Guideline

The role of endoscopy in the management of patients with peptic ulcer disease

La úlcera péptica (UP) es una pérdida de sustancia en aquellas partes del tracto digestivo que contactan con el ácido y la pepsina, y que se extiende más allá de la muscularis mucosa. Su localización más frecuente es el duodeno y el estómago. La incidencia de la UP se cifra entre el 0,1% y el 0,3% en la población general, y la mortalidad, en relación con sus complicaciones, es de 2-3 casos por 100000 habitantes/año. Las causas principales son la infección por Helicobacter pylori (HP) y el consumo de antiinflamatorios no esteroideos (AINE) que condicionan un desequilibrio entre los factores agresivos y defensivos que regulan la función de la mucosa gastroduodenal. El espectro clínico de la enfermedad ulcerosa es muy variable: asintomática (70%), «epigastralgia de ritmo ulceroso», molestias inespecíficas o síntomas y signos en relación con sus complicaciones (hemorragia digestiva alta, perforación, estenosis pilórica-duodenal y penetración a órganos vecinos). La endoscopia digestiva alta permite el diagnóstico per se de la UP, así como de su etiología (toma de biopsias para descartar malignidad e investigar infección por HP). El tratamiento antisecretor con inhibidores de la bomba de protones (IBP) es la base de la terapia de la enfermedad ulcerosa. La erradicación del HP cuando se detecte la infección y la supresión de los AINE son fundamentales para favorecer la cicatrización y prevenir la recidiva ulcerosa.

A peptic ulcer (PU) is a loss of matter in parts of the digestive tract that are in contact with acid and pepsin and which extend beyond the muscularis mucosae. The most frequent location is the duodenum and stomach. The incidence of PU is between 0.1% and 0.3% of the general population and the mortality rate, which is in relation to its complications, is 2-3 cases per 100,000 inhabitants/year. The main causes are Helicobacter pylori (HP) infection and the consumption of non-steroidal anti-inflammatory drugs (NSAIDs) that cause an imbalance between the aggressive and defensive factors that regulate gastroduodenal mucosa function. The clinical spectrum of ulcer disease is highly variable, ranging from asymptomatic (70%), “ulcerative-rate epigastric pain,” nonspecific discomfort, or symptoms and signs related to its complications (upper gastrointestinal bleeding, perforation, pyloric-duodenal stenosis, and penetration to neighboring organs). Upper endoscopy allows for a diagnosis per se of PU as well as its etiology (collecting biopsies to rule out malignancy and investigate HP infection). Antisecretory treatment with proton-pump inhibitors (PPIs) is the mainstay of treatment for ulcer disease. The eradication of HP when the infection is detected and cessation of NSAID use are essential to promote healing and prevent ulcer recurrence.

The purpose of this Clinical Practice Update (CPU) Expert Review is to provide clinicians with guidance on best practices for performing a high-quality upper endoscopic exam.

The best practice advice statements presented herein were developed from a combination of available evidence from published literature, guidelines, and consensus-based expert opinion. No formal rating of the strength or quality of the evidence was carried out, which aligns with standard processes for American Gastroenterological Association (AGA) Institute CPUs. These statements are meant to provide practical, timely advice to clinicians practicing in the United States. This Expert Review was commissioned and approved by the American Gastroenterological Association (AGA) Institute Clinical Practice Updates (CPU) Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPU Committee and external peer review through standard procedures of Clinical Gastroenterology & Hepatology.

Endoscopists should ensure that upper endoscopy is being performed for an appropriate indication and that informed consent clearly explaining the risks, benefits, alternatives, sedation plan, and potential diagnostic and therapeutic interventions is obtained. These elements should be documented by the endoscopist before the procedure.

Endoscopists should ensure that adequate visualization of the upper gastrointestinal mucosa, using mucosal cleansing and insufflation as necessary, is achieved and documented.

A high-definition white-light endoscopy system should be used for upper endoscopy instead of a standard-definition white-light endoscopy system whenever possible. The endoscope used for the procedure should be documented in the procedure note.

Image enhancement technologies should be used during the upper endoscopic examination to improve the diagnostic yield for preneoplasia and neoplasia. Suspicious areas should be clearly described, photodocumented, and biopsied separately.

Endoscopists should spend sufficient time carefully inspecting the foregut mucosa in an anterograde and retroflexed view to improve the detection and characterization of abnormalities.

Endoscopists should document any abnormalities noted on upper endoscopy using established classifications and standard terminology whenever possible.

Endoscopists should perform biopsies for the evaluation and management of foregut conditions using standardized biopsy protocols.

