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## Complete Summary

#### GUIDELINE TITLE

ASGE guideline: the role of endoscopy in the surveillance of
premalignant conditions of the upper GI tract.

#### BIBLIOGRAPHIC SOURCE(S)

Hirota WK, Zuckerman MJ, Adler DG, Davila RE, Egan J, Leighton JA,
Qureshi WA, Rajan E, Fanelli R, Wheeler-Harbaugh J, Baron TH, Faigel DO,
Standards of Practice Committee, American Society for Gastrointestinal
Endoscopy. ASGE guideline: the role of endoscopy in the surveillance of
premalignant conditions of the upper GI tract. Gastrointest Endosc 2006
Apr;63(4):570-80. \[171 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16564854)

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Premalignant conditions of the upper gastrointestinal tract, including:

-   Barrett\'s esophagus

-   Gastroesophageal reflux disease

-   Achalasia

-   Caustic ingestion injury

-   Tylosis

-   Upper aerodigestive tract cancer

-   Squamous cell cancer of the head and neck

-   Gastric epithelial polyps

-   Intestinal metaplasia of the stomach

-   Gastric intestinal dysplasia

-   Pernicious anemia

-   Postgastrectomy

-   Familial adenomatous polyposis

-   Hereditary nonpolyposis colorectal cancer syndrome

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Management\
Screening

#### CLINICAL SPECIALTY

Gastroenterology\
Oncology

#### INTENDED USERS

Physicians

#### GUIDELINE OBJECTIVE(S)

To provide guidelines for surveillance of premalignant upper
gastrointestinal conditions with endoscopic follow-up of individuals who
are at increased risk for malignancy or in whom a neoplastic lesion has
been identified and removed

#### TARGET POPULATION

Patients with premalignant conditions of the upper gastrointestinal
tract

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Surveillance endoscopy

2.  Biopsy of endoscopic specimens

3.  Gastric polyp removal

4.  Surgical consultation and referral

#### MAJOR OUTCOMES CONSIDERED

-   Incidence of cancer arising from upper gastrointestinal (UGI)
    premalignant conditions

-   Survival benefit of surveillance endoscopy procedures

-   Cost of surveillance procedures

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

In preparing this guideline, a MEDLINE literature search was performed,
and additional references were obtained from the bibliographies of the
identified articles and from recommendations of expert consultants.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Expert Consensus

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Guidelines for appropriate utilization of endoscopy are based on a
critical review of the available data and expert consensus.

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

Published cost analyses were reviewed:

-   Economic models suggest that screening high-risk individuals (eg,
    white males, chronic reflux, age \>50 years) is cost effective
    compared to no screening. These models, however, conflict with each
    other regarding the cost effectiveness of further surveillance in
    patients with Barrett\'s esophagus who are nondysplastic.

-   The use of unsedated endoscopy may be a feasible and cost-saving
    approach for screening and surveillance but requires a motivated
    patient who will forgo conscious sedation.

-   The role of endoscopic surveillance in achalasia is controversial.
    Despite the lack of demonstrable cost effectiveness, several authors
    have advocated periodic endoscopy as reasonable after 15 years.

-   The role of endoscopic screening and surveillance in patients with
    upper aerodigestive tract cancers is controversial. Despite the lack
    of demonstrable cost effectiveness or prolonged survival, several
    authors have advocated periodic endoscopy.

#### METHOD OF GUIDELINE VALIDATION

Not stated

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not applicable

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

The summary of recommendations is followed by evidence grades (A-C)
identifying the type of supporting evidence. Definitions of the evidence
grades are presented at the end of the \"Major Recommendations\" field.

**[Esophageal Cancer]{.underline}**

**Barrett\'s Esophagus**

1.  Screening esophagogastroduodenoscopy (EGD) for Barrett\'s esophagus
    should be considered in selected patients with chronic, longstanding
    gastroesophageal reflux disease (GERD). After a negative screening
    examination, further screening endoscopy is not indicated.

2.  The cost effectiveness of surveillance in patients without dysplasia
    is controversial. Surveillance endoscopy is appropriate for patients
    fit to undergo therapy, should endoscopic/histologic findings
    dictate. For patients with established Barrett\'s esophagus of any
    length and with no dysplasia, after 2 consecutive examinations
    within 1 year, an acceptable interval for additional surveillance is
    every 3 years.

