Reflux self-medication and limited healthcare consultation: Systemic inadequacies in Barrett’s esophagus screening, surveillance, and management

Abstract

Huibertse et al recently published a study in World Journal of Gastroenterology, demonstrating that 57.5% of Dutch adults with gastroesophageal reflux symptoms have never consulted a physician, while 36.6% of this unscreened group regularly use over-the-counter acid suppressants and 11.1% already fulfil current European Society of Gastrointestinal Endoscopy criteria for Barrett’s esophagus (BE) screening. Long-term, potent self-medication effectively masks the very symptoms meant to trigger medical consultation, rendering physician-dependent strategies obsolete. This alarming pattern unfolds as obesity - the most powerful modifiable risk factor for erosive reflux, BE, and esophageal adenocarcinoma - continues its unrelenting rise across Europe. Even when BE is eventually diagnosed, surveillance adherence remains inconsistent, particularly in longer segments where neoplastic progression risk is highest. The convergence of widespread self-medication, escalating obesity, low public awareness, and suboptimal surveillance quality exposes the structural failure of current passive, symptom-driven screening models. Reaching this largely unrecognized high-risk group may benefit from enhanced primary-care engagement, appropriate referral for specialist assessment, and the selective use of emerging prediction and non-endoscopic screening tools. Only a population-oriented paradigm will close the widening gap between risk and detection, preventing the next wave of preventable esophageal adenocarcinomas.

Key Words: Barrett’s esophagus; Screening; Gastroesophageal reflux disease; Obesity; Self-medication

Core Tip: Current models for identifying Barrett’s esophagus (BE) rely on patients seeking care for gastroesophageal reflux disease, yet more than half of symptomatic individuals never consult a physician and many mask symptoms with over-the-counter therapy. This creates a largely invisible high-risk population, further amplified by rising obesity and inconsistent surveillance quality. Evidence from population-based studies, registry data, and emerging non-endoscopic tools highlights the need to shift from symptom-driven screening to proactive, risk-based, and system-level strategies to improve BE detection and prevent esophageal adenocarcinoma.

This editorial refers to "Self-management and help-seeking behavior for gastroesophageal reflux symptoms: A population-based survey" by Huibertse et al, 2026; https://doi.org/10.3748/wjg.v32.i2.112395.

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INTRODUCTION

For more than two decades, gastroesophageal reflux disease (GERD), Barrett’s esophagus (BE), and esophageal adenocarcinoma (EAC) have been conceptualized through a symptom-driven paradigm[1,2]: Troublesome reflux or regurgitation prompt consultation, BE identification via endoscopy, and surveillance. Yet, this seemingly intuitive cascade is increasingly misaligned with real-world patient behavior and population-level risk dynamics. New population-based data from the Netherlands decisively demonstrate that the very first step - medical consultation for reflux symptoms - is now failing at a structural level.

LIMITATIONS OF THE SYMPTOM-DRIVEN PARADIGM IN BARRETT’S SCREENING

In the study by Huibertse et al[3] published in a recent issue of the World Journal of Gastroenterology, 57.5% of Dutch adults with reflux symptoms had never consulted a physician, and among this large unscreened group, 36.6% regularly used over-the-counter (OTC) acid-suppressive therapy, while 11.1% met current European Society of Gastrointestinal Endoscopy (ESGE) criteria for BE screening[4]. The population-based survey by Huibertse et al[3] provides robust, contemporary evidence on real-world help-seeking and self-management patterns, derived from a large cohort (n = 3214 respondents, of whom 1572 reported reflux symptoms) randomly selected from the national Dutch population registry. This design minimizes selection and referral biases commonly seen in clinic- or endoscopy-based studies, enhances representativeness (particularly for gender), and employs validated instruments for symptom assessment, thereby offering reliable insights applicable to Western European healthcare systems with universal access and strong primary care gatekeeping.

