Dec. 4, 2012 -- Acid reflux is the most common reason U.S. adults undergo a procedure where a viewing tube is put down their throat. But many people don’t need it, according to new advice from one of internal medicine’s main professional groups.
“Overuse of upper endoscopy contributes to higher health care costs without improving patient outcomes,” doctors from the American College of Physicians write in the Annals of Internal Medicine. Published studies suggest that 10% to 40% of endoscopies don’t improve patients’ health, according to the authors.
In the procedure, a doctor inserts an endoscope, a thin flexible tube equipped with a camera and a light, through the mouth of a sedated patient and into the esophagus, stomach, and first portion of the small intestine.
Despite a lack of supporting evidence, the authors write, doctors routinely use endoscopy to diagnose and manage gastroesophageal reflux disease, or GERD, which develops when stomach acid leaks into the esophagus.
As many as 40% of U.S. adults report having some GERD symptoms -- namely heartburn and regurgitation.
Looking for Barrett’s
Doctors use endoscopy in GERD patients mainly to check for a condition called Barrett's esophagus, which affects about 10% of people who’ve had chronic heartburn for at least five years, says Nicholas Shaheen, MD, MPH, an author of the new advice paper. Barrett’s occurs when stomach acids damage the lining of the esophagus.
GERD and Barrett's esophagus have been linked to an increased risk of a type of cancer called esophageal adenocarcinoma.
Although the overall risk for the cancer is still low, esophageal adenocarcinoma, which used to represent only a small minority of cancers in the esophagus, has increased 500% since the 1970s. It now accounts for more than half the cases in the U.S., says Shaheen, a gastroenterologist who directs the Center for Esophageal Diseases and Swallowing at the University of North Carolina, Chapel Hill.
While smoking and drinking are stronger risk factors for another cancer type of the esophagus, the rise of esophageal adenocarcinoma is thought to be tied to the U.S. obesity epidemic, Shaheen says. That's in part because overweight and obese people are more likely to have GERD, he says.
“Given the rising prevalence of chronic GERD symptoms, it is perhaps not surprising that the use of upper endoscopy for GERD indications is also rising,” the authors of the advice paper write. In fact, over the past decade, there's been an increase of greater than 40% in the use of upper endoscopy among Medicare patients.
Scoping for Dollars
Fear of a malpractice lawsuit over a missed cancer, financial incentives, and expectations on the part of GERD patients and their primary care providers, who refer them to gastroenterologists for evaluation, are among the factors behind the overuse of upper endoscopy, the authors write. “We have always equated better care with more care,” Shaheen says. "That’s just the American way.”
But GERD symptoms alone are a poor predictor of esophageal adenocarcinoma risk, according to the paper. For one, 40% of people diagnosed with the cancer have no heartburn. For another, 80% of cases of esophageal adenocarcinoma occur in men, possibly because they’re more likely to carry their excess weight in their belly, where it can do more harm than in other parts of the body.
In other words, the authors write, a woman with GERD is as likely to develop esophageal adenocarcinoma as a man is to develop breast cancer. Men don’t routinely get mammograms, so women with GERD shouldn’t routinely get upper endoscopy, Shaheen says.
When to Scope
Upper endoscopy should be performed only in these groups of GERD patients, according to the advice paper:
- People with “alarm symptoms” such as bleeding, anemia, weight loss, difficulty swallowing, and recurrent vomiting. Men and women whose GERD symptoms persist after taking a proton pump inhibitor (PPI) drug twice daily for one to two months. These drugs decrease the production of stomach acid; they include drugs such as Nexium, Prevacid, Prilosec, and Protonix.
- People with severe, erosive inflammation of the esophagus after a two-month course of PPI treatment, or those with a history of narrowing of the esophagus with recurrent swallowing problems.
- Men older than 50 with chronic GERD symptoms for more than five years and who have additional risk factors, such as obesity and nighttime symptoms.
Patients found to have Barrett's esophagus shouldn’t be screened more often than every three to five years, unless they also have the presence of abnormal cells indicating a greater risk for developing into cancer, according to the paper.
The paper also notes that unnecessary endoscopy exposes patients to preventable harms, may lead to additional unnecessary interventions, and results in unnecessary costs.
By routinely referring GERD patients to a gastroenterologist for an upper endoscopy, “primary care doctors are trying to do the right thing,” says David Johnson, MD, chief of gastroenterology at Eastern Virginia Medical School and past president of the American College of Gastroenterology. He was not involved in writing the new paper.
Johnson calls the paper “a wonderful directive,” though, for primary care doctors trying to advise GERD patients on whether they need to undergo upper endoscopy.