Upper Endoscopy for Gastroesophageal Reflux Disease: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians (ACP)

Nearly 38% of the upper endoscopies performed in outpatients with gastroesophageal reflux disease and low-risk dyspepsia do not adhere to current best-practice guidelines. The most common inappropriate uses were in patients who received an inadequate course of proton pump inhibitors (PPIs) before upper endoscopy and in those who underwent too-frequent surveillance of Barrett’s esophagus. Inappropriate use of endoscopy generates unnecessary costs and exposes patients to harms without improving outcomes.

Read the full text here and download the paper. http://annals.org/article.aspx?articleid=1470281

Best Practice Advice

• Upper endoscopy is indicated in men and women with heartburn and alarm symptoms (dysphagia, bleeding, anemia, weight loss, and recurrent vomiting).
• Upper endoscopy is indicated in men and women with:
  • Typical GERD symptoms that persist despite a therapeutic trial of 4 to 8 weeks of twice-daily proton-pump inhibitor therapy.
  • Severe erosive esophagitis after a 2-month course of proton-pump inhibitor therapy to assess healing and rule out Barrett esophagus. Recurrent endoscopy after this follow-up examination is not indicated in the absence of Barrett esophagus.
  • History of esophageal stricture who have recurrent symptoms of dysphagia.
• Upper endoscopy may be indicated:
  • In men older than 50 years with chronic GERD symptoms (symptoms for more than 5 years) and additional risk factors (nocturnal reflux symptoms, hiatal hernia, elevated body mass index, tobacco use, and intra-abdominal distribution of fat) to detect esophageal adenocarcinoma and Barrett esophagus.
  • For surveillance evaluation in men and women with a history of Barrett esophagus. In men and women with Barrett esophagus and no dysplasia, surveillance examinations should occur at intervals no more frequently than 3 to 5 years. More frequent intervals are indicated in patients with Barrett esophagus and dysplasia.

GERD, Barrett Esophagus, and Esophageal Adenocarcinoma
Tissue injury is not necessary to fulfill disease criteria, as 50% to 85% of patients with GERD have nonerosive reflux disease. As many as 40% of U.S. adults report some symptoms of reflux (heartburn and regurgitation), and 10% to 20% have symptoms on a weekly or more frequent basis. Approximately 10% of patients with chronic heartburn symptoms have Barrett esophagus. GERD and Barrett esophagus are associated with an increased risk for esophageal adenocarcinoma. While the absolute risk for adenocarcinoma of the esophagus in the general population remains low (26 cases per 1 million in the U.S. population), its incidence has increased more than 5-fold in the past 40 years. Adenocarcinoma of the esophagus carries a poor prognosis with a 5-year survival rate less than 20%. Given the rising prevalence of chronic GERD, the use of upper endoscopy for GERD indications is rising in an effort to promote early detection and reduce the risk for death from adenocarcinoma of the esophagus. Since 1% to 5% of the U.S. adult population may have Barrett esophagus, the public health and financial implications of endoscopic screening and surveillance programs are substantial.

All 3 major U.S. gastroenterologic professional societies have released guidelines but differ in recommendations.

• The American Society of Gastrointestinal Endoscopy (ASGE) recommends that screening upper endoscopy be considered in selected patients with chronic, longstanding GERD:
  • Frequent GERD symptoms (several times per week),
  • Chronic GERD symptoms (symptoms for >5 years)
  • Age > 50 years
  • White race
  • Male sex
  • Nocturnal reflux symptoms
• The American Gastroenterological Association (AGA) guidelines recommend against screening the general population with GERD for Barrett esophagus and esophageal adenocarcinoma but should be considered in patients with GERD who have several risk factors associated with esophageal adenocarcinoma
  • Age 50 years or older
  • Male sex
  • White race
  • Hiatal hernia
  • Elevated body mass index
  • Intra-abdominal distribution of fat
• The American College of Gastroenterology (ACG) guidelines note that screening for Barrett’s esophagus in the general population cannot be recommended at this time. The use of screening in selective populations at higher risk remains to be established, and therefore should be individualized.
  • GERD symptoms
  • Body mass index

Formulation of these guidelines was hampered by the generally poor quality of data about the use of endoscopic screening and surveillance programs. In many cases, expert opinion formed the basis for specific recommendations.

