Gastroenterology

Eleven Tests and Treatments to Question

by
Canadian Association of Gastroenterology
Canadian IBD Network for Research and Growth in Quality Improvement
Crohn’s and Colitis Canada
Last updated: November 2021

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.
1

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.

Sources:

Cahir C, et al. Proton pump inhibitors: potential cost reductions by applying prescribing guidelines. BMC Health Serv Res. 2012 Nov 19;12:408. PMID: 23163956.

Related Resources:

Patient Pamphlet: Treating Heartburn and Gastro-Esophageal Reflex (GERD): Using proton-pump inhibitors (PPI) carefully

Toolkit: Bye-Bye, PPI – A toolkit for deprescribing proton pump inhibitors in EMR-enabled primary care settings
Avoid using an upper GI series to investigate dyspepsia.
2

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.

Sources:

Makris N, et al. Cost-effectiveness of alternative approaches in the management of dyspepsia. Int J Technol Assess Health Care. 2003 Summer;19(3):446-64. PMID: 12962332.

Talley NJ, et al. American gastroenterological association technical review on the evaluation of dyspepsia. Gastroenterology. 2005 Nov;129(5):1756-80. PMID: 16285971.
Avoid performing an endoscopy for dyspepsia without alarm symptoms for patients under the age of 60 years.
3

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 60. 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.

Sources:

Moayyedi P, Lacy BE, Andrews CN, Enns RA, Howden CW, Vakil N. ACG and CAG Clinical Guideline: Management of Dyspepsia. Am J Gastroenterol 2017;112:988-1013. PMID: 28631728
Avoid performing a colonoscopy for constipation in those under the age of 50 years without family history of colon cancer or alarm features.
4

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.

Sources:

Ford AC, et al. Diagnostic utility of alarm features for colorectal cancer: systematic review and meta-analysis. Gut. 2008 Nov;57(11):1545-53. PMID: 18676420.

Related Resources:

Patient Pamphlet: Colonoscopy: When you need it – and when you don’t
Don’t routinely perform colonoscopy in IBS patients <50 years of age without alarm features.
5

Data is conflicting, and while some evidence suggested that IBS patients are at increased risk for organic disease over the long-term compared with individuals in the general population, absolute rates remain low. With respect to CRC, the risk is low in the general population <50 years of age, and IBS is not a recognized risk factor for CRC. There appears to be little or no evidence that IBS increases the risk of CRC over the short-term compared with the general population, with the exception of a study from Taiwan that suggested a 3.6 times higher 10-year risk in the IBS group compared with the non-IBS group Finally, data do not support the idea that patients may be reassured by a normal colonoscopy. Therefore, the consensus group concluded that routine colonoscopy is generally not warranted in IBS patients <50 years of age, and alarm symptoms do not appear to increase the risk of CRC sufficiently to warrant routine colonoscopy. Alarm features that warrant investigation include, but are not limited to, rectal bleeding, weight loss and anemia.

GRADE: Strong recommendation, very low-quality evidence

Sources:

Moayyedi P et al. Canadian Association of Gastroenterology Clinical Practice Guideline for the Management of Irritable Bowel Syndrome (IBS). J Can Assoc Gastroenterol. 2019 Apr;2(1):6-29. PMID: 31294724. https://pubmed.ncbi.nlm.nih.gov/31294724/
Don’t prescribe oral corticosteroids in adults with Crohn’s disease of any severity in order to maintain complete remission.
6

The adverse effects of long-term corticosteroid use are well-known and well-documented. In the TREAT registry, prednisone therapy was independently associated with serious infections (hazard ratio [HR], 1.57; 95% CI, 1.17–2.10; P = .002). No safe lower limit of dosing has been identified in which patients are spared from the adverse effects. The risks of long-term corticosteroid therapy and the lack of evidence supporting efficacy over placebo in this setting led the consensus group to recommend against the use of maintenance corticosteroid therapy.

GRADE: Strong recommendation, low-quality evidence

Sources:

Panaccione R et al. Canadian Association of Gastroenterology Clinical Practice Guideline for the Management of Luminal Crohn’s Disease. Clin Gastroenterol Hepatol. 2019 Aug;17(9):1680-1713. Epub 2019 Mar 7. PMID: 30853616. https://pubmed.ncbi.nlm.nih.gov/30853616/
Don’t prescribe oral corticosteroids in children with Crohn's Disease of any severity in order to maintain clinical remission.
7

There is a lack of demonstrated efficacy of steroids in preventing relapse and concerns around the adverse events associated with long-term use, particularly in children.

GRADE: Strong recommendation, low-quality evidence.

Sources:

Mack DR et al. Canadian Association of Gastroenterology Clinical Practice Guideline for the Medical Management of Pediatric Luminal Crohn’s Disease. Gastroenterology. 2019 Aug;157(2):320-348. Epub 2019 Jul 15. PMID: 31320109. https://pubmed.ncbi.nlm.nih.gov/31320109/
Don’t use opioids long-term to manage abdominal pain in inflammatory bowel disease (IBD).
8

While opioids may be used to manage abdominal pain in select acute settings in IBD patients, their prolonged use may mask the symptoms of active IBD or its complications (e.g., bowel perforation or megacolon). Chronic opioid use has been proven ineffective for non-malignancy associated chronic pain and is associated with excess mortality. Moreover, because of their potential risk for dependence, their long-term use for managing IBD-related abdominal pain should be avoided especially in the context of the opioid crisis in North America.