These findings reveal a silent, self-managed, and clinically invisible reflux population - one that is growing, ageing, and increasingly intersecting with Europe’s escalating obesity rates[5]. At the same time, population-level awareness of esophageal cancer symptoms - particularly dysphagia - is alarmingly low[6]. These findings are consistent with observations reported in other populations. A multicenter United States survey of 472 adults older than 50 years with chronic GERD revealed gaps in BE screening[7]. Only 13.2% recalled ever being advised to undergo screening endoscopy, and a mere 5.3% reported having had one. Knowledge was strikingly limited: Two-thirds correctly identified standard risk factors, and only 19.5% believed that patients with longstanding reflux actually require screening. Non-Hispanic Black respondents expressed significantly greater concern about the disease and stronger interest in screening than White participants, yet they reported substantially higher barriers, including access difficulties, cost concerns, transportation issues, mistrust of the healthcare system, fear of the procedure, and perceived discrimination[7]. It should also be mentioned, that complicated GERD is overwhelmingly prominent in the white race, while East Asians in the United States rarely report heartburn and rarely develop severe reflux-related complications[8-10]. Black patients frequently experience heartburn but seldom progress to serious complications. These notable racial differences highlight the limited value of symptom-based screening in non-White populations[8].

Physician- and system-level factors also play a critical role and warrant equal emphasis in explaining the low rates of medical consultation among individuals with reflux symptoms. In resource-limited primary care consultations, systematic assessment of gastroesophageal reflux is commonly abbreviated or overlooked, with clinicians frequently awaiting patient-initiated disclosure of symptoms instead of actively asking for hallmark features (such as heartburn or regurgitation), less obvious manifestations (including chronic nocturnal cough or voice changes), or usage of OTC antacids. This practice often fails to capture patients exhibiting several well-established risk indicators - namely, age exceeding 50 years, male sex, central obesity, or smoking history - despite their presence in routine clinical records[11]. Analyses of primary care practice patterns have revealed marked deficiencies in familiarity with and adherence to BE screening recommendations, leading to infrequent identification and referral of suitable candidates even when opportunities arise during standard visits[11].

Of greater concern, the symptom- based rationale to select patients for Barrett’s screening systematically misses a large proportion of affected individuals[12] - a limitation even more critical in the era of freely available OTC acid suppressants. Emerging data indicate that as many as 60% of Barrett’s cases occur in the absence of GERD symptoms[13,14], a finding that challenges symptom-driven screening strategies. In keeping with two rigorous meta-analyses, the association between reflux symptoms and BE is far weaker than traditionally assumed[15]. Taylor and Rubenstein[12] found that GERD symptoms confer virtually no increased risk of short-segment BE [odds ratio (OR) = 1.15, 95%CI: 0.76-1.73] and only a fivefold risk of long-segment disease (OR = 4.92, 95%CI: 2.01-12.0), while a more recent meta-analysis of 43 studies confirmed that, even in true general-population cohorts, approximately one-third to one-half of all Barrett’s cases occur in individuals who deny heartburn or regurgitation[15]. It should also be underlined that the prevalence of GERD symptoms varies dramatically by geographic region, ranging from as low as 2.5%-7.8% in East Asia to 18.1%-27.8% in North America and up to 33% in parts of the Middle East and South America, even when identical diagnostic criteria are applied[1,16]. This variation further complicates the performance of any symptom-dependent screening strategy.

PERSISTENT GAPS IN RISK-FACTOR-BASED SCREENING

A further complexity arises when observing how various professional societies execute Barrett’s screening across different healthcare settings[4,17]. Although no major guideline advocates population-wide screening, most recommend that endoscopy may be considered for individuals who accumulate several established risk factors, typically including age above 50 years, male sex, white race, chronic GERD symptoms, central obesity, smoking history, and a family history of BE or EAC. This broad consensus is evident across Western societies such as the American College of Gastroenterology (ACG), American Gastroenterological Association (AGA), American Society for Gastrointestinal Endoscopy, British Society of Gastroenterology, Asia Pacific Association of Gastroenterology, and ESGE, despite differences in the number of risk factors required before screening is advised[18]. Multivariate risk stratification in used to set up predictive models for esophageal cancer screening: The seminal tool developed incorporating reflux frequency, age, waist-to-hip ratio, and cumulative smoking exposure, performs substantially better than symptom-based criteria alone[19,20]. Nevertheless, this risk-factor-driven paradigm remains intrinsically constrained by the same symptom-dependent entry point that is already shown to be unreliable[21]. A sizeable proportion of patients who ultimately develop EAC report no prior history of chronic reflux[22,23], and meta-analytic data demonstrate that only a small fraction of individuals with cancer have a documented Barrett’s diagnosis, even though most are found to harbor Barrett’s epithelium at the time of EAC detection[24]. These observations expose a persistent mislinking between the populations targeted by guideline-based screening algorithms and those who actually progress to malignancy.

