Gastroenterology

Five Things Physicians and Patients Should Question


Released October 29, 2014

1

Don’t maintain long term Proton Pump Inhibitor (PPI) therapy for gastrointestinal symptoms without an attempt to stop/reduce PPI at least once per year in most patients.

PPIs are effective drugs for the treatment of gastro-esophageal reflux disease (GERD). Patients should always be prescribed the lowest dose of drug that manages their symptoms. Even though GERD is often a chronic condition, over time the disease may not require acid suppression and it is important that patients do not take drugs that are no longer necessary. For this reason patients should try stopping their acid suppressive therapy at least once per year. Patients with Barrett’s esophagus, Los Angeles Grade D esophagitis, and gastrointestinal bleeding would be exempt from this.

2

Avoid using an upper GI series to investigate dyspepsia.

Upper GI series are often requested for the investigation of upper gastrointestinal symptoms. This investigation has a significant proportion of false positive and false negative results compared with endoscopy, and studies have consistently found that this is not a cost-effective approach compared to other strategies of managing dyspepsia.

3

Avoid performing an endoscopy for dyspepsia without alarm symptoms for patients under the age of 55 years.

Endoscopy is an accurate test for diagnosing dyspepsia, but organic pathology that does not respond to acid suppression or Helicobacter pylori eradication therapy is rare under the age of 55. Most guidelines therefore recommend as the first line approach for managing dyspepsia either empirical proton pump inhibitor therapy or a non-invasive test for Helicobacter pylori and then offering therapy if the patient is positive. If the patient has alarm features such as progressive dysphagia, anemia or weight loss, endoscopy may be appropriate.

4

Avoid performing a colonoscopy for constipation in those under the age of 50 years without family history of colon cancer or alarm features.

Constipation is a common problem and systematic review data suggests this is not an accurate symptom in diagnosing organic disease. If the patient is also under the age of 50 and does not have a family history of colon cancer and there are no alarm features such as anemia or weight loss, then the risk of colorectal cancer is very low and the risks of colonoscopy usually outweigh the benefits in these patients.

5

Don’t routinely use long term steroid therapy in inflammatory bowel disease.

The risks of long term steroid therapy (therapy for more than 4 months and/or more than two courses in a year) outweigh any benefits in inflammatory bowel disease and should not be given to patients. Instead, they should be offered more effective maintenance therapy such as immunosuppression or biologic therapy that are safer and have more evidence for efficacy.


How the list was created

This list was created by polling the Canadian Association of Gastroenterology (CAG) Quality Leads on items that were felt to meet the goals of Choosing Wisely Canada. The five items were selected for being the most frequently identified and reflected common GI disorders managed by health care professionals. This list was then voted on by the CAG Quality Leads and the statements were further modified for language by the group.


Sources

1

Cahir C, Fahey T, Tilson L, Teljeur C, Bennett K. Proton pump inhibitors: potential cost reductions by applying prescribing guidelines. BMC Health Serv. Res. 2012;12:408.

2

Makris N, Barkun A, Crott R, Fallone CA. Cost-effectiveness of alternative approaches in the management of dyspepsia. Int. J. Technol. Assess. Health Care. Summer 2003;19(3):446-464.

Talley NJ, Vakil NB, Moayyedi P. American gastroenterological association technical review on the evaluation of dyspepsia. Gastroenterology. Nov 2005;129(5):1756-1780.

3

Makris N, Barkun A, Crott R, Fallone CA. Cost-effectiveness of alternative approaches in the management of dyspepsia. Int. J. Technol. Assess. Health Care. Summer 2003;19(3):446-464.

Talley NJ, Vakil NB, Moayyedi P. American gastroenterological association technical review on the evaluation of dyspepsia. Gastroenterology. Nov 2005;129(5):1756-1780.

4

Ford AC, Veldhuyzen van Zanten SJ, Rodgers CC, Talley NJ, Vakil NB, Moayyedi P. Diagnostic utility of alarm features for colorectal cancer: systematic review and meta-analysis. Gut. Nov 2008;57(11):1545-1553.

5

Talley NJ, Abreu MT, Achkar JP, et al. An evidence-based systematic review on medical therapies for inflammatory bowel disease. Am. J. Gastroenterol. Apr 2011;106 Suppl 1:S2-25; quiz S26.