Routine use of upper endoscopy for most patients with gastroesophageal reflux disease (GERD) does not improve patient health, is associated with preventable harms, and may lead to unnecessary interventions and costs, says the American College of Physicians (ACP) Clinical Guidelines Committee in a new evidence-based clinical policy paper.
Heartburn, a symptom of GERD, is a common reason for people to see a doctor. Long term complications of GERD can include scarring of the esophagus (strictures) and esophagus cancer. A small number of people with GERD develop an abnormal lining to the esophagus (called Barrett's) and a higher risk for esophagus cancer. Some doctors routinely use endoscopy to diagnose GERD and then to screen people with GERD for Barrett's and cancer.
However, the benefits of using endoscopy this way are uncertain. After reviewing available evidence, the ACP advises that upper endoscopy should not be routinely performed in women of any age or in men under the age of 50 with GERD symptoms because the incidence of cancer is very low in these populations.
Upper endoscopy is indicated in patients with GERD symptoms who are unresponsive to medicine to reduce gastric acid production for a period of four to eight weeks or who have a history of narrowing or tightening of the esophagus with recurrent difficult or painful swallowing.
Screening with upper endoscopy may be indicated in men over 50 with multiple risk factors for Barrett's esophagus. Among patients found to have Barrett's esophagus, upper endoscopy is indicated every three to five years. Physicians should utilize education strategies to inform patients about current and effective standards of care.
Medicine to reduce gastric acid production is warranted in most patients with typical GERD symptoms such as heartburn or regurgitation.
John I. Allen, MD, MBA, AGAF, vice president of the American Gastroenterological Association, authored an accompanying editorial. According to Dr. Allen, the overuse of endoscopy highlights a significant problem in our health care delivery system where "volume drives payment, reimbursements occur in independent silos, decisions are often made without informed patient input, and health outcomes are dissociated economically from specific services rendered." To be good stewards of our health care resources, Dr. Allen says, physicians must work to avoid low-value care.