Gastroenterological Society of Australia: tests, treatments and procedures clinicians and consumers should question

Colonoscopy, with or without polypectomy, is an invasive procedure with a small but not insignificant risk of complications, including perforation or major haemorrhage postpolypectomy, depending on size of lesion. Surveillance colonoscopies place a significant burden on endoscopy services. Consequently, surveillance colonoscopy should be targeted at those who are most likely to benefit and at the minimum frequency required to provide adequate protection against the development of cancer. Cancer Council Australia guidelines, endorsed by NHMRC, state that if one to two adenomas less than one cm in diameter are removed via a high quality colonoscopy, a follow up interval of five years is recommended. For larger adenomas, three or more adenomas or adenomas containing villous features or high grade dysplasia, which are removed via a high quality colonoscopy, the recommended follow-up period is three years.

Supporting evidence

  • Cancer Council Australia, ‘Clinical Practice Guidelines for Surveillance Colonoscopy’, December 2011.
  • Winawer SJ, Zauber AG, O’Brien MJ, et al. Randomised comparison of surveillance intervals after colonoscopic removal of newly diagnosed adenomatous polyps. N Engl J Med 1993; 328(13):901-6. 

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The faecal occult blood test (FOBT) was developed for use in the outpatient setting for colorectal cancer screening in asymptomatic patients with average risk of colorectal carcinoma. Studies suggest that it has limited positive impact for hospitalised patients who report rectal bleeding or require investigation for iron deficiency or gastrointestinal symptoms, as it is unlikely to change patient management and may in fact delay investigations while waiting for the results of the test. Inappropriate use of the FOBT may lead to unnecessary additional investigations (e.g. colonoscopy), which also carries risks and may limit the availability of such investigations for more appropriate indications.

Supporting evidence

  • Friedman A, Chan A, Chin LC, et al. Use and abuse of faecal occult blood tests in an acute hospital patient setting. Int Med Journal 2010;40:107-11.
  • Ip S, Sokoro AAH, Kaita L, et al. Use of fecal occult blood testing in hospitalized patients: results of an audit. Can J Gastroenterol Hepatol 2014;28(9):489-94.
  • Sharma VK, Komanduri S, Nayyar S, et al. An audit of the utility of in-patient fecal occult blood testing. Am J Gastroenterol 2001;96(4):1256-60.

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While proton pump inhibitors (PPIs) are effective drugs for the treatment of gastroesophageal reflux disease (GERD), their use has been linked to increased risk of fractures, pneumonia, enteric infections, vitamin and mineral deficiencies, and acute interstitial nephritis, particularly among older people who make up the largest proportion of PPI users. While there is insufficient evidence to establish causation, these reports deserve consideration when prescribing long term PPI use. This is especially because some patients may be able to stop PPI use immediately after the initial course of therapy without experiencing 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.

Supporting evidence

  • Choudhry MN, Soran H, Ziglam HM. Overuse and inappropriate prescribing of proton pump inhibitors in patients with Clostridium difficile-associated disease. QJ Med 2008;101:445-8.
  • Hollingworth S, Duncan EL, Martin JH. Marked increase in proton pump inhibitors use in Australia. Pharmacoepidemiol Drug Saf 2010;19:1019-24.
  • National Institute for Health and Care Excellence. Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management. Clinical guideline 2014.

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The value of testing for coeliac genes is primarily as a negative test – if the gene test is negative then coeliac disease may be excluded. However as a coeliac gene can be found in approximately one third of the population, a positive result does not make coeliac disease a certainty. Serological testing, in a patient consuming an appropriate amount of gluten, is the appropriate first line screening test for coeliac disease. A small bowel biopsy is then required if serology is positive.

Supporting evidence

  • Fasano A, Catassi C. Celiac disease. N Engl J Med 2012; 367:2419-26.
  • Megiorni F, Pizutti A. HLA-DQA1 and HLA-DQB1 in Celiac disease predisposition: practical implications of the HLA molecular typing. J Biomed Sci 2012;19:88.

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Barrett’s Oesophagus (or Barrett’s mucosa) is the term given to a change which occurs in the lining of the lower oesophagus. It occurs in a small proportion of patients with longstanding gastro-oesophageal reflux. The condition requires surveillance because of an increased risk of oesophageal adenocarcinoma (EAC). This usually develops slowly over a period of some years and can be predicted by the finding of pre-cancerous changes (dysplasia) on biopsies. However, systematic surveillance of Barrett’s Oesophagus patients has not been shown to be cost-effective, and no randomised controlled trials have been conducted to compare surveillance with the natural history of Barrett’s Oesophagus. According to currently-accepted guidelines, it is appropriate and safe to examine the oesophagus and check for dysplasia every three years, as cellular changes occur very slowly.

Supporting evidence

  • Spechler SJ, Souza RF. Barrett’s Esophagus. N Engl J Med 2014;371:836-45.
  • Shaheen NJ, Falk GW, Iyer PG, Gerson LB. ACG clinical guideline: diagnosis and management of Barrett’s esophagus. Am J Gastroenterol 2016;111:30-50.

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The Gastroenterological Society of Australia (GESA) initially engaged its members through its regular online communications, sharing the aims of the EVOLVE initiative, as well as background information on the US and Canadian versions of Choosing Wisely. Members were provided with a copy of the five recommendations made by the American Gastroenterology Association. GESA also consulted externally, with the EVOLVE Lead Fellow addressing the GUT club and the Inflammatory Bowel Disease Group on the initiative. All members of GESA were invited to submit proposed items for the Top 5 list. The GESA Council reviewed all items before reaching consensus on the recommended final list. A review of the evidence for the shortlisted items was then undertaken and the final list and its rationales were signed off by the GESA Council in May 2016.

Last reviewed 01 October 2016