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Appropriate Use Criteria for Gastrointestinal Transit Scintigraphy

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Appropriate Use Criteria for Gastrointestinal Transit Scintigraphy NEWSLINE Appropriate Use Criteria for Gastrointestinal Transit Scintigraphy Alan H. Maurer1, Thomas Abell2, Paige Bennett1, Jesus R. Diaz1, Lucinda A. Harris3, William Hasler2, Andrei Iagaru1, Kenneth L. Koch2, Richard W. McCallum, Henry P. Parkman, Satish S.C. Rao, and Mark Tulchinsky4 1Society of Nuclear Medicine and Molecular Imaging; 2American Gastroenterological Association; 3American College of Physicians; and 4American College of Nuclear Medicine From the Newsline editor: Appropriate use criteria (AUC) wireless motility capsules have been introduced (1,2). The are statements that contain indications describing when advantages of scintigraphy for studying GI motility still remain and how often an intervention should be performed under valid despite the long time that has elapsed since the first the optimal combination of scientific evidence, clinical application of a radiolabeled meal to measure gastric emptying judgment, and patient values while avoiding unnecessary (GE). Scintigraphy is noninvasive, does not disturb normal provisions of services. SNMMI is a qualified provider-led physiology, and can provide accurate quantification of the bulk entity under the Medicare Appropriate Use Criteria pro- transit of an orally administered radiolabeled solid or liquid gram for advanced diagnostic imaging, allowing referring meal. Compared with radiographic methods, scintigraphy in- physicians to use SNMMI AUC to fulfill the requirements of volves low radiation exposure of the patient, is quantifiable, the 2014 Protecting Access to Medicare Act. SNMMI follows a and uses commonly ingested foods rather than barium or balanced multidisciplinary approach to guidance development nonphysiological radiopaque markers. by including various stakeholders in the development process. Gastroenterologists and primary care physicians are For background and a detailed explanation of this develop- often faced with a wide range of symptoms in a patient, ment process, see http://www.snmmi.org/ClinicalPractice/ including early satiety, pain, nausea, vomiting, bloating, content.aspx?ItemNumber515665. This Newsline article is diarrhea, constipation, or difficulty passing a bowel move- a summary of the complete text of the AUC, which is avail- ment. GI symptoms in patients often overlap and may or able at www.snmmi.org/auc. may not be associated with meal ingestion. It is difficult to assess whether a patient’s symptoms are due to an under- EXECUTIVE SUMMARY lying structural pathology or are functional. The authors of The appropriate use of scintigraphy for studying gas- this AUC document recognize that management of these trointestinal (GI) motility requires not only an understand- patients is complex and the decision to perform any diag- ing of the normal physiology and pathophysiology of the nostic study must take into consideration the entire patient various disorders that can affect the GI tract but also an presentation. The recommendations in this document do not understanding of the numerous methods and associated preclude the use of other testing. Referring health care pro- technical details of the current clinically available modal- viders should always consider the patient history, physical ities for studying GI motility. Developing recommendations findings, and results of previously acquired tests before using on the appropriate use of GI transit scintigraphy requires GI scintigraphy studies. This AUC document is presented to input from experts in the fields of nuclear medicine, radiol- assist health care practitioners in the appropriate use of GI ogy, and gastroenterology. This document has therefore been scintigraphy in evaluating patients with GI tract symptoms. It prepared with input from representatives with this exper- is not intended to replace good clinical judgment. tise from various professional societies (Appendix A). These As scintigraphy does not provide detailed anatomic experts reviewed the current literature with the methodology images of the GI tract, it is particularly important to make described below and established appropriateness ratings for sure an anatomic cause for the patient’s symptoms has been a wide range of clinical scenarios experienced by patients excluded before assuming that the patient has a nonstructural who have symptoms associated with suspected abnormal primary motility disorder. This is typically performed by GI function. The appropriate use criteria (AUC) delineated in using radiographic imaging or endoscopic methods. this report are intended to assist referring medical practitioners In reviewing the literature on GI transit scintigraphy, it is in the diagnosis and management of patients with symp- apparent