Most patients with symptoms of gastroesophageal reflux disease (GERD) should not routinely undergo endoscopy to examine the upper gastrointestinal tract, according to recommendations published today in the Annals of Internal Medicine. Such screening should be reserved for a select group of patients with symptoms that may suggest a more serious underlying condition of the esophagus, such as bleeding, recurrent vomiting, or weight loss.
Many patients experience symptoms of heartburn, and such patients are increasingly referred for upper endoscopy to assess their condition. (An upper endoscopy involves passing an endoscope through the mouth and throat to view the esophagus, stomach, and upper part of the small intestine.) However, most patients with GERD will not benefit from such screening but will be exposed to the small risks of the procedure and its substantial cost, about $800, according to the authors. Inconsistent professional guidelines, financial incentives to perform endoscopies, and patient expectations may be contributing to overuse of endoscopy for patients with GERD.
“The evidence indicates that upper endoscopy is indicated in patients with heartburn only when accompanied by other serious symptoms, such as difficult or painful swallowing, bleeding, anemia, weight loss, or recurrent vomiting,” said David L. Bronson, MD, president of the American College of Physicians (ACP), in a statement. “The procedure is not an appropriate first step for most patients with heartburn.”
The recommendations are part of the ACP’s High Value Care Initiative, which aims to improve patient care while reducing unnecessary health care costs. The authors suggest that in patients with heartburn symptoms, endoscopy should be reserved for those who also have potential signs of a more serious condition, which, in addition to bleeding, recurrent vomiting, or weight loss, include difficult or painful swallowing and anemia.
Additionally, patients with GERD who do not respond to 4 to 8 weeks of therapy with a proton pump inhibitor or those with severe corrosive esophagitis after 2 months of such treatment should undergo endoscopy, according to recommendations. Men older than age 50 years with chronic GERD and symptoms such as nocturnal reflux, hiatal hernia, elevated body mass index, tobacco use, and an intra-abdominal distribution of fat should also undergo endoscopic screening for Barrett esophagus or signs of cancer.
Consumer Reports, which is collaborating with the ACP on the High Value Care Initiative, has created a brochure to help patients understand the risks, benefits, and costs associated with endoscopy.