3.  Patients with high-grade dysplasia are at significant risk for
    prevalent or incident cancer. Patients who are surgical candidates
    may elect to have definitive therapy. Patients who elect
    surveillance endoscopy should undergo follow-up every 3 months for
    at least 1 year, with multiple large capacity biopsy specimens
    obtained at 1 cm intervals. After 1 year of no cancer detection, the
    interval of surveillance may be lengthened if there are no
    dysplastic changes on 2 subsequent endoscopies performed at 3-month
    intervals. High-grade dysplasia should be confirmed by an expert GI
    pathologist.

4.  Surveillance in patients with low-grade dysplasia is recommended.
    The significance of low-grade dysplasia as a risk factor for cancer
    remains poorly defined; therefore, the optimal interval and biopsy
    protocol has not been established. A follow-up EGD (i.e., at 6
    months) should be performed with concentrated biopsies in the area
    of dysplasia. If low-grade dysplasia is confirmed, then one possible
    management scheme would be surveillance at 12 months and yearly
    thereafter as long as dysplasia persists.

5.  If the presence or degree of dysplasia is indeterminate and there is
    evidence of acute inflammation due to gastroesophageal acid reflux,
    repeat biopsy should be performed after 8 weeks of effective
    acid-suppression therapy.

**Achalasia**

1.  There are insufficient data to support routine endoscopic
    surveillance for patients with achalasia.

2.  If surveillance were to be considered, it would be reasonable to
    initiate it 15 years after onset of symptoms, but the subsequent
    surveillance interval is not defined.

**Caustic Injury**

1.  Begin endoscopic surveillance 15 to 20 years after caustic
    ingestion.

2.  The time interval of endoscopic surveillance requires study.
    Generally, endoscopic examination should not be conducted more
    frequently than every 1 to 3 years. There should be a low threshold
    to evaluate swallowing problems with endoscopy.

**Tylosis**

1.  Begin endoscopic surveillance at age 30 years.

2.  The time interval of endoscopic surveillance requires study.
    Generally, endoscopic examination should not be conducted more
    frequently than every 1 to 3 years.

**History of Upper Aerodigestive Tract Cancer**

1.  There are insufficient data to support routine endoscopic
    surveillance for patients with previous aerodigestive squamous cell
    cancer.

2.  A single endoscopy may be indicated to identify synchronous
    esophageal cancer.

**[Gastric Cancer]{.underline}**

**Gastric Epithelial Polyps**

1.  Adenomatous gastric polyps are at increased risk for malignant
    transformation and should be resected completely. Hyperplastic
    polyps have a rare malignant potential. Endoscopic polyp appearance
    cannot differentiate histologic subtypes; therefore biopsy or
    polypectomy is recommended when a polyp is encountered.

2.  Polypoid defects of any size detected radiographically should be
    evaluated endoscopically, with biopsy and/or removal of the lesions.

3.  Polyps should be endoscopically excised wherever feasible and
    clinically appropriate. If endoscopic polypectomy is not possible, a
    biopsy of the polyp should be performed, and if adenomatous or
    dysplastic tissue is detected, referral for surgical resection
    should be considered. If representative biopsy samples are obtained
    and the polyp is nondysplastic, no further intervention is
    necessary. If it is felt that endoscopic biopsy cannot sufficiently
    exclude the presence of dysplastic elements, referral for surgical
    resection is reasonable in polyps that cannot be removed
    endoscopically.

4.  When multiple gastric polyps are encountered, a biopsy of the
    largest polyps should be performed or they should be excised, and
    representative biopsy specimens should be taken from some others.
    Further management should be based on histologic results.

5.  Surveillance endoscopy 1 year after removing adenomatous gastric
    polyps is reasonable to assess recurrence at the prior excision
    site, new or previously missed polyps, and/or supervening early
    carcinoma. If the results of this examination are negative, repeat
    surveillance endoscopy should be repeated no more frequently than at
    3- to 5-year intervals. Follow-up after resection of polyps with
    high-grade dysplasia and early gastric cancer should be
    individualized.

6.  No surveillance endoscopy is necessary after adequate sampling or
    removal of nondysplastic gastric polyps.

**Gastric Intestinal Metaplasia and Dysplasia**

1.  Endoscopic surveillance for gastric intestinal metaplasia has not
    been extensively studied in the U.S. and therefore cannot be
    uniformly recommended.

