The upper gastrointestinal (GI) endoscopy has become the go-to diagnostic tool for diagnosing gastroesophageal reflux disease or GERD among people with persistent heartburn. But earlier this week, the American College of Physicians (ACP) released new guidelines for upper GI endoscopy screening that significantly scales back the number of people who should receive the test when they complain of persistent heartburn.
Why the change, and what does this mean for GERD diagnosis and treatment? First, let’s start by understanding exactly what an upper GI endoscopy is and why it is used.
What is an endoscopy?
Italian-German physician Philip Bozzini developed the modern upper GI endoscopy in the early 1800s. In the test, a doctor passes an endoscope, which is a flexible tube with a lighted camera on the end, down the esophagus, giving the physician a close-up view of the esophagus. That allows physicians to detect any abnormalities. An endoscopy also allows physicians to biopsy tissue from the esophagus if they suspect the presence of some kind of abnormal growth, such as cancerous cells.
Physicians often use an endoscopy to view the esophagus of people who report persistent heartburn. They’re looking for inflammation in the esophagus caused by stomach acid to diagnose GERD or some other related condition.
Treatment leads to a diagnosis
But the new guidelines from the ACP recommend that physicians stop performing an upper GI endoscopy on all patients who report persistent heartburn or GERD. The goal is to spare patients the invasive endoscopy and instead simply begin treatment as if the diagnosis were GERD.
The treatment for GERD usually starts with diet changes and antacids and progresses in response to the symptoms. If the symptoms persist, physicians may prescribe a proton pump inhibitor to shut off the acid pumps in the stomach.
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According to the new ACP guidelines, if the symptoms wane in response to the treatment, physicians can assume the patient has GERD and continue treatment without ever having to do an endoscopy.
Dr. Nicholas Shaheen, director of the Center for Esophageal Diseases and Swallowing at the University of North Carolina, puts it best: “…if the symptoms resolve, that’s good therapy and also a diagnostic test.”
But what about cancer?
It is true that one of the conditions an endoscopy can detect is Barrett’s esophagus, which can lead to cancer of the esophagus. Barrett’s esophagus is caused by persistent heartburn over an extended period of time, so those with GERD are at an especially high risk of the condition. There is some concern that by phasing out the routine upper endoscopy when patients have persistent heartburn, some cases of Barrett’s esophagus or even esophageal cancer could be missed.
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However, physicians from the ACP said that even among people with GERD, especially women, the risk of developing esophageal cancer is about equivalent to the risk a man has of developing breast cancer. In this case, the thinking is that the risk and discomfort associated with an invasive endoscopy isn’t justified by the small number of esophageal cancer cases the endoscopy might detect.
Who should be screened?
There are still a few populations that the ACP recommends should be more aggressively screened through an upper GI endoscopy. Men over 50 who have had GERD for more than five years and have life style risk factors for esophageal cancer, such as smoking and obesity should still be screened. Also, people who have persistent heartburn along with vomiting and difficulty swallowing and people who have persistent heartburn, even after GERD treatment should have an endoscopy.
The idea is, as always, to detect cancer as early as possible, but without undergoing too many costly or unnecessary diagnostic tests.
Society of Laparoendoscopic Surgeons. Let There Be Light: A Historical Analysis of Endoscopy’s Ascension Since Antiquity. (Chapter 6). Retrieved from: http://laparoscopy.blogs.com/endoscopyhistory/chapter_6/index.html
U.S Department of Health and Human Services, National Digestive Disease Information Clearinghouse. Upper GI Endoscopy (April, 2012). Retreived from: http://digestive.niddk.nih.gov/ddiseases/pubs/upperendoscopy/
HealthDay News, New Guidelines Urge Limiting Endoscopy for GERD. (December 4, 2012). Retrieved from: http://health.usnews.com/health-news/news/articles/2012/12/04/new-guidelines-urge-limiting-endoscopy-for-gerd_print.html
Published On: December 07, 2012