

Persistent vomiting Frequent or severe, not relieved by simple measures → 2WW UGI / same-day review

Haematemesis Vomiting blood or coffee-grounds → 999 / A&E (upper GI bleed)

Melaena Tarry black stools → 999 / A&E (upper GI bleed)

Iron-deficiency anaemia Confirmed on FBC + ferritin without obvious cause → 2WW UGI

Epigastric mass Palpable on examination → 2WW UGI

Age ≥55 + new or changed dyspepsia Especially with any of the above or unexplained → 2WW UGI (per NICE NG12)

Sudden severe epigastric pain Tearing or board-like rigidity → 999 (perforated ulcer, aortic aneurysm)

Jaundice Scleral icterus, dark urine → 2WW UGI / hepatobiliary (pancreatic cancer)

Upper GI cancer (oesophageal, gastric, pancreatic) frequently presents with dyspepsia-like symptoms — delay kills. UK 5-year survival for oesophageal cancer is only ~15% when diagnosed late.
NICE NG12 (2015, updated 2023) mandates urgent 2WW referral for dysphagia at any age, and for age ≥55 with weight loss, upper abdominal pain, or reflux symptoms that are new or changed.
Haematemesis carries a 10% mortality rate — do not delay.
Missing a perforated peptic ulcer leads to peritonitis within hours; mortality rises steeply with delay.
The ALARM acronym (Anaemia, Loss of weight, Anorexia, Recent progressive symptoms, Melaena/haematemesis) is a useful mnemonic.

Diagnose

Confirm dyspepsia and identify the likely cause

Done

Dyspepsia is a symptom complex — not a diagnosis. Establish which subtype applies to guide management.

Definition

Epigastric pain or discomfort, bloating, fullness, nausea, or heartburn — intermittent or persistent, ≥4 weeks. Note: heartburn-predominant = GORD; consider separately.

Key history

Site & character of pain · Relationship to meals (before vs after) · Acid taste / waterbrash · Bloating / early satiety · Nausea / vomiting · Nocturnal symptoms · Symptom duration & pattern
Ask specifically: NSAIDs, aspirin, steroids, bisphosphonates, iron supplements (all ulcerogenic) · Alcohol · Smoking · H. pylori risk (immigrant from high-prevalence country, previous infection, household contact)

Symptom pattern

Ulcer-like: Burning epigastric pain, relieved by food/antacids, wakes at night
Dysmotility-like: Bloating, nausea, early satiety, upper abdominal discomfort
GORD-predominant: Heartburn > epigastric pain, worse lying flat, acid regurgitation
Unspecified: Mixed / doesn't fit neatly

H. pylori risk

High prevalence areas: South Asia, Africa, Eastern Europe, Latin America. Prevalence in UK general population ~30–40% but higher in migrants. Always test before empirical PPI in appropriate patients (see Step 5).

Medication review

Check prescriptions AND OTC: NSAIDs, low-dose aspirin, clopidogrel, SSRIs, bisphosphonates, calcium antagonists (may worsen reflux), iron. Stop or review causative medications before escalating.

NICE CKS Dyspepsia (2023) emphasises identifying the symptom subtype as it directs whether to test-and-treat for H. pylori, use empirical PPIs, or refer.
NSAIDs account for up to 25% of peptic ulcer disease — stopping them alone may resolve symptoms.
H. pylori eradication cures ~80% of duodenal ulcers and reduces gastric cancer risk — identifying this at the outset saves unnecessary long-term PPI use.

Diagnose

Classify by subtype — drives the treatment pathway

Done

Functional dyspepsia (Rome IV criteria) vs organic cause — this distinction affects prognosis, treatment goals, and patient expectations.

Functional dyspepsia Rome IV

One or more of: bothersome postprandial fullness, early satiation, epigastric pain or burning — at least 3 days/week for ≥3 months (onset ≥6 months ago) — with no structural cause on investigation.
Subtypes: PDS (postprandial distress: meal-triggered) | EPS (epigastric pain syndrome: localised pain/burning)

Peptic ulcer disease

H. pylori-associated or NSAID-induced. Confirmed on OGD. Ulcer-like symptom pattern. More likely with known H. pylori, NSAID use, or prior ulcer.