2.  Patients at increased risk for gastric cancer due to ethnic
    background or family history may benefit from surveillance.

3.  Endoscopic surveillance should incorporate a topographic mapping of
    the entire stomach.

4.  Patients with confirmed high-grade dysplasia are at significant risk
    for progressing to cancer and should be considered for gastrectomy
    or local (e.g., endoscopic) resection.

**Pernicious Anemia and Gastric Carcinoid Tumors**

1.  A single endoscopy should be considered to identify prevalent
    lesions (gastric cancer, carcinoid tumors) in patients with
    pernicious anemia, but there are insufficient data to support
    routine subsequent endoscopic surveillance for these patients.

2.  Surveillance of carcinoid tumors is controversial and should be
    individualized to the patient.

**Postgastric Surgery**

1.  There are insufficient data to support routine endoscopic
    surveillance for patients with previous partial gastrectomy for
    peptic ulcer disease.

2.  Because gastric surgeries are performed for peptic ulcer disease, an
    index endoscopy should be performed to establish the presence of
    *Helicobacter pylori* infection, chronic gastritis, and/or
    intestinal metaplasia.

3.  If surveillance is considered, it should be initiated after an
    interval of 15 to 20 years. Multiple biopsies from the anastomosis
    and gastric remnant should be taken. The threshold should be low in
    order to endoscopically evaluate upper gastrointestinal symptoms.

**[Familial Adenomatous Polyposis and Hereditary Nonpolyposis Colorectal
Cancer]{.underline}**

1.  Patients with familial adenomatous polyposis (FAP) should undergo
    upper endoscopy with both end-viewing and side-viewing instruments.
    The optimal timing of initial upper endoscopy is unknown, but could
    be performed around the time the patient is considered for
    colectomy, or early in the third decade of life. If no adenomas are
    detected, another exam should be performed in 5 years because
    adenomatous change may occur later in the course of the disease.

2.  For patients with duodenal and periampullary adenomas, surveillance
    endoscopy and biopsy should be performed at intervals based on stage
    of disease. Endoscopic treatment of papillary adenomas may be
    appropriate in selected patients. If excision is complete, one
    approach is for follow-up endoscopy and multiple biopsies every 6
    months for a minimum of 2 years, with endoscopy thereafter at 3-year
    intervals.

3.  A biopsy of the duodenal polyps should be performed or sampled at
    the time of initial discovery and on each subsequent examination to
    determine the stage of duodenal polyposis. The frequency of exams
    and referral for prophylactic surgery are determined on the basis of
    duodenal polyp stage.

4.  Biopsies of gastric polyps in patients with FAP may be performed to
    confirm that they are fundic gland polyps and to assess for
    dysplasia. Antral polyps are usually adenomas and should be
    resected.

5.  Surgical consultation should be obtained for those patients with
    advanced (stage IV) duodenal polyposis in an effort to prevent
    periampullary/duodenal carcinoma. Management of high-grade dysplasia
    in the periampullary region (surgery/ablative therapy versus more
    frequent surveillance) is controversial and must be individualized.

6.  Patients with hereditary nonpolyposis colorectal cancer (HNPCC) are
    at increased risk for the development of gastric and small-bowel
    cancer. Although there is insufficient data to show a benefit for
    upper endoscopic surveillance in patients with HNPCC, endoscopic
    surveillance should be considered.

**[Summary]{.underline}**

-   Patients with chronic GERD at risk for Barrett\'s esophagus should
    be considered for endoscopic screening (**B**).

-   In patients with Barrett\'s esophagus without dysplasia, the cost
    effectiveness of surveillance endoscopy is controversial. If
    surveillance is performed, an interval of 3 years is acceptable
    (**C**).

-   Although an increased cancer risk has not been established in
    patients with Barrett\'s esophagus and low-grade dysplasia,
    endoscopy at 6 months and yearly thereafter should be considered
    (**C**).

-   Patients with Barrett\'s esophagus with confirmed high-grade
    dysplasia should be considered for surgery or aggressive endoscopic
    therapy (**B**). Patients with high-grade dysplasia who elect
    endoscopic surveillance should be followed up closely (i.e., every 3
    months) for at least 1 year. If no further high-grade dysplasia is
    confirmed, then the interval between follow-ups may be lengthened
    (**B**).

-   There are insufficient data to recommend routine surveillance for
    patients with achalasia (**C**).