The value of endoscopy is well-substantiated in several clinical settings.

• GERD associated with the alarm symptoms of dysphagia, bleeding, anemia, weight loss, or recurrent vomiting merits investigation with upper endoscopy because of its yield of potentially clinically actionable findings, such as cancer of the esophagus or stomach, bleeding lesions in the foregut, or stenosis of the esophagus or pylorus.
• Patients with a documented history of severe erosive esophagitis (grade B or worse on a validated A-to-D scoring system) treated with PPIs have a substantial rate of incomplete healing with medical therapy and may have Barrett esophagus in the areas of previously denuded esophageal epithelium. For these reasons, follow-up upper endoscopy is recommended after 8 weeks of PPI therapy for severe esophagitis to ensure healing and to rule out Barrett esophagus.
• The use of upper endoscopy in patients with esophageal stricture secondary to GERD is largely symptom-based. Because recurrence of strictures is common, repeated upper endoscopy with dilatation may be required.
• Screening intervals for patients with Barrett esophagus without dysplasia are recommended at 3- to 5-year intervals. More frequent endoscopy is reserved for the subset of patients who develop low- or high-grade dysplasia, as they face a higher risk for progression to cancer.
• In patients with chronic GERD whose initial endoscopic screening results were negative, no additional endoscopic screening is necessary, even if the patient continues medical therapy. Observational data show that the likelihood of development of Barrett esophagus in the 5 years after a negative result in such patients is less than 2%. Therefore, routine serial endoscopy in patients with initially negative results for Barrett esophagus is not recommended. Patient and primary caregiver expectations may promote overuse as patients may anticipate serial cancer screening and may inappropriately view no screening or a once-in-a-lifetime screening upper endoscopy for GERD symptoms as inadequate. Patients who have Barrett esophagus and no dysplasia may be dissatisfied with a 3- to 5-year interval of surveillance examinations, as patients with Barrett esophagus grossly overestimate their risk for esophageal cancer.

Summary of the ACP best practice advice:

The ACP has found evidence that upper endoscopy is indicated in patients with heartburn and alarm symptoms, such as dysphagia, bleeding, anemia, weight loss, and recurrent vomiting. However, upper endoscopy is not an appropriate first step in most patients with GERD symptoms and is indicated only when empirical PPI therapy for 4 to 8 weeks is unsuccessful. Upper endoscopy is not indicated in asymptomatic patients with a history of esophageal stricture but is appropriate in patients with recurrent symptoms of dysphagia. Screening upper endoscopy should not be routinely done in women of any age or in men younger than 50 years regardless of GERD symptoms because the incidence of cancer is very low in these populations. Screening endoscopy may be indicated in men older than 50 years with several risk factors for Barrett esophagus. This screening decision should include an assessment of the patient’s life-limiting comorbid conditions. Risk factors include chronic GERD symptoms (symptoms of >5 years’ duration), nocturnal reflux symptoms, hiatal hernia, elevated body mass index, tobacco use, and intra-abdominal distribution of fat. If an initial screening examination is negative for Barrett esophagus or esophageal adenocarcinoma, recurrent periodic endoscopy is not indicated. Among patients found to have Barrett esophagus on screening upper endoscopy, endoscopic surveillance may be indicated at 3- to 5-year intervals. More frequent endoscopic examinations are reserved for patients with low- or high-grade dysplasia because of their higher risk for progression to cancer.

Unnecessary endoscopy exposes patients to preventable harms, may lead to additional unnecessary interventions, and results in unnecessary costs. Patient education strategies should be used to inform patients about current and effective standards of care.