New guidance from the American College of Physicians aims to prevent unnecessary procedures and their associated complications and costs.
The utilization of esophagogastric duodenoscopy (EGD) in patients with gastroesophageal reflux disease (GERD) has increased dramatically during the last decade. Much of this increase is attributable to the use of EGD as a screening test for Barrett esophagus (BE), which is a precancerous condition. However, recent studies suggest that endoscopic surveillance for BE is overutilized (JW Gastroenterol Mar 30 2012) and that the incidence of progression from BE to esophageal adenocarcinoma has been overestimated (JW Gastroenterol Aug 19 2011).
Within this context, the American College of Physicians has released best practice advice to clinicians on appropriate referral indications for EGD in patients with GERD:
- Heartburn and "alarm symptoms" (dysphagia, bleeding, vomiting, weight loss, anemia)
- Persistent GERD symptoms despite twice-daily use of proton-pump inhibitor therapy for 4 to 8 weeks
- Severe erosive esophagitis after a 2-month course of proton-pump inhibitor therapy to assess healing and rule out BE
- A history of esophageal stricture with recurrent dysphagia symptoms
- Established BE (if no dysplasia, surveillance interval not to exceed 3 to 5 years)
- Men aged ≥50 years with chronic GERD symptoms (>5 years) and additional risk factors (nocturnal GERD, hiatal hernia, increased body-mass index, intra-abdominal fat distribution, and tobacco use)
Screening EGD should not be recommended for women of any age or for men aged <50 years.
Comment: EGD is overutilized in patients with GERD for multiple reasons, including concern about medical malpractice for missed diagnosis, and, more commonly, open-access referral for EGD from primary care physicians. The latter situation places the gastroenterologist in an awkward position between the patient and the referring doctor. Of course, gastroenterologists clearly overutilize EGD as well. For both sets of providers, these clear, pragmatic guidelines should lay the foundation for cost-effective and appropriate utilization of EGD in patients with GERD.