COMMENTARY

When Should Endoscopy Be Done in the Patient With Reflux?

M. Brian Fennerty, MD

Disclosures

March 10, 2003

In This Article

Endoscopy for the Diagnosis of GERD

The diagnosis of GERD should, in most circumstances, be made on the basis of the presentation of a patient with typical symptoms of heartburn and/or regurgitation.[1] Using esophageal pH monitoring as a gold standard, the specificity of daily heartburn is estimated at 70% to 80%, and the specificity of daily regurgitation at 80% to 95%, for the diagnosis of GERD. Therefore, PCPs should be on "equal footing" with gastroenterologists in their ability to evaluate for these symptoms and make the diagnosis of GERD. Despite this observation, patients are often still referred for an endoscopic examination as part of the initial evaluation of their GERD symptoms. Why does this occur?

The older medical literature often gave the impression that referral for endoscopy was necessary for a definitive diagnosis of GERD. This suggestion was in part perpetuated by early clinical trials of new therapies for GERD that routinely required endoscopy be done to provide an objective criterion (ie, esophagitis) for documenting the presence of reflux disease in order for a patient to be included in these studies. Healing of esophagitis, as determined by endoscopy, was also often used in these trials as the primary end point of the therapy being evaluated. The latter in turn led to a proliferation of objective rating scales of esophagitis, such as the Hetzel-Dent, Savary-Miller, and Los Angeles classifications, to assess the severity of esophagitis. Over time, esophagitis became synonymous with GERD, despite the fact that most patients with GERD did not have esophagitis. This misconception led many PCPs to begin referring patients with GERD for diagnostic endoscopy to document esophagitis (ie, to diagnose GERD), when in reality, endoscopy is probably the least sensitive of our diagnostic tests for this disorder (the clinical history, results of a trial of therapy with a PPI, and ambulatory esophageal pH monitoring all have a sensitivity of approximately 80% vs endoscopy's sensitivity of only 50% in this setting).

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