A guide to GERD, H pylori infection, and Barrett esophagus
How long should you treat GERD with a PPI? When should you order an endoscopy or test for Helicobacter pylori? How might H pylori treatment choices vary with a patient’s antibiotic history?
PRACTICE RECOMMENDATIONS
› Recommend endoscopy for patients with gastroesophageal reflux disease (GERD) and red flag symptoms: dysphagia, unintentional weight loss, or bleeding. B
› Recommend long-term use of a proton pump inhibitor at the lowest tolerated dose in patients with esophagitis or Barrett esophagus. C
› Test for Helicobacter pylori in patients with peptic ulcer disease, in those with past ulcers not investigated for H pylori, and in those starting chronic nonsteroidal anti-inflammatory drug therapy. A
› Use a urea breath test, stool antigen study, or endoscopically obtained biopsy to test for H pylori. A
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Not everyone with BE experiences GERD symptoms; sometimes BE may be diagnosed incidentally on upper endoscopy performed for unrelated symptoms.11 GERD patients who are currently asymptomatic and had a normal prior upper endoscopy do not require surveillance.
Diagnosis and management
BE is diagnosed based on specific endoscopic and histologic findings. The presence of dysplasia (either low grade or high grade) or its absence has important treatment implications. When histology is indefinite for dysplasia, treat reflux and, following acid suppression with PPIs for 3 to 6 months, repeat endoscopy (since reactive changes with reflux may obscure results).11
Nondysplastic BE has a risk of progressing to cancer in only 0.2% to 0.5% of affected patients per year.11 Guidelines for BE without dysplasia advise repeating surveillance endoscopy every 3 to 5 years after appropriate counseling regarding overall low risk of cancer progression.11,31 Surveillance endoscopy recommendations exist despite the lack of prospective randomized trials that demonstrate benefit. The rationale for surveillance is that survival in EAC is stage dependent and often EAC metastasizes prior to the development of symptoms from the tumor. Observational cohort studies in BE have demonstrated that surveillance endoscopy programs find EAC at earlier stages with improved survival; however, lead and length time bias may attenuate or eliminate these surveillance benefits.11,32
Risk for neoplastic progression increases with degree of dysplasia. BE with low-grade dysplasia and high-grade dysplasia have a risk of cancer progression of 0.7% per year and 7% per year, respectively.11
Historically, esophagectomy was the preferred treatment for BE with dysplasia. Now, endoscopic eradication therapies, including radiofrequency ablation and endoscopic mucosal resection for nodular BE, are the usual treatment for either low- or high-grade dysplasia.11
Chemoprophylaxis with PPIs. Most patients with BE have symptoms of GERD or reflux esophagitis, so treatment with a PPI is indicated for symptom control. In patients with BE without GERD, PPI use may still be indicated, although this is controversial. Current guidelines recommend once-daily PPI therapy for BE (twice daily only if needed for symptom control) to reduce reflux-associated inflammation and recommend against routine prescription of aspirin or NSAIDs for BE.11 In vitro and observational studies support PPI use to prevent progression to EAC11,33; however, data from randomized controlled trials to support their use are limited.34,35
CORRESPONDENCE
Megan Everson, MD, Medical College of Wisconsin, 229 South Morrison Street, Appleton WI, 54911; megan.everson@mosaicfamilyhealth.org
