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Upper Endoscopy for Gastroesophageal Reflux Disease FREE

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The full report is titled “Upper Endoscopy for Gastroesophageal Reflux Disease: Best Practice Advice From the Clinical Guidelines Committee of the American College of Physicians.” It is in the 4 December 2012 issue of Annals of Internal Medicine (volume 157, pages 808-816). The authors are N.J. Shaheen, D.S. Weinberg, T.D. Denberg, R. Chou, A. Qaseem, and P. Shekelle, for the Clinical Guidelines Committee of the American College of Physicians.

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Ann Intern Med. 2012;157(11):I-28. doi:10.7326/0003-4819-157-11-201212040-00001
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Who developed these recommendations?

The Clinical Guidelines Committee of the American College of Physicians (ACP) developed this advice.

What is the problem and what is known about it so far?

In gastroesophageal reflux disease (GERD), stomach contents flow up and into the esophagus, which causes heartburn. Medicines called proton-pump inhibitors (PPIs) decrease the amount of acid the stomach makes. If heartburn resolves with PPIs, GERD is the likely diagnosis. Another test for GERD is to examine the esophagus with an instrument passed through the mouth (upper endoscopy). Narrowing of the esophagus (strictures) and esophageal cancer are long-term complications of GERD. Approximately 10% of people with long-term heartburn develop an abnormal lining to the esophagus (called Barrett esophagus) and a higher risk for esophageal cancer. Before cancer develops, the cells lining the esophagus may show dysplasia (precancerous changes). Barrett or dysplasia can be diagnosed with endoscopy and biopsies. The benefits of using endoscopy to routinely screen people with GERD for Barrett and cancer are uncertain. Many people have GERD, but few develop cancer. The ACP developed these recommendations to help doctors make good decisions about when to refer patients with GERD for endoscopy.

Is there any benefit of upper endoscopy in patients with GERD who do not have features associated with serious conditions, such as cancer?

PPIs are the preferred first therapy. Early endoscopy usually does not change treatment. GERD does not require repeated evaluation if symptoms respond to treatment. Frequent endoscopy in patients with Barrett has not been shown to be better at preventing cancer than endoscopy every 3 to 5 years.

What is the harm of ordering upper endoscopy in patients with GERD who do not have features associated with serious conditions, such as cancer?

Endoscopy complications include poking a hole in the esophagus, bleeding, pneumonia, and anesthesia side effects. Misdiagnosis can lead to unnecessary procedures. People labeled with Barrett can also have problems getting insurance.

Why are so many unnecessary upper endoscopy tests done for GERD?

Patients may expect testing when they see a doctor, and it can be easier for doctors to order tests than to explain why they are not testing. Potential law suits if tests are not ordered and financial incentives may also play a role for doctors.

What does the ACP recommend that patients and doctors do?

Endoscopy is not the appropriate first step for most patients with GERD symptoms.

Endoscopy should be done if difficulty swallowing, bleeding, anemia (a low blood cell count), weight loss, or repeated vomiting is present; symptoms persist despite 4 to 8 weeks of twice-daily PPIs; needed to confirm healing and look for Barrett after 2 months of PPIs in patients with severe inflammation of the esophagus; or swallowing problems return after previous esophageal stricture.

Consider endoscopy to screen for Barrett in men older than 50 years with more than 5 years of GERD symptoms and nighttime symptoms, hiatal hernia, overweight, or tobacco use.

Screening endoscopy should not be done in women of any age or in men younger than 50 years.

If the initial screening endoscopy results are negative for Barrett or cancer, repeated endoscopy is not indicated.

If Barrett but no dysplasia is present, endoscopy should be done every 3 to 5 years. More frequent endoscopy is indicated if dysplasia is present.





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