New Guidelines Urge Limiting Endoscopy for GERD
TUESDAY, Dec. 4 -- Heartburn can usually be diagnosed and managed without the use of an invasive procedure called an upper endoscopy, according to new recommendations for doctors.
Many physicians perform upper endoscopies to screen people who have had long-term heartburn for cancer of the esophagus because heartburn, also known as gastroesophageal reflux disease (GERD), can raise the risk of this cancer.
Upper endoscopy involves placing a long, flexible tube down the throat that takes pictures of the esophagus, stomach and other parts of the gastrointestinal tract.
The new guidelines by the American College of Physicians (ACP) recommend against screening the general population with GERD this way, partly because the cancer is rare even in this at-risk group.
"It's an area of uncertainty if screening prevents death from cancer," said guidelines author Dr. Nicholas Shaheen, director of the Center for Esophageal Diseases and Swallowing at the University of North Carolina.
Although the ACP guidelines are similar to those of organizations such as the American Gastroenterological Association, they stand apart for specifically recommending against screening women with GERD for esophageal cancer.
However, the ACP guidelines do recommend screening men over 50 who have had GERD for more than five years and who have other risk factors for esophageal cancer, including smoking and being overweight, because this group faces elevated esophageal cancer risk.
"Even if you came to me the first time and fit that profile, we might talk to you about a screening endoscopy," Shaheen said.
"The hope is that if you bring patients in that have risk factors for cancer, we can find cancer in precancerous state and intervene then. Survival is very poor once you get to the late stage of this cancer," Shaheen said.
The guidelines, based on a review of current research on GERD and the use of endoscopy, were published Dec. 4 in the Annals of Internal Medicine.
The guidelines point to two other groups that should receive an upper endoscopy. One is people who experience GERD along with symptoms including vomiting and difficulty swallowing, which can be signs of treatable conditions, such as narrowing of the esophagus.
Upper endoscopy is also recommended for those who continue to have heartburn despite medications.
"Most people with GERD symptoms don't need an upper endoscopy. All they need is treatment, and if the symptoms resolve, that's good therapy and also a diagnostic test," Shaheen said.
"If symptoms are occurring everyday or frequently during the week, it's worth discussing with your physician because you might require [prescription medications like] proton pump inhibitors [PPIs]," Shaheen said. "On the other hand, say that you're having symptoms once a week or every other week after pizza and beer, you might get away just fine with antacid or over-the-counter H2 blockers."
Proton pump inhibitor drugs include Prilosec and Prevacid, while H2 blockers include Tagamet and Zantac.
Dr. Benjamin Havemann, a gastroenterologist in private practice in Austin, Texas, said that lifestyle changes, such as avoiding food and drink before bed, not overeating and elevating the head in bed, can also help reduce heartburn.
Forty percent of adults in the United States report GERD symptoms such as heartburn and regurgitation, according to study background information. And the number of upper endoscopies performed is on the rise.
"There is misusage [of upper endoscopies] -- some who need it aren't getting it, some who don't are. As many as a third of the examinations don't meet the criteria that have been created for appropriate usage," said guidelines author Shaheen.
He attributed misusage to factors including doctors' desire to be exhaustive, patients' expectations, as well financial incentives and fear of being sued for not recommending a test.
The new guidelines "may be very helpful in eliminating unnecessary referral from [primary care physicians] to gastroenterologists" who perform the procedure, said Texas gastroenterologist Havemann, adding that the guidelines are reasonable and evidence-based.
"The recommendation to not screen female GERD patients is compelling," Havemann said.
The authors of the ACP guidelines point out that the risk of esophageal cancer in women with GERD is similar to that of breast cancer among men, a group that is not recommended to receive breast cancer screening. "That's something I will talk about with a woman about why not to use screening upper endoscopy," Havemann said.
Havemann thinks that upper endoscopies are particularly overused in young people who could get relief from prescription medication.
In addition, it is not recommended to do a follow-up endoscopy if the first one shows no signs of cancer or Barrett esophagus, a condition in which the esophagus is damaged and which can also increase the risk of developing esophageal cancer. However some of these patients do receive repeat endoscopies, Havemann said.
However, although not mentioned in the current guidelines, patients who don't take PPIs because of concerns about long-term side effects may need endoscopies to monitor potential GERD complications, he added.
Although upper endoscopies are low-risk, leading to complications like bleeding and tissue tearing in only about one in 1,000 to one in 10,000 cases, there are other reasons to avoid the procedure, Shaheen said.
An upper endoscopy costs $800, and even insured patients may have to pay a substantial share of this cost, the authors of the ACP guidelines wrote.
"It can be incredibly wasteful and expensive," Shaheen said. "While we don't want to deny anybody needed services, if we see areas with the potential to limit expense and improve care, it's our role to point those out."
Posted: December 2012
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