TUESDAY, Dec. 4 (HealthDay News) -- Heartburn can usually be
diagnosed and managed without the use of an invasive procedure
called an upper endoscopy, according to new recommendations for
Many physicians perform upper endoscopies to screen people who
have had long-term heartburn for cancer of the esophagus because
heartburn, also known as gastroesophageal reflux disease (GERD),
can raise the risk of this cancer.
Upper endoscopy involves placing a long, flexible tube down the
throat that takes pictures of the esophagus, stomach and other
parts of the gastrointestinal tract.
The new guidelines by the American College of Physicians (ACP)
recommend against screening the general population with GERD this
way, partly because the cancer is rare even in this at-risk
"It's an area of uncertainty if screening prevents death from
cancer," said guidelines author Dr. Nicholas Shaheen, director of
the Center for Esophageal Diseases and Swallowing at the University
of North Carolina.
Although the ACP guidelines are similar to those of
organizations such as the American Gastroenterological Association,
they stand apart for specifically recommending against screening
women with GERD for esophageal cancer.
However, the ACP guidelines do recommend screening men over 50
who have had GERD for more than five years and who have other risk
factors for esophageal cancer, including smoking and being
overweight, because this group faces elevated esophageal cancer
"Even if you came to me the first time and fit that profile, we
might talk to you about a screening endoscopy," Shaheen said.
"The hope is that if you bring patients in that have risk
factors for cancer, we can find cancer in precancerous state and
intervene then. Survival is very poor once you get to the late
stage of this cancer," Shaheen said.
The guidelines, based on a review of current research on GERD
and the use of endoscopy, were published Dec. 4 in the
Annals of Internal Medicine.
The guidelines point to two other groups that should receive an
upper endoscopy. One is people who experience GERD along with
symptoms including vomiting and difficulty swallowing, which can be
signs of treatable conditions, such as narrowing of the
Upper endoscopy is also recommended for those who continue to
have heartburn despite medications.
"Most people with GERD symptoms don't need an upper endoscopy.
All they need is treatment, and if the symptoms resolve, that's
good therapy and also a diagnostic test," Shaheen said.
"If symptoms are occurring everyday or frequently during the
week, it's worth discussing with your physician because you might
require [prescription medications like] proton pump inhibitors
[PPIs]," Shaheen said. "On the other hand, say that you're having
symptoms once a week or every other week after pizza and beer, you
might get away just fine with antacid or over-the-counter H2
Proton pump inhibitor drugs include Prilosec and Prevacid, while
H2 blockers include Tagamet and Zantac.
Dr. Benjamin Havemann, a gastroenterologist in private practice
in Austin, Texas, said that lifestyle changes, such as avoiding
food and drink before bed, not overeating and elevating the head in
bed, can also help reduce heartburn.
Forty percent of adults in the United States report GERD
symptoms such as heartburn and regurgitation, according to study
background information. And the number of upper endoscopies
performed is on the rise.
"There is misusage [of upper endoscopies] -- some who need it
aren't getting it, some who don't are. As many as a third of the
examinations don't meet the criteria that have been created for
appropriate usage," said guidelines author Shaheen.
He attributed misusage to factors including doctors' desire to
be exhaustive, patients' expectations, as well financial incentives
and fear of being sued for not recommending a test.
The new guidelines "may be very helpful in eliminating
unnecessary referral from [primary care physicians] to
gastroenterologists" who perform the procedure, said Texas
gastroenterologist Havemann, adding that the guidelines are
reasonable and evidence-based.
"The recommendation to not screen female GERD patients is
compelling," Havemann said.
The authors of the ACP guidelines point out that the risk of
esophageal cancer in women with GERD is similar to that of breast
cancer among men, a group that is not recommended to receive breast
cancer screening. "That's something I will talk about with a woman
about why not to use screening upper endoscopy," Havemann said.
Havemann thinks that upper endoscopies are particularly overused
in young people who could get relief from prescription
In addition, it is not recommended to do a follow-up endoscopy
if the first one shows no signs of cancer or Barrett esophagus, a
condition in which the esophagus is damaged and which can also
increase the risk of developing esophageal cancer. However some of
these patients do receive repeat endoscopies, Havemann said.
However, although not mentioned in the current guidelines,
patients who don't take PPIs because of concerns about long-term
side effects may need endoscopies to monitor potential GERD
complications, he added.
Although upper endoscopies are low-risk, leading to
complications like bleeding and tissue tearing in only about one in
1,000 to one in 10,000 cases, there are other reasons to avoid the
procedure, Shaheen said.
An upper endoscopy costs $800, and even insured patients may
have to pay a substantial share of this cost, the authors of the
ACP guidelines wrote.
"It can be incredibly wasteful and expensive," Shaheen said.
"While we don't want to deny anybody needed services, if we see
areas with the potential to limit expense and improve care, it's
our role to point those out."
To learn more about GERD, visit the
National Institute of Diabetes and Digestive and