GERD: High-Risk Patients Get Endoscopic Short Shrift

Neil Osterweil

January 27, 2014

Endoscopy for gastroesophageal reflux disease (GERD) may be both too much and not enough of a good thing, according to a new study. In a retrospective review of records on nearly half a million patients with uncomplicated GERD, researchers found that endoscopy is overused in patients at low risk for serious complications of GERD and underused in those at high risk.

Men older than 65 years had a more than 6-fold greater risk for Barrett esophagus (BE) or esophageal, gastric, or duodenal cancer (E/GC) than a reference sample of women younger than 50, but the men were significantly less likely to have undergone esophagogastroduodenoscopy (EGD), report Jennifer R. Kramer, PhD, MPH from Veterans Affairs Health Services Research & Development in Washington, DC, and colleagues.

The diagnostic yield was 10.1% for BE and 0.81% for E/GC.

"Given the high BE and/or E/GC prevalence (11%) at the time of EGD, this mismatch between high-risk groups and likelihood of receiving EGD may contribute to missed opportunities for conducting effective screening EGD," the investigators write in a research letter published online January 27 in JAMA Internal Medicine.

The study highlights the problems clinicians face when trying to determine which patients with GERD might benefit from EGD, note Nicholas J. Talley, MD, PhD, FRACP, from the University of Newcastle and Kate E. Napthali, FRACP, from the John Hunter Hospital, both in Newcastle, New South Wales, Australia, in an invited commentary.

"We still miss most patients with BE despite the widespread use of EGD; up to 95% of cases of adenocarcinoma occur in the setting of no prior diagnosis of BE. The data from Kramer et al suggest that this may in part be due to underutilization of EGD in high-risk cases," they write.

They note, however, that patients with symptomatic reflux are not at increased risk for death compared with the general populations and that "there is still no convincing evidence that endoscopic screening of symptomatic GERD will reduce esophageal adenocarcinoma rates (stopping smoking and losing weight would probably be more valuable)."

Practice–Guideline Mismatch

Current guidelines from the American Society for Gastrointestinal Endoscopy and the American College of Gastroenterology recommend screening for BE or esophageal cancer in patients with uncomplicated GERD, especially those at high risk: men, whites, those with duration of symptoms more than 5 years, age over 50, or family history of BE or esophageal cancer.

To determine the use of screening EGD, predictors of use, and diagnostic yield, Dr. Kramer and colleagues reviewed Department of Veterans Affairs data on 499,073 patients with a first diagnosis of uncomplicated GERD, defined as GERD without alarm symptoms or signs of anemia, decompensated liver disease, gastrointestinal bleeding, celiac disease, any metastatic cancer, or any chemotherapy.

They found that men and those older than 50 were less likely to undergo endoscopy but were more likely to be diagnosed with BE or with E/GC. Predictors for EGD use included chest pain, dyspepsia, and proton-pump inhibitor and/or histamine-2 receptor antagonist use, number of Veterans Affairs visits, gastrointestinal clinic visit, rural residence, and high number of EDG procedures per facility. However, these factors were not associated with or were negatively associated with increased likelihood of BE and E/GC.

The authors caution that "without alarm symptoms, the utility of EGD outside of BE and cancer screening is unknown and the volume of EGD performed in this low-risk population may crowd out availability for screening and surveillance EGD in higher-risk patients."

The study was supported by grants from the National Institutes of Health. The authors and the editorialists have disclosed no relevant financial relationships.

JAMA Intern Med. Published online January 27, 2014. Abstract Commentary

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