Sources:

Targownik LE, et al. The prevalence and predictors of opioid use in inflammatory bowel disease: a population-based analysis. Am J Gastroenterol. 2014 Oct;109(10):1613-20. PMID: 25178702.

Related Resources:

Campaign: Opioid Wisely
Don’t unnecessarily prolong the course of intravenous corticosteroids in patients with acute severe ulcerative colitis (UC) in the absence of clinical response.
9

Non-response to intravenous corticosteroids for acute severe UC can be predicted after the first 72 hours of treatment. However, about a third of non-responders receive systemic steroid monotherapy beyond 7 days. This prolonged use of ineffective systemic steroids may unnecessarily lengthen hospitalization days and increase risk of postoperative complications in those who eventually require colectomy.

Sources:

Bitton A, et al. Treatment of hospitalized adult patients with severe ulcerative colitis: Toronto consensus statements. Am J Gastroenterol. 2012 Feb;107(2):179-94. PMID: 22108451.

Kaplan GG, et al. Impact of hospital volume on postoperative morbidity and mortality following a colectomy for ulcerative colitis. Gastroenterology. 2008 Mar;134(3):680-7. PMID: 18242604.

Nguyen GC, et al. Quality of Care and Outcomes Among Hospitalized Inflammatory Bowel Disease Patients: A Multicenter Retrospective Study. Inflamm Bowel Dis. 2017 May;23(5):695-701. PMID: 28426451.

Randall J, et al. Delayed surgery for acute severe colitis is associated with increased risk of postoperative complications. Br J Surg. 2010 Mar;97(3):404-9. PMID: 20101648.
Don’t initiate or escalate long-term medical therapies for the treatment of inflammatory bowel disease (IBD) based only on symptoms.
10

Clinical symptoms often prompt initiation or escalation of medical treatments for inflammatory bowel disease (IBD). However, functional bowel disorders (e.g., irritable bowel syndrome) coexist in 20% of IBD patients and can mimic symptoms of the latter. Clinical symptoms, in fact, do not correlate well with IBD disease activity. Consequently, relying on only clinical symptoms without confirming active disease may commit patients to long-term treatments that have potentially significant adverse effects and resource implications.

Sources:

Abdalla MI, et al. Prevalence and Impact of Inflammatory Bowel Disease-Irritable Bowel Syndrome on Patient-reported Outcomes in CCFA Partners. Inflamm Bowel Dis. 2017 Feb;23(2):325-331. PMID: 28092305.

Colombel JF, et al. Management Strategies to Improve Outcomes of Patients with Inflammatory Bowel Diseases. Gastroenterology. 2017 Feb;152(2):351-361.e5. PMID: 27720840.
Don’t use abdominal computed tomography (CT) scan to assess inflammatory bowel disease (IBD) in the acute setting unless there is suspicion of a complication (obstruction, perforation, abscess) or a non-IBD etiology for abdominal symptoms.
11

Abdominal CT scanning is effective for the time-sensitive diagnosis of IBD complications such as obstruction, perforation, or non-IBD related causes of abdominal pain when these are suspected. The effective ionizing radiation dose from a single conventional abdominal CT scan (10-20mSv) is within acceptable safety limits (<50mSv). However, minimizing inappropriate utilization of CT is a priority because repeated exposure to ionizing radiation over a lifetime, particularly among younger IBD patients, may potentially increase the risk of malignancy. In the acute setting (e.g., emergency department), abdominal CT scan should only be used when there is suspicion of a complication of IBD and should not be used for the assessment of disease activity.

Sources:

Kim DH. ACR Appropriateness Criteria Crohn Disease. J Am Coll Radiol. 2015 Oct;12(10):1048-57.e4. PMID: 26435118.

Smith-Bindman R, et al. Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. Arch Intern Med. 2009 Dec 14;169(22):2078-86. PMID: 20008690.
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.

The recommendations related to IBD were developed by the Canadian IBD Network for Research and Growth in Quality Improvement (CINERGI) in collaboration with Crohn’s and Colitis Canada (CCC) and the Canadian Association of Gastroenterology (CAG). The CINERGI group comprises 14 gastroenterologists specialized in the care of inflammatory bowel disease representing 12 academic centres across Canada. A preliminary survey was sent to the CINERGI working group to solicit candidate recommendations. The top ten recommendations were selected by the working group members through an online voting platform. During a face-to-face consensus meeting in Toronto on November 4, 2016 that included CINERGI working group members, two radiologists, representatives from CCC and CAG, and two patient representatives, a modified Delphi process was used to select the top five recommendations. This list was submitted to the CAG Quality Affairs Committee, the Executive Board, and the CAG general membership for feedback and approval.