Summaries of Must-Read Clinical Literature, Guidelines, and FDA Actions
Barrett’s Esophagus Uncommon in Patients with Uncomplicated GERD
Key clinical point: Few patients with uncomplicated GERD have Barrett’s esophagus, but they often undergo esophagogastroduodenoscopy anyway.
Major finding: GERD without alarm symptoms accounted for 13.5% of all esophagogastroduodenoscopies. Only 5.6% of patients with uncomplicated GERD had suspected Barrett’s esophagus of any length, and 1.4% had suspected Barrett’s esophagus of 3 cm or longer.
Study details: Multicenter retrospective study of 543,103 esophagogastroduodenoscopies.
Disclosures: The National Institute of Diabetes and Digestive and Kidney Diseases provided funding. The researchers reported having no conflicts of interest.
Lin EC et al. Clin Gastroenterol Hepatol. 2019 Apr. doi: 10.1016/j.cgh.2018.08.066.
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.
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.