The experience of Japan provides a compelling counterpoint that illustrates how healthcare system design can fundamentally reshape detection patterns[25]. Owing to the very low incidence of EAC, Japanese guidelines do not recommend Barrett’s screening of any kind. Yet, because upper endoscopy is widely used as part of routine health check-ups aimed at early detection of gastric cancer, large proportions of Barrett’s cases are identified incidentally, and EACs are disproportionately detected at an early, curable stage[25]. This model highlights the potential for high-endoscopy-penetration systems to uncover BE and early neoplasia that would otherwise remain clinically silent. In contrast, Western systems that base screening eligibility on symptomatic GERD plus layered risk factors inadvertently exclude many individuals who are biologically predisposed to malignant progression but do not report or recognize reflux symptoms[21]. The Japanese example therefore underscores a critical insight: Endoscopic opportunity, rather than symptom burden, may ultimately determine whether BE is detected before it evolves into cancer.

REAL-WORLD FAILURES OF BARRETT’S SURVEILLANCE

Even when BE is successfully diagnosed, the subsequent step of endoscopic surveillance is marked by substantial variability in adherence, quality, and outcomes[4,17]. Modern guidelines have become increasingly prescriptive regarding the elements that constitute high-quality surveillance. Both ESGE and ACG emphasize meticulous mucosal inspection with high-definition white-light endoscopy, routine incorporation of electronic or dye-based chromoendoscopy, standardized photographic documentation, and rigorous application of the Seattle biopsy protocol[26].

Substantial evidence indicates that real-world practice falls far short of recommended surveillance standards for BE. Large registry analyses consistently show that many patients do not undergo endoscopy within the guideline-recommended intervals[27]. For example, a systematic review and meta-analysis by Roumans et al[28] that included 56 studies and more than 14000 patients found highly variable and generally poor adherence to surveillance intervals, with adherence rates differing markedly by country, practice setting, and endoscopist experience. Similarly, data from the United States GIQuIC registry published by Kolb et al[29] covering over 20000 endoscopies performed by 572 endoscopists, revealed that appropriate surveillance intervals for non-dysplastic Barrett’s were followed in only 77%-82% of cases, with wide variation between individual endoscopists and sites.

Patients with long-segment BE - those at the highest risk of developing high-grade dysplasia or adenocarcinoma - show the greatest loss to follow-up. Studies have repeatedly shown that the likelihood of non-adherence to the Seattle biopsy protocol increases by approximately 31% for every additional centimeter of Barrett’s length[29,30]. In the same GIQuIC cohort of nearly 59000 procedures, systematic under sampling was common in longer segments because of the greater time and technical demands required for adequate four-quadrant biopsies every 1-2 cm[29]. Earlier community-based work by Abrams et al[31] had already documented Seattle protocol adherence at just 51%, with the lowest rates observed precisely in patients with the longest BE segments taken together, these large-scale registry studies and meta-analyses confirm that the patients who stand to benefit most from rigorous surveillance are paradoxically the least likely to receive it according to guideline standards[32], highlighting a critical quality gap in current clinical practice.