GORD

Heartburn dominant, acid regurgitation, relief with antacids, worse post-prandially and lying flat. Can co-exist with dyspepsia. Manage with full-dose PPI 4–8 weeks.

H. pylori-associated

Positive test-and-treat. Eradication may cure symptoms in PUD and improves functional dyspepsia in ~10% of cases (NNT ~14).

Medication-induced

Clear temporal link to new drug. Symptoms resolve on stopping/switching. Most common: NSAIDs, aspirin, bisphosphonates, iron.

Other / secondary

Coeliac disease (serological testing if suspected), biliary disease, chronic pancreatitis, gastroparesis (diabetes), IBS overlap. Consider if atypical features.

Functional dyspepsia has a benign prognosis but requires patient education — setting expectations prevents repeated unnecessary investigations and reassurance-seeking.
Rome IV criteria provide a positive diagnostic framework so functional dyspepsia is diagnosed actively, not just by exclusion.
Patients whose dyspepsia is due to H. pylori infection and whose infection is eradicated have long-term improvement in ~10% of cases above placebo — modest but clinically important and cost-effective.
Misdiagnosing GORD as functional dyspepsia means missing Barrett's oesophagus surveillance criteria — critical distinction.

Diagnose

Targeted examination — exclude surgical and serious pathology

Done

Examination is often normal in uncomplicated dyspepsia — but abnormal findings mandate urgent action.

General inspection

Pallor (anaemia — bleed or malignancy) · Jaundice (biliary/pancreatic) · Cachexia/weight loss · Distress level

Vital signs

Tachycardia + hypotension → haemodynamic compromise from GI bleed → 999. Temperature → consider infection / cholangitis.

Abdominal palpation

Epigastric tenderness: Common in PUD and GORD — not diagnostic but correlates with pathology
Epigastric mass: Hard, irregular → 2WW UGI
Hepatomegaly: May indicate metastatic disease
Succussion splash: Gastric outlet obstruction (pyloric stenosis)
Peritonism / guarding / rebound: → 999 (perforation, ischaemia)

BMI

Obesity drives GORD and dyspepsia. Record BMI — relevant to lifestyle advice and drug dosing. BMI >30 → address weight as core treatment.

Lymphadenopathy

Left supraclavicular (Virchow's node) → 2WW UGI (gastric cancer metastasis — Troisier's sign)

Oropharynx

Dental erosions → chronic GORD. Visible peristalsis → gastric outlet obstruction (rare but important).

Examination changes management: a palpable epigastric mass upgrades a routine consultation to a 2WW referral.
Haemodynamic instability (tachycardia, hypotension) in a patient with epigastric pain is a GI bleed until proven otherwise — do not send home.
Virchow's node (left supraclavicular lymphadenopathy) is a known metastatic sign for gastric cancer and should be checked in any atypical presentation in patients ≥45.

Diagnose

Investigations — what to order and what to avoid

Done

In uncomplicated dyspepsia in patients <55 without alarm features, the key investigation is H. pylori testing — not a battery of bloods.

H. pylori test First-line

Urea breath test (UBT) — preferred: 93% sensitivity, 97% specificity. Stop PPI 2 weeks before, antibiotics 4 weeks before.
H. pylori stool antigen (HpSA) — if UBT unavailable. Same PPI/antibiotic stop rules.
Serology — not recommended for active infection (cannot distinguish past from current infection).
Endoscopy-based CLO test — if referred for OGD only.

FBC Bloods

If anaemia suspected (pallor, alarm features, heavy menstrual loss). Microcytic anaemia + low ferritin = iron deficiency → investigate cause. Not routine in straightforward dyspepsia.

LFTs / Amylase

If biliary/pancreatic pathology suspected (RUQ pain, jaundice, alcohol history). Not routine.

Coeliac serology If indicated

Anti-TTG IgA + total IgA if IBS-type overlap, bloating, diarrhoea, or iron deficiency. Must be eating gluten at time of test.

Fasting glucose / HbA1c

If gastroparesis suspected (diabetes + dysmotility symptoms: early satiety, vomiting, bloating). Not routine.

