Many gastroenterologists overdiagnose Barrett’s Esophagus

When you see a specialist, you expect to hear from an expert who will diagnose your condition and then recommend the appropriate treatment. But that may not be the case, especially if you’re dealing with gastroenterologists and your symptoms appear to resemble those of Barrett’s Esophagus, a condition in which the lining of the esophagus is damaged by stomach acid.

When gastroenterologists were asked in a survey to cite the criteria for diagnosing and managing Barrett’s, most gave answers that differed from published guidelines, suggesting overdiagnosis and an excessive burden on patients.

Barrett’s can be a precursor to cancer of the esophagus. It happens with repeated episodes of reflux when stomach acid is expelled upward into the esophagus. Typically the lower part of the esophagus closer to the stomach becomes chronically inflamed. Heartburn is the usual symptom from these repeated episodes of reflux, or even difficulty swallowing.

Under a microscope, Barrett’s is diagnosed when a biopsy from the esophagus shows that the normal cells have been transformed into “dysplastic” or precancerous cells. The cells look more like those seen in the colon than those that should be lining the upper part of the gastrointestinal system.

In the survey of 261 gastroenterologists presented last week at Digestive Disease Week in Chicago, 23% failed to name the only criterion for Barrett’s endorsed by the official American College of Gastroenterology (ACG) practice guideline, while more than half listed other criteria.

Furthermore, about a third said they perform follow-up exams in patients with non-dysplastic Barrett’s more frequently than the 3-year interval recommended by the ACG.

The ACG guideline defines Barrett’s as a change in the lower lining of the esophagus of any length to a columnar-type mucosa, with biopsy confirmation as intestinal metaplasia. Although 77% of respondents correctly indicated that such a finding would be adequate for a diagnosis of Barrett’s, respondents could name multiple criteria and a substantial number endorsed one or more criteria not included in the ACG guideline including (1) irregular-appearing squamocolumnar junction with biopsy finding of intestinal metaplasia (47%); normal-appearing squamocolumnar junction with biopsy finding of intestinal metaplasia (22%); visible columnar-type mucosa above the gastroesophageal junction (17%) and irregular-appearing squamocolumnar junction without biopsy ( 3%).

The guideline also indicates that, for nondysplastic Barrett’s esophagus, follow-up endoscopy should be performed every three years. This interval was seconded by 55% of respondents in the survey. Some 34% respondents indicated that they perform endoscopies in such cases every one or two years, while another 9% said their preferred follow-up interval varied, depending on the length of the dysplastic segment.

The survey also found that, compared with salaried physicians, those with “productivity-based incomes” were significantly more likely to perform endoscopies at 1- or 2-year intervals in nondysplastic patients.

Source: MedPage Today

Reference: “Poor compliance with guidelines in the diagnosis and management of Barrett’s esophagus” DDW 2011; Abstract Sa1064.