A further critical barrier to effective BE management is the accurate histopathological interpretation of dysplasia[26]. Grading dysplasia, especially distinguishing indefinite changes from true low-grade dysplasia (LGD), demands substantial expertise in gastrointestinal pathology. Both the American College of Gastroenterology 2022 guideline and the British Society of Gastroenterology 2014 guideline - as reaffirmed in the National Institute for Health and Care Excellence 2024-endorsed update - explicitly require that any diagnosis of dysplasia - regardless of grade - be confirmed by at least one, and preferably two, expert gastrointestinal pathologists before irreversible management decisions are made[17,33-35]. For example, a multicenter study of 147 patients with community-diagnosed LGD in BE found that 85% of cases were downgraded to non-dysplastic Barrett’s or indefinite for dysplasia upon expert panel review, with the confirmed LGD subgroup showing a markedly elevated progression risk to high-grade dysplasia or adenocarcinoma (13.4% per year vs 0.49% in downgraded cases)[36]. Similarly, inter-observer agreement among pathologists for LGD remains only fair (κ = 0.31; 95%CI: 0.21-0.42), even when reviewing a patient’s entire set of biopsies, whereas agreement for nondysplastic BE and high-grade dysplasia reaches substantial levels (κ = 0.66 and 0.76, respectively). Collapsing LGD and high-grade into a single "dysplasia-positive" category improves overall agreement to substantial (κ = 0.70), highlighting that challenges often stem from grading severity rather than detecting dysplasia itself[37]. Without systematic access to centralized expert pathology review, many patients are either over-treated (unnecessary ablation) or under-treated (missed progression), markedly diminishing the clinical yield of surveillance programs.

Decentralized BE care remains a major barrier to effective surveillance. Despite ESGE 2023[4], ACG 2022[17], and AGA 2025[30] guidelines mandating that dysplastic BE management and endoscopic therapy occur only in high-volume expert centers (≥ 10-15 ablations/year/endoscopist), most surveillance endoscopies are still performed in low-volume community settings with poor adherence to quality standards. Real-world studies show Seattle biopsy protocol adherence of only 50%-70%, surveillance interval compliance < 60%, and dysplasia detection rates of 4%-7%[38]. A large Dutch prospective trial (n = 1244 nondysplastic BE) demonstrated that clustering procedures on dedicated BE lists performed by interested endoscopists significantly improved biopsy protocol adherence (85% vs 66%; adjusted OR = 4.45, 95%CI: 2.07-9.57) and interval adherence (60% vs 47%; adjusted OR = 1.64, 95%CI: 1.03-2.61). This approach also showed a trend toward fewer EACs (0% vs 1.1%; P = 0.07)[39]. At the primary-care level, the United States SCREEN-BE survey revealed that only 15.5% of primary care providers (vs 75.8% of gastroenterologists) know current screening guidelines, leading to frequent under- and over-screening[38]. These systemic deficits - fragmented care, inconsistent quality, and knowledge gaps - explain why the modest mortality benefit of surveillance in nondysplastic BE[30,40] is rarely realized in routine practice. These interconnected barriers - at patient, physician, system, and epidemiological levels - are summarized in Table 1.

Table 1 Barriers to Barrett’s esophagus screening and mitigation strategies.

Category	Key barriers	Supporting evidence	Potential strategies/mitigations
Patient-related	Under-recognition of reflux significance; symptom masking by long-term OTC acid suppressants; low awareness of cancer risk	57.5% never consulted physician; 36.6% regular OTC use[4]; low awareness of dysphagia as alarm symptom[6]	Public education on reflux-related cancer risk; proactive non-endoscopic screening tools (e.g., Cytosponge-TFF3)
Physician-related	Limited systematic reflux history-taking in primary care; reliance on spontaneous reporting; suboptimal guideline knowledge	Missed opportunities despite multiple risk factors[11]; marked deficiencies in familiarity with screening recommendations[38]	Targeted primary care education; structured reflux questionnaires; integration of risk-prediction models into electronic health records
System-level	Fragmented care pathways; decentralized surveillance in low-volume settings; inconsistent referral to expert centers	Seattle protocol adherence 50%-70%; poor surveillance interval compliance; dysplasia management not centralized[29,38,39]	Dedicated Barrett’s lists; mandatory high-volume centers for dysplastic cases; national quality registries
Epidemiological	Rising central obesity; high proportion of asymptomatic BE; geographic and racial variations in symptom expression	Escalating obesity prevalence[10]; up to 60% of BE cases asymptomatic[13,14]; racial differences in complication rates[8-10]	Population-based risk stratification; broader use of non-symptom-dependent screening approaches

BE: Barrett’s esophagus; OTC: Over-the-counter.

Taken together, these observations indicate that the shortcomings of Barrett’s surveillance no longer stem from uncertainty about what constitutes high-quality care - this is clearly defined - but from the absence of mechanisms to ensure that care is delivered with the rigor, consistency, and specialization required to prevent malignant progression. This results to a surveillance system that is technically sophisticated on paper yet frequently inadequate in practice.