OGD Via referral

Indicated only via 2WW pathway (alarm features) or if symptoms persist despite 2 full treatment courses. NOT a first-line investigation in primary care.

Do NOT order

H. pylori serology (unreliable for active infection) · Abdominal USS routinely · Gastric emptying studies in primary care · H. pylori breath test while on PPI/antibiotics (false negatives)

NICE CKS (2023) recommends a "test-and-treat" strategy for H. pylori in uninvestigated dyspepsia before empirical PPI — this is cost-effective and reduces long-term PPI dependency.
PPIs must be stopped 2 weeks before UBT/HpSA — failure to stop leads to false negative results, perpetuating untreated infection.
Routine OGD for all dyspepsia would overwhelm endoscopy services — NICE restricts this appropriately to alarm features or treatment failure.
Coeliac disease prevalence in the UK is ~1% and is commonly missed — a low threshold for testing is clinically appropriate in bloating-predominant dyspepsia.

Refer

Referral criteria — who needs specialist input?

Done

Most dyspepsia is managed entirely in primary care. Refer when alarm features are present, or when primary care management has failed.

999 / A&E

Haematemesis · Melaena · Peritonism / guarding (perforation) · Haemodynamic instability (tachycardia, hypotension)

Same-day assessment

Severe persistent vomiting with inability to keep fluids down (dehydration risk) · Acute severe epigastric pain with no clear cause — rule out perforation, AAA

2WW UGI endoscopy

Any age: Dysphagia · Haematemesis
Age ≥55 + any of: weight loss, reflux, upper abdominal pain (new/changed), nausea/vomiting (unexplained)
Any age: Epigastric mass · Confirmed iron-deficiency anaemia without clear cause · Suspicious lymphadenopathy
(Per NICE NG12 / NG43)

Routine gastroenterology

Symptoms persisting after 2 full courses of treatment (H. pylori eradication + PPI) with no alarm features · Suspected functional dyspepsia refractory to primary care management · Coeliac disease confirmed (for dietary review and follow-up)

Manage in primary care

Age <55 · No alarm features · Uncomplicated dyspepsia / GORD · Responds to H. pylori eradication or PPI · Medication-induced dyspepsia · Functional dyspepsia with normal investigations

Dietitian referral

Confirmed coeliac disease (urgent — for gluten-free diet education) · Functional dyspepsia with dietary triggers · BMI >35 with GORD

NICE NG12 (Suspected cancer recognition) defines the 2WW criteria — these are updated regularly; always cross-check with current guidance.
Age ≥55 is the threshold for lowered suspicion — gastric cancer incidence rises sharply after this age. In the UK, mean age at diagnosis is 72.
Appropriate non-referral in primary care is equally important — unnecessary OGD requests increase waiting times and patient anxiety.

Treat

Stepwise treatment — test-and-treat, then escalate

Done

Follow the NICE CKS pathway: always address medication causes first, then test-and-treat for H. pylori, then empirical PPI, then consider specialist review.

H. pylori positive

Triple therapy eradication 1st line

Clarithromycin-based (if local resistance <20%):
Omeprazole 20 mg BD + Amoxicillin 1 g BD + Clarithromycin 500 mg BD — 7 days

Metronidazole-based (penicillin allergy or resistance):
Omeprazole 20 mg BD + Metronidazole 400 mg BD + Clarithromycin 500 mg BD — 7 days

Confirm eradication with UBT or HpSA 4 weeks after completion (off PPI 2 weeks)

H. pylori negative or not tested

Empirical PPI 1st line

Omeprazole 20 mg OD or Lansoprazole 30 mg OD — 4 weeks, taken 30 min before food

If partial response: increase to full dose BD for 4–8 weeks (GORD)

Review after 4 weeks — step down to lowest effective dose or PRN

Step 1Remove causative medications Stop NSAIDs, aspirin (if clinically safe to do so), bisphosphonates, iron. Switch NSAID to paracetamol. If NSAID must continue, add PPI gastroprotection: Omeprazole 20 mg OD.

Step 2Test and treat H. pylori UBT or HpSA test. If positive → 7-day triple therapy (see above). Confirm eradication at 4 weeks.

