Chapter 5: Gastrointestinal Disorders

BARRETT ESOPHAGUS (BE)

Population

• – Lower risk: General population with gastroesophageal reflux disease (GERD).

• – Moderate risk: GERD and ≥1 other risk factor: age >50 y, male sex, white, obesity (BMI ≥30), central adiposity, tobacco use.

• – High risk: Family history of esophageal adenocarcinoma or BE.

Recommendations

ASGE 2019

• – Do not screen lower-risk general population with GERD.

• – Screen moderate- to high-risk individuals using upper endoscopy (EGD) and biopsy.

Sources

• – Gastrointest Endosc. 2019;90(3):335-359.

• – Am J Gastroenterol. 2016;111(1):30-50.

Comments

1. Forty percent of persons with BE and esophageal cancer have no preceding GERD symptoms.

2. Treat all persons with biopsy-proven BE with proton pump inhibitor (PPI) therapy, including asymptomatic individuals.

CELIAC DISEASE

Population

• – Children and adults.

Recommendations

USPSTF 2017, AAFP 2017

• – Insufficient evidence regarding screening of asymptomatic individuals.

Sources

• – USPSTF. JAMA. 2017;317(12):1252.

• – AAFP. Clinical Recommendations: Screening for Celiac Disease. 2017.

ACG 2013

• – Consider serologic testing with IgA tissue transglutaminase antibody and total IgA level, in asymptomatic persons with type 1 diabetes mellitus (3%–10% concurrent celiac disease) every 1–2 y.

Source

• – Am J Gastroenterol. 2013;108(5):656-676.

NICE 2015

• – Do not screen the general population.

• – Screen first-degree relatives of individuals with celiac disease.

• – Offer testing to persons with persistent unexplained abdominal or gastrointestinal symptoms, faltering growth, prolonged fatigue, unexpected weight loss, severe or persistent mouth ulcers; unexplained iron, vitamin B12 or folate deficiency; type 1 diabetes, autoimmune thyroid disease, adult irritable bowel syndrome.

• – Consider testing individuals with metabolic bone disease, unexplained neurological symptoms (particularly peripheral neuropathy or ataxia), unexplained subfertility or recurrent miscarriage, persistently raised liver enzymes with unknown cause, dental enamel defects, Down syndrome, Turner syndrome.

Source

• – NICE. Coeliac Disease: Recognition, Assessment and Management. 2015.

Comments

1. Serologic testing and biopsy must be performed while on gluten-containing diet.

2. IgA tissue transglutaminase (TTG) antibody is the test of choice (>90% sensitivity and specificity), along with total IgA level. If equivocal TTG, perform IgA endomysial antibody test.

COLORECTAL CANCER

Population

• – Average-risk adults.^a

Recommendations

AAFP 2018, USPSTF 2017

• – Age 50–75 y: Screen all patients.

• – Age 76–85 y: Individualize screening decision.

• – Age >85 y: ...