PMID- 10443907
OWN - NLM
STAT- MEDLINE
DCOM- 19990913
LR  - 20131121
IS  - 0954-691X (Print)
IS  - 0954-691X (Linking)
VI  - 11 Suppl 1
DP  - 1999 Jun
TI  - Treat or investigate?
PG  - S11-5
AB  - Although upper gastrointestinal endoscopy provides very useful information about 
      organic diseases, such as ulcers or cancer, there are still some questions about 
      the most cost-effective strategy to apply in gastroesophageal reflux disease 
      (GERD). In other words, is it mandatory to perform endoscopy in all patients 
      before starting anti-reflux therapy, or is it better to treat empirically with an 
      antisecretory drug? There are several factors in support of an empirical approach 
      for the management of GERD in clinical practice. Indeed, typical symptoms like 
      heartburn or regurgitation are very specific for the diagnosis of GERD when they 
      are dominant. However, heartburn and regurgitation are so frequent in the primary 
      care setting that it is not practical or even feasible to investigate all 
      patients. In contrast, the prevalence of esophagitis in the community is very 
      low. At least half of the patients referred to an open-access endoscopy unit are 
      'endoscopy-negative' or show irrelevant findings. In fact, most patients with 
      esophagitis have mild lesions at endoscopy, and severe complications (such as 
      stenosis or ulcer) are very rare. Moreover, there is no evidence that 
      mild-to-moderate esophagitis worsens with time. Last but not least, symptoms are 
      what matter to the patient. They can adversely impact the quality of life, 
      whether or not esophagitis is present at endoscopy. On the other hand, empirical 
      therapy should not result in the masking of organic diseases or delaying the 
      investigation of conditions in which late diagnosis and treatment could have an 
      impact. The risk of masking malignancy is age, context and geographically 
      dependent. However, there is a quite good consensus that an empirical approach 
      for the management of GERD is acceptable if symptoms are typical, the patient is 
      young (< 45 years old) and there are no alarm symptoms. Other concerns about 
      empirical therapy in GERD include: (a) inappropriate prolonged use of drug 
      therapy, (b) weakening of subsequent investigation, (c) side effects, and (d) a 
      great likelihood of symptom recurrence, possibly resulting in postponement of 
      endoscopy and increased direct and indirect costs (sick-leave days). Indeed, the 
      long-term expense for different strategies depends on the cost of endoscopy (with 
      or without sedation), the cost of physician visits and the symptom recurrence 
      rate. If GERD is associated with a high rate of recurrences, savings may be 
      relatively modest with an empirical strategy. On the contrary, reducing the cost 
      of endoscopy and developing open-access endoscopy units without long waiting 
      lists may be more cost-effective than promoting empirical treatment. In 
      conclusion, a symptom-based strategy is certainly practical and feasible for the 
      majority of GERD patients seen by general practitioners in the primary care 
      setting. In these patients, a proton pump inhibitor (PPI) can be safely 
      prescribed in empirical conditions, provided simple guidelines are followed. 
      Symptom relief can also be used as an indication of healing in patients with mild 
      or moderate esophagitis at initial endoscopy. In contrast, endoscopy is still 
      indicated in patients with persistent or recurrent symptoms of GERD. The role of 
      the PPI test for diagnosis of GERD should be further validated before being 
      widely recommended.
FAU - Galmiche, J P
AU  - Galmiche JP
AD  - Hopital Hotel Dieu, Service Hepato-gastro-enterologie, Nantes, France.
LA  - eng
PT  - Journal Article
PT  - Review
PL  - England
TA  - Eur J Gastroenterol Hepatol
JT  - European journal of gastroenterology & hepatology
JID - 9000874
RN  - 0 (Proton Pump Inhibitors)
SB  - IM
MH  - Endoscopy, Gastrointestinal
MH  - Gastroesophageal Reflux/*diagnosis/*drug therapy
MH  - Humans
MH  - *Proton Pump Inhibitors
RF  - 9
EDAT- 1999/08/12 00:00
MHDA- 1999/08/12 00:01
CRDT- 1999/08/12 00:00
PHST- 1999/08/12 00:00 [pubmed]
PHST- 1999/08/12 00:01 [medline]
PHST- 1999/08/12 00:00 [entrez]
PST - ppublish
SO  - Eur J Gastroenterol Hepatol. 1999 Jun;11 Suppl 1:S11-5.