that although some studies such as GE and esophageal toms thought to arise from altered GI motility in the esoph- transit have been available for over 50 y, the use of scintigraphy agus, stomach, small bowel, and colon. to image and quantify GI motility continues to undergo mod- ernization and advancement. Methods such as esophageal transit INTRODUCTION scintigraphy (ETS) that were established many years ago have Direct measurement of GI motility is classically performed been replaced in many centers by more advanced manometric by a gastroenterologist by placing a tube or catheter-based techniques, although they remain in limited use in select insti- probe within the GI tract to directly measure pressure changes tutions where there is clinical expertise that is often not avail- within a lumen, electrical signals, or pH. Recently, less invasive able in other institutions. GE studies continue to evolve with Newsline 11N advances that permit simultaneous measurement of other with intact peristalsis but high-amplitude contractions or indices of gastric motility, such as accommodation and antral isolated elevated pressures in the LES (6,7). The use of contractions (3–5). Because of such advancements, this AUC manometry potentially supplemented by ETS for equivo- report may need to be updated as newer and more special- cal manometry results will, in large part, be determined by ized techniques are developed. local expertise and availability. NEWSLINE As with many imaging studies, few multicenter studies Summary of Recommendations have examined clinical outcomes. Our appropriateness rat- Clinical scenarios for esophageal transit (often per- ings are influenced by the clinical experience of the expert formed with gastroesophageal reflux [GER] studies) are panel, which included both imaging specialists and gastro- presented in Table 1. Esophageal manometry, barium swal- enterologists who perform, order, and use these studies in low radiography, and pH monitoring are typically used for the diagnosis and management of patients with a wide range first-line evaluation of patients with suspected esophageal of GI symptoms. dysmotility and GER. Use of ETS is limited by the avail- These AUC recommendations are intended to apply ability of local expertise with experience in the methodol- primarily to adults. Because no well-defined normal values ogy, but, when available, such expertise is most commonly for radiolabeled meals have been established in children used when there are equivocal or nondiagnostic findings (due to concerns about radiation exposure of children in- from first-line studies. volved in research) and because established GI transit proto- cols require development of normal values, this committee GE OF SOLIDS (SOLID NUTRIENT felt that pooled data on normal values in children in the lit- erature were insufficient to confirm the validity of GI transit OR EQUIVALENT) studies in children. Many sites have, however, developed in- Introduction/Background stitutional experience that may be used to validate their local GE studies are usually ordered to confirm or exclude study procedures. whether gastroparesis (delayed GE) is a cause of the patient’s This document may also be useful for nuclear medicine symptoms. Gastroparesis is usually associated with upper GI physicians, radiologists, and technologists, as well as for symptoms, which include nausea (92% of patients), vomiting developers of clinical decision support tools as guidance in (84%), abdominal fullness or distention (75%), and early validating requests for imaging patients with GI tract symp- satiety (60%) (8). Etiologies for gastroparesis include diabe- toms. Radiology benefit managers and other third-party tes; postgastric surgical conditions; infections (especially payers may also use these AUC. It is our intention that the postviral); neuromuscular, autoimmune, and connective tis- AUC be used to help ensure the appropriate ordering of GI sue diseases; and idiopathic disease. motility scintigraphic testing in patients with GI symptoms Patients often do not have well-defined GI symptoms who lack appropriate diagnosis and treatment. and present with concerns about dyspepsia (symptoms of any pain or discomfort thought to originate in the upper GI tract). The goal of diagnosing delayed GE is to identify ESOPHAGEAL TRANSIT SCINTIGRAPHY (ETS) patients who will benefit from a prokinetic drug or other Introduction/Background treatment to alleviate symptoms. A GE study is indicated There are several tests of esophageal motor function. for patients with suspected gastroparesis or dyspepsia after The decision about which diagnostic study to use for esoph- an anatomic cause for symptoms has been excluded. A GE ageal dysmotility depends on the patient’s symptoms. If study may also be indicated in the absence of dyspeptic dysphagia is present, a barium swallow or endoscopy
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