Upper Endoscopy Overused in GERD Management

New clinical guidelines advocate that the use of upper endoscopy in the diagnosis and monitoring of gastroesophageal reflux disease (GERD) and other conditions be trimmed back.

The new clinical guideline recommendations from the American College of Physicians (ACP; Philadelphia, PA, USA), were designed to help primary care physicians decide when to refer patients for upper endoscopy. To do so, a team of gastroenterologists, general internists, and clinical epidemiologists reviewed the literature on use of upper endoscopy in the setting of GERD, as well as the epidemiology of GERD and esophageal adenocarcinoma. Clinical guidelines from professional organizations recommending use of upper endoscopy in GERD were also compared.

The recommendations are to reserve upper endoscopy for the following situations: Heartburn with alarm symptoms, like anemia, weight loss, bleeding, dysphagia, or recurrent vomiting. Persistent GERD symptoms despite maximal therapy with twice-daily proton pump inhibitors (PPI) for 4–8 weeks. Severe erosive esophagitis after two months of medical treatment to monitor healing and rule out Barrett's esophagus. History of symptomatic esophageal stricture in the presence of recurrent symptoms of dysphagia. Screening for Barrett's esophagus or esophageal adenocarcinoma in men with GERD ages 50 and older with additional risk factors of GERD symptoms for more than five years, such as nocturnal reflux symptoms, hiatal hernia, overweight or obesity, tobacco use, or an intra-abdominal distribution of fat. Monitoring men and women with a history of Barrett's esophagus (no more than every 3–5 years without dysplasia).

The ACP guideline committee added that although upper endoscopy is a low-risk procedure, potential complications could include perforation, cardiovascular events, aspiration pneumonia, respiratory failure, hypotension, dysrhythmia, and reactions to anesthesia agents. The new guidelines were published in the December 4, 2012, issue of Annals of Internal Medicine.

“Avoidance of repetitive, low-yield endoscopy that has little effect on clinical management or health outcomes will improve patient care and reduce costs,” concluded ACP guideline committee chairman Nicholas Shaheen, MD, MPH, of the University of North Carolina (UNC; Chapel Hill, NC, USA) and colleagues. “Using upper endoscopy in situations other than those recommended in the guidelines is likely only to generate unnecessary costs and expose patients to risks without improving clinical outcomes.”

Related Links:
American College of Physicians
University of North Carolina