REDEFINING SCREENING AND MANAGEMENT IN REFLUX DISEASE

To overcome the limitations of symptom-driven endoscopy, minimally invasive non-endoscopic screening tools are now ready for large-scale deployment[41,42]. The most clinically mature is the Cytosponge-TFF3 test - a swallowable cell-collection device coupled with a biomarker for intestinal metaplasia[43]. In the pragmatic BEST3 trial conducted across 109 English primary-care practices, adults aged ≥ 50 years taking acid suppressants for ≥ 6 months were randomised to usual care or an offer of Cytosponge-TFF3[44,45]. In the intention-to-treat analysis, offering the test increased the diagnosis of Barrett’s oesophagus tenfold (140 cases vs 13 cases; adjusted rate ratio = 10.6, 95%CI: 6.0-18.8) with nine early curable lesions (four dysplastic BE, five stage I cancers) detected in the intervention arm and none in usual care. Of the 1654 patients who successfully swallowed the device, 95% completed the procedure without sedation in a nurse-led primary-care setting, with > 99% acceptability and only one minor adverse event requiring endoscopic removal[45]. When combined with emerging tools - such as breath-based volatile organic compound analysis, circulating methylated DNA panels, or machine-learning-enhanced risk scores - these approaches enable proactive, office-based triage of high-risk individuals, reserving confirmatory endoscopy for those most likely to benefit[42].

Finally, even the most effective screening programme will only increase the number of patients requiring long-term management of reflux disease, making the persistent underuse of definitive anti-reflux procedures a critical missed opportunity[46]. Up to 40% of patients on PPIs have persistent troublesome symptoms (predominantly regurgitation) despite optimised medical therapy[47,48], yet fewer than 5% are ever referred for surgical evaluation and < 0.1% of the > 10 million Germans with GERD undergo anti-reflux surgery annually[49]. Laparoscopic fundoplication remains the gold standard (80%-90% long-term symptom control), while newer minimally invasive options - magnetic sphincter augmentation (LINX), transoral incisionless fundoplication (TIF), and the RefluxStop device - achieve 70%-90% PPI independence with substantially lower rates of dysphagia and gas-bloat than traditional wraps[45]. Importantly, recent evidence shows that lack of response to PPIs does not predict surgical failure[50]. When reflux is objectively confirmed by pH-impedance testing, surgery significantly outperforms further medical escalation even in truly PPI-refractory patients[50]. Systematic surgical referral after objective documentation of ongoing reflux - rather than continued cycling through ineffective drugs - is therefore essential to close the therapeutic gap and prevent both progression to Barrett’s and unnecessary long-term suffering[46].

Collectively, the convergence of widespread long-term self-medication, escalating obesity rates, persistent gaps in primary-care engagement and surveillance quality, and the multifaceted barriers outlined in Table 1 exposes a structural inadequacy in current passive, physician-dependent models for BE detection and management. A shift toward a more proactive, population-oriented paradigm - integrating enhanced primary-care involvement, non-endoscopic tools, and centralized expert care - is therefore essential to bridge the widening gap between rising risk and timely detection.

CONCLUSION

The population-based survey conducted by Huibertse et al[3] conclusively illustrates limitations of current symptom-driven screening strategies for BE. Among 1572 Dutch adults reporting gastro-esophageal reflux symptoms, 57.5% had never consulted a primary-care physician, 36.6% of this unscreened subgroup regularly used OTC acid-suppressive medication, and 11.1% already met ESGE screening criteria. Long-term self-medication with potent acid suppressants effectively masks the symptoms intended to prompt medical evaluation, while the rise in central obesity - the most powerful modifiable risk factor for erosive esophagitis, BE, and EAC - continues to enlarge the biologically high-risk population across Europe[5]. Compounding this challenge, real-world adherence to BE surveillance guidelines remains suboptimal, particularly in long-segment disease, with persistent gaps in primary-care awareness, histopathological confirmation of dysplasia, and centralisation of care in high-volume centres[29,38,39]. These combined challenges suggest that further refinement of screening approaches may be needed to more effectively identify individuals at risk.