From the AGA Journals

Barrett’s esophagus uncommon in patients with uncomplicated GERD

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Not time to abandon screening for Barrett’s yet

The utility and cost-effectiveness of screening for Barrett’s esophagus with esophagogastroduodenoscopy (EGD) remain contentious issues. National GI societies currently recommend screening in only a limited high-risk population, mainly white men aged 50 or older with chronic GERD and one or more additional risk factors. It is unclear to what degree those guidelines are adhered to in clinical practice. This study by Lin et al. sheds further light on this issue. The investigators showed that a significant proportion (more than 10%) of EGDs were performed for uncomplicated GERD, with less than one-quarter of those patients meeting the minimal criteria for screening for Barrett’s esophagus. Among this group, the prevalence of Barrett’s esophagus was found to be lower than previously reported. The data offer compelling evidence that screening low-risk patients with uncomplicated GERD by using upper endoscopy is not cost effective, and is at best marginally cost effective if limited to the high-risk group identified by national GI societies. The question arises whether we should abandon screening for Barrett’s esophagus altogether.

Dr. Nabil M. Mansour, Baylor College of Medicine, Houston

Dr. Nabil M. Mansour

The challenge, however, is that the incidence of esophageal adenocarcinoma continues to rise (albeit at a slower pace in recent years), and 5-year survival of patients diagnosed with esophageal adenocarcinoma remains extremely poor. Therefore, prevention remains the optimal strategy. The solution may lie in adopting a lower-cost screening modality that can replace endoscopy for this purpose, and while many such techniques are under investigation, further studies are required to find a widely applicable alternative to EGD.

Nabil M. Mansour, MD, is an assistant professor, department of medicine, section of gastroenterology and hepatology, Baylor College of Medicine, Houston. He has no conflicts of interest.


 

FROM CLINICAL GASTROENTEROLOGY AND HEPATOLOGY

Uncomplicated gastroesophageal reflux disease (GERD) accounted for 13.5% of esophagogastroduodenoscopies, but 5.6% of these patients had suspected Barrett’s esophagus and only 1.4% had suspected long-segment Barrett’s esophagus, researchers reported. The study appears in the April issue of Clinical Gastroenterology and Hepatology.

“The prevalence of suspected Barrett’s esophagus is lower than in prior time periods. This raises questions about the utility of esophagogastroduodenoscopies to detect Barrett’s esophagus in patients with uncomplicated GERD,” wrote Emery C. Lin, MD, of Oregon Health and Science University, Portland, and his associates there and at Massachusetts General Hospital, Boston.

Symptoms of GERD affect more than one in four U.S. adults and are a risk factor for Barrett’s esophagus. However, the prevalence of Barrett’s esophagus is unclear in patients with dysphagia and in the era of proton pump inhibitors, the researchers said. The American Gastroenterological Association strongly discourages reflexively screening patients with GERD for Barrett’s esophagus, but “weakly recommends” screening GERD patients with multiple risk factors for Barrett’s esophagus, including chronic GERD, hiatal hernia, older age (50 years and up), white race, male sex, increased body mass index, and intra-abdominal adiposity.

To understand the prevalence and findings of esophagogastroduodenoscopy in patients with GERD without alarm symptoms (including weight loss, dysphagia, and bleeding), the investigators studied 543,103 of these procedures performed at 82 sites in the United States between 2003 and 2013. The data came from the National Endoscopic Database, which generates endoscopy reports using a structured computer form.

A total of 73,535 esophagogastroduodenoscopies (13.5%) were performed for GERD without alarm symptoms. Among these patients, 4,122 (5.6%) had suspected Barrett’s esophagus, of which 24.2% had suspected long-segment Barrett’s esophagus (3 cm or longer). Among patients with uncomplicated GERD, the prevalence of suspected Barrett’s esophagus was 5.6%, and the prevalence of long-segment disease was 1.4%.

Although male sex, older age, and white race were significant risk factors for suspected Barrett’s esophagus and suspected long-segment disease, 23.6% of esophagogastroduodenoscopies were performed in white men older than 50 years. “We find that low-risk populations with uncomplicated GERD make up a significant number of esophagogastroduodenoscopies done for uncomplicated GERD,” the investigators wrote. “If esophagogastroduodenoscopies were limited to patients that met the AGA criteria of being male, white, and age over 50, we would have detected 34 of 47 (72.3%) of esophageal tumors and found suspected Barrett’s esophagus in nearly 10%, while reducing the burden of endoscopy by more than 75%.”

Hiatal hernia was a significant correlate of suspected Barrett’s esophagus (odds ratio, 1.6), the researchers noted. Esophagitis was not associated with suspected Barrett’s esophagus overall but did correlate with long-segment disease. Esophagitis might mask underlying short-segment Barrett’s esophagus, and short-segment Barrett’s esophagus might be milder in nature and more responsive to antisecretory therapy, the researchers said. They noted that severe (grade C/D) esophagitis was strongly linked with both short-segment and long-segment Barrett’s esophagus.

The National Institute of Diabetes and Digestive and Kidney Diseases provided funding. The researchers reported having no conflicts of interest.

SOURCE: Lin EC et al. Clin Gastroenterol Hepatol. 2019 Apr. doi: 10.1016/j.cgh.2018.08.066.

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