Endoscopists should provide patients with management recommendations based on the specific endoscopic findings (eg, peptic ulcer disease, erosive esophagitis), and this should be documented in the medical record. If recommendations are contingent upon histopathology results (eg, H pylori infection, Barrett’s esophagus), then endoscopists should document that appropriate guidance will be provided after results are available.

Endoscopists should document whether subsequent surveillance endoscopy is indicated and, if so, provide appropriate surveillance intervals. If the determination of surveillance is contingent on histopathology results, then endoscopists should document that surveillance intervals will be suggested after results are available.

La enfermedad ulcerosa péptica es una patología frecuente; aunque su incidencia ha disminuido en los últimos años, sigue siendo una causa importante de morbimortalidad asociada a un elevado gasto sanitario. Los factores de riesgo más importantes son la infección por Helicobacter pylori (H. pylori) y el uso de antiinflamatorios no esteroideos. La mayoría de los pacientes con enfermedad ulcerosa péptica permanecen asintomáticos, siendo la clínica más frecuente la dispepsia, a menudo característica (dispepsia ulcerosa). También puede comenzar con complicaciones como hemorragia digestiva alta, perforación o estenosis. La técnica diagnóstica de elección es la endoscopia digestiva alta. El tratamiento con inhibidores de la bomba de protones, la erradicación de H. pylori y evitar el consumo de antiinflamatorios no esteroideos son la base del tratamiento. Sin embargo, la prevención es la mejor estrategia, incluye una adecuada indicación de inhibidores de la bomba de protones, la investigación y tratamiento de H. pylori, evitar los antiinflamatorios no esteroideos o utilizar aquellos menos gastrolesivos.

Peptic ulcer disease is a frequent pathology; although the incidence has decreased in recent years, it continues to be an important cause of morbidity and mortality associated with high healthcare costs. The most important risk factors are Helicobacter pylori (H. pylori) infection and the use of non-steroidal anti-inflammatory drugs. Most patients with peptic ulcer disease remain asymptomatic, with dyspepsia being the most frequent and often characteristic symptom. It can also debut with complications such as upper gastrointestinal bleeding, perforation or stenosis. The diagnostic technique of choice is upper gastrointestinal endoscopy. Treatment with proton pump inhibitors, eradication of H. pylori and avoiding the use of non-steroidal anti-inflammatory drugs are the basis of treatment.

However, prevention is the best strategy, it includes an adequate indication of proton pump inhibitors, investigation and treatment of H. pylori, avoiding non-steroidal anti-inflammatory drugs or using those that are less gastrolesive.

To assess the radiation dose in standard barium swallow studies (BaSS) performed at a large tertiary referral centre, benchmarked against the national diagnostic reference level (NDRL), and to provide evidence to support reducing radiation dose through improving operator's training.

In this retrospective observational study, 1,004 adult BaSS (M:F = 411:593) were assessed. The radiation dose was first compared with NDRL, and then stratified by the operator's training level and compared using analysis of variance (ANOVA). The operators were categorised as radiology residents, advanced radiography practitioners, GI radiology fellows, and GI radiology consultants. Further comparative analysis is performed by comparing the test radiation dose when stratified based on the referrer's specialty, and whether they were performed for female patients of childbearing age.

The findings show 68.2% of BaSS performed are within the NDRL and demonstrated statistically significant correlation (p<0.0001) between radiation dose and operator's training level, and for female patients of childbearing age (p<0.002) and the rest. The median dose was lower with more senior operators. There was no significant correlation between radiation dose and the referrer's specialty.

The study presents evidence to support revisiting consultant-supervised BaSS training, in the interests of lowering the radiation exposure to patients and improving compliance with the NDRL.

When performed appropriately and safely, esophagogastroduodenoscopy (EGD) is an invaluable tool for diagnosing and monitoring a range of upper gastrointestinal disorders and cancers. With more than 6 million EGDs being performed in the United States and reports of missed upper GI (UGI) lesions, both experienced and budding endoscopists should keep a number of essential considerations in mind when performing an EGD, and that starts with obtaining a thorough patient medical history and ensuring that informed consent has been obtained. The right approach, including good posture, appropriate intubation, and proper use of torque, as well as slow endoscope insertion and withdrawal, helps make for a smooth and effective procedure. A clean mucosa, achieved using water and de-foaming and mucolytic agents, ensures clear visibility. Meticulous inspection of the mucosa will allow the endoscopist to detect all lesions and abnormalities. Adherence to established and indication-specific biopsy protocols and use of validated classification criteria should help histopathologists confirm a diagnosis. Maintaining vigilance after an endoscopy and informing our patients of symptoms and signs of procedure-related adverse events is essential for the early recognition and management of these possible adverse events. Finally, an evidence-based schedule of follow-up endoscopy built on endoscopic and histologic findings and risk factors for disease progression will help avoid overutilization of endoscopies.