Step 3Empirical full-dose PPI × 4 weeks If H. pylori negative or eradicated but symptoms persist. Omeprazole 20–40 mg OD or Lansoprazole 30 mg OD before food.

Step 4Antacids / alginates PRN For breakthrough symptoms. Gaviscon Advance 10 mL after meals + at bedtime (alginate barrier). Suitable alongside PPI or as sole treatment for mild/intermittent symptoms.

Step 5H2 receptor antagonist If PPI poorly tolerated or patient preference. Famotidine 20 mg BD. Less effective than PPIs but useful as add-on nocturnal acid suppression in GORD.

Step 6Prokinetics (dysmotility-type) Domperidone 10 mg TDS before meals (max 7 days — cardiac risk, QTc prolongation). Metoclopramide 10 mg TDS (max 5 days). Use only short-term; avoid in elderly (extrapyramidal effects).

Step 7Low-dose tricyclic antidepressant For refractory functional dyspepsia (EPS type). Amitriptyline 10 mg nocte — increasing to 25–50 mg if tolerated. NNT ~6 for functional dyspepsia. Explain this is for nerve sensitisation, not depression.

Step 8Mirtazapine (PDS subtype) If nausea/early satiety predominant and TCA not tolerated. Mirtazapine 15 mg nocte. Limited UK prescribing data — consider gastroenterology input.

Failed 2nd courseRefer routine gastroenterology For OGD + specialist review if symptoms persist after two treatment courses with no alarm features.

PPI long-term use

Caution Annual review mandatory. Step down to lowest effective dose. Consider stopping trial if symptom-free >3 months. Risks of long-term PPI: hypomagnesaemia, B12 deficiency, C. diff, increased fracture risk, CKD. Check Mg and B12 annually if on PPI >1 year.

H. pylori 2nd-line eradication

If 1st-line fails (confirmed on UBT/HpSA): Quadruple therapy — Omeprazole 20 mg BD + Bismuth subsalicylate 120 mg QDS + Tetracycline 500 mg QDS + Metronidazole 400 mg TDS — 14 days. Refer to gastroenterology if 2nd line fails.

NSAID gastroprotection

Any patient requiring ongoing NSAID: add Omeprazole 20 mg OD routinely. Higher-risk patients (age >65, PUD history, corticosteroids, anticoagulants): consider misoprostol or COX-2 selective NSAID.

Test-and-treat H. pylori before empirical PPI is cost-effective and reduces long-term PPI dependency (NICE CKS 2023, Cochrane 2019).
H. pylori eradication cures ~80% of duodenal ulcers and ~60% of gastric ulcers — far superior to PPI alone for ulcer disease.
PPIs at step 3 relieve symptoms in ~60–70% of GORD cases (NNT ~3) but are less effective in functional dyspepsia (NNT ~9).
Domperidone and metoclopramide have a maximum duration — cardiac risk (QTc prolongation) and extrapyramidal effects respectively. Never prescribe long-term without specialist input.
Low-dose TCAs work via central visceral hypersensitivity modulation — the mechanism is well-established in functional GI disorders (Rome Foundation 2021).
Long-term PPI review is mandated by NHS England and NICE — patients on PPIs for >8 weeks should have a documented reason and annual review.

Lifestyle

Non-pharmacological interventions — first-line, not afterthought

Done

Lifestyle modification is core treatment — address these at every consultation. Many patients can reduce or stop medication with sustained lifestyle change.

Dietary modification Eat smaller, regular meals. Avoid fatty/spicy foods, chocolate, citrus, raw onion, peppermint. Identify and avoid personal trigger foods. Don't eat within 3 hours of bedtime.

Posture & timing Stay upright 2–3 hours post-meals. Elevate head of bed 15–20 cm (use bed blocks — not extra pillows). Reduces nocturnal GORD by reducing acid exposure.

Weight loss BMI >25 strongly associated with dyspepsia and GORD. Every 1 unit reduction in BMI reduces GORD symptom frequency. Target BMI <25. Refer to weight management if BMI >30.

Alcohol Reduces lower oesophageal sphincter (LOS) tone. Advise ≤14 units/week with alcohol-free days. Complete abstinence often resolves alcohol-related dyspepsia.