-   Patients with a severe caustic esophageal injury should undergo
    surveillance every 1 to 3 years beginning 15 to 20 years after the
    injury (**C**).

-   Patients with tylosis should undergo surveillance endoscopy every 1
    to 3 years beginning at age 30 years (**C**).

-   There are insufficient data to support routine endoscopic
    surveillance for patients with previous aerodigestive squamous cell
    cancer (**C**).

-   Adenomatous gastric polyps should be resected because of the risk
    for malignant transformation (**B**). Adenomatous polyps may recur
    in synchronous and metachronous sites, and surveillance endoscopies
    should be performed at 3- to 5-year intervals (**C**).

-   Endoscopic surveillance for gastric intestinal metaplasia has not
    been extensively studied in the U.S. and therefore cannot be
    routinely recommended (**C**). However, there may be a subgroup of
    high-risk patients who will benefit from endoscopic surveillance
    (**B**).

-   Patients with confirmed gastric high-grade dysplasia should be
    considered for gastrectomy or local resection because of the high
    incidence of prevalent carcinoma (**B**).

-   Patients with pernicious anemia may be considered for a single
    screening endoscopy, particularly if symptomatic, but there are
    insufficient data to recommend ongoing surveillance (**C**).

-   There are insufficient data to support routine endoscopic
    surveillance in patients with previous partial gastrectomy for
    peptic ulcer disease (**C**).

-   Patients with FAP should undergo regular surveillance endoscopy
    using both end-viewing and side-viewing endoscopes, starting around
    the time of colectomy or after age 30 years (**B**).

-   Patients with HNPCC have an increased risk of gastric and
    small-bowel cancer (**B**). Surveillance should be strongly
    considered (**C**).

**[Definitions]{.underline}**:

A.  Prospective controlled trials

B.  Observational studies

C.  Expert opinion

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and classified for the
recommendations using the following scheme:

A.  Prospective controlled trials

B.  Observational studies

C.  Expert opinion

When little or no data exist from well-designed prospective trials,
emphasis is given to results from large series and reports from
recognized experts. Guidelines for appropriate utilization of endoscopy
are based on a critical review of the available data and expert
consensus.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Appropriate utilization of surveillance endoscopy in patients with
premalignant conditions of the upper gastrointestinal tract

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   Further controlled clinical studies are needed to clarify aspects of
    this statement, and revision may be necessary as new data appear.
    Clinical consideration may justify a course of action at variance to
    these recommendations.

-   The natural history of many of these premalignant conditions is not
    well characterized, and published surveillance data are limited by
    both lead-time and length-time bias.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness\
Staying Healthy

#### IOM DOMAIN

Effectiveness\
Timeliness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Hirota WK, Zuckerman MJ, Adler DG, Davila RE, Egan J, Leighton JA,
Qureshi WA, Rajan E, Fanelli R, Wheeler-Harbaugh J, Baron TH, Faigel DO,
Standards of Practice Committee, American Society for Gastrointestinal
Endoscopy. ASGE guideline: the role of endoscopy in the surveillance of
premalignant conditions of the upper GI tract. Gastrointest Endosc 2006
Apr;63(4):570-80. \[171 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16564854)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2006 Apr

#### GUIDELINE DEVELOPER(S)

American Society for Gastrointestinal Endoscopy - Medical Specialty
Society

#### SOURCE(S) OF FUNDING

American Society for Gastrointestinal Endoscopy

#### GUIDELINE COMMITTEE

Standards of Practice Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Committee Members*: William K. Hirota, MD; Marc J. Zuckerman, MD;
Douglas G. Adler, MD; Raquel E. Davila, MD; James Egan, MD; Jonathan A.
Leighton, MD; Waqar A. Qureshi, MD; Elizabeth Rajan, MD; Robert Fanelli,
MD (*SAGES Representative*); Jo Wheeler-Harbaugh, RN (*SGNA
Representative*); Todd H. Baron, MD (*Vice Chair*); Douglas O. Faigel,
MD (*Chair*)

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available in Portable Document Format (PDF) from the
[American Society for Gastrointestinal Endoscopy (ASGE) Web
site](http://www.asge.org/PublicationsProductsIndex.aspx?id=352).

Print copies: Available from the American Society for Gastrointestinal
Endoscopy, 1520 Kensington Road, Suite 202, Oak Brook, IL 60523

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on June 9, 2006.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions.

### DISCLAIMER

#### NGC DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008