A reader recently wrote to ask about whether physicians usually do biopsies during an upper endoscopy. He didn’t realize he was asking a loaded question! Here’s my take on the question.
Learn more: The role of biopsies in the diagnosis of GERD
Biopsies are essential in patients with visible abnormalities
In a patient undergoing endoscopy for suspected esophageal disease, including adenocarcinoma prognosis, a biopsy is essential in the following situations:
1. When there is any visible focal abnormality in the esophagus (stricture, mass, ulcer, erythema, inlet patch, web, Schatzki ring, etc.)
Most GIs will do this, although the thoroughness of the biopsies varies greatly. The diagnosis is more likely to be accurate when the biopsy is thorough.
Learn more: Inside your esophagus: The damage caused by GERD
2. In patients with a visible columnar lined esophagus without any focal lesions.
The recommendation is that biopsies be taken at intervals of 1-2 cm (four quadrant biopsies from each level) from the squamocolumnar junction to the end of the esophagus. This recommendation is rarely followed. Most GIs will take a few random biopsies from all over and submit them all in one bottle. This is not appropriate. Endoscopy is a significant procedure for a patient. A thorough job with biopsies increases the probability of an accurate diagnosis – anything less is substandard care. So why aren’t GIs always thorough? (a) Biopsies are time consuming and increase the duration of the procedure and (b) The reimbursement for endoscopy with biopsy does not change with number of biopsies taken.
What if the esophagus looks normal?
The American Gastroenterological Association (AGA) recommends that patients who are endoscopically normal should not undergo biopsy. The majority of GIs who do endoscopy follow this recommendation; however, this recommendation is difficult to understand. Most GIs will say that if they take a biopsy of a GERD patient who is endoscopically normal, approximately 10% will have intestinal metaplasia. Everyone recognizes that this is abnormal, and almost everyone will agree that this is likely the precursor of cancer in this region . The actual risk of cancer or for an adenocarcinoma prognosis with this finding is unknown and likely to be small. The reason they will give for not taking biopsies is that they do not know what to do with the finding if there is intestinal metaplasia. This is a classic catch-22 situation: “I will not biopsy because I do not know what to do with the patient if they have intestinal metaplasia. I will never know the significance of intestinal metaplasia if I do not biopsy.”
The choice is yours
I strongly believe biopsies should be taken at the squamo-columnar junction in GERD patients who do not have an endoscopic abnormality. This would help us catch pre-cancerous changes in their earliest stages. The challenge, then, is what to do if a patient has intestinal metaplasia. While periodic surveillance is the norm for patients diagnosed with Barrett’s esophagus (intestinal metaplasia AND visible abnormality), there isn’t a clear standard for surveillance of intestinal metaplasia without visible abnormality.
If you have a biopsy and learn you have intestinal metaplasia, you’ll need to discuss your options and make an informed decision together with your doctor. Endoscopic surveillance is costly and may not be justified on the basis of cost-effectiveness in the entire population. However, if you are worried about even a small cancer risk, this maybe appropriate. In some cases, you may be asked to pay for the surveillance if your insurer refuses to cover the cost. This may change your mind, but it has to be your choice.