Smoking cessation Smoking reduces LOS pressure and delays gastric emptying — directly worsens dyspepsia and GORD. Refer to NHS Stop Smoking Service. Cessation reduces dyspepsia symptoms within weeks.

Stress management Strong brain-gut axis evidence in functional dyspepsia. Mindfulness-based therapy, CBT (refer via IAPT/Talking Therapies) reduces symptom severity. NNT ~4 for CBT in functional GI disorders.

Clothing & posture Avoid tight-fitting clothing around abdomen (increases intra-abdominal pressure). Avoid bending and heavy lifting post-meals.

Caffeine reduction Coffee and tea increase acid secretion. Advise reducing to ≤2 cups/day or switching to low-acid alternatives. Carbonated drinks worsen bloating — switch to still water.

Medication timing Take bisphosphonates and iron with a full glass of water, remain upright for 30 minutes. Never take NSAID on an empty stomach. Review all medication timing to minimise GI irritation.

Weight loss of 5–10% body weight reduces GORD symptom frequency by up to 40% — comparable to full-dose PPI therapy in obese patients.
Head-of-bed elevation reduces oesophageal acid exposure time by 67% in studies of nocturnal GORD — a free intervention.
CBT improves functional dyspepsia symptom scores by 30–40% in RCTs — NICE recommends psychological therapies for refractory functional GI disorders (CG61).
Patients who make sustained lifestyle changes have lower long-term PPI dependency, fewer GP visits, and better quality of life.

Safety

Follow-up, monitoring & safety-netting

Done

Always safety-net. Dyspepsia can evolve — new alarm features at any point mandate urgent re-assessment.

After H. pylori treatment

Confirm eradication with UBT or HpSA at 4–6 weeks after completing antibiotics (off PPI for 2 weeks before test). If negative → eradication successful. If positive → second-line quadruple therapy. Do not assume cure without testing.

After PPI course

4 weeks: Review symptom response. If resolved → step down to lowest effective dose or stop (PRN only). If partial → continue full dose 4 more weeks. If no response → reassess diagnosis, consider H. pylori testing if not done.

Long-term PPI review

Annually: Review indication. Check Mg²⁺ (hypomagnesaemia) and B12 (deficiency) if on PPI >1 year. Attempt annual PPI step-down / stopping trial. Document clinical reason if continuing.

Functional dyspepsia

6–8 weeks: Review response to low-dose TCA / psychological therapy. Reassurance and explanation of the brain-gut axis at each visit. If no improvement after 2 treatment trials → routine gastroenterology referral.

Coeliac disease

Annual review (GP or dietitian): Symptom control on gluten-free diet · FBC, ferritin, folate, B12, Vitamin D, Ca²⁺ · Anti-TTG antibody to assess dietary adherence · Bone density (DXA) at diagnosis and 2-yearly if osteopenia

Safety-net 999

New haematemesis · Melaena · Collapse / syncope · Severe acute abdominal pain with rigidity

Safety-net same-day

New dysphagia · Rapidly progressive symptoms · Inability to swallow fluids · New unintentional weight loss · Persistent vomiting >24 hours

Safety-net 2WW

Any new alarm feature developing during follow-up in a patient previously managed conservatively → re-trigger 2WW UGI pathway immediately

Patient information

Provide written information: NHS Choices Dyspepsia leaflet · Guts UK patient information · Explain that dyspepsia can recur — knowing when to re-consult is key to patient safety

Confirmed H. pylori eradication is mandatory — untreated persistent infection continues to drive ulcer disease and carries a 3–6× increased risk of gastric adenocarcinoma.
Up to 50% of patients on long-term PPIs have no clear ongoing indication on review — annual step-down attempts can safely reduce unnecessary prescribing (NHS STOPP criteria).
Alarm features can develop de novo in a patient previously diagnosed with functional dyspepsia — a safety-netting "red-flag return" plan is essential and should be documented in the notes.
In coeliac disease, annual bloods and anti-TTG monitoring identify dietary non-compliance before malabsorption complications develop (osteoporosis, lymphoma risk).