COMMENTARY

When Should Endoscopy Be Done in the Patient With Reflux?

M. Brian Fennerty, MD

Disclosures

March 10, 2003

In This Article

What Are the Indications for Early Endoscopy in a Patient With Suspected GERD?

When evaluating a patient with suspected GERD, the presenting symptom derived from the clinical history is perhaps the most reliable parameter for making a diagnosis of GERD, as discussed above. In addition to the symptoms of heartburn and regurgitation, other important factors in the history that support a diagnosis of GERD are the temporal relation of symptoms to meals, aggravation of symptoms when lying down, and relief of symptoms with use of antisecretory agents.[1,5,6] For a patient presenting in this fashion, no further diagnostic evaluation is warranted and therapy for GERD can be instituted. However, prompt referral for endoscopic examination is indicated in patients who present with or later develop alarm symptoms, such as dysphagia, odynophagia, anemia, or weight loss. The presence of these so-called "alarm" symptoms may indicate serious complications of GERD or the presence of other serious upper gastrointestinal pathology (ie, ulcer disease, peptic stricture, or malignancy).[1,5,6] Conversely, in the absence of alarm symptoms, forgoing early endoscopy in favor of an empirical pharmacologic treatment approach is unlikely to result in missing much clinically serious upper gastrointestinal pathology.

Referral for endoscopy or other diagnostic tests for GERD is still recommended for patients who continue to be symptomatic despite appropriate trials of potent antisecretory medical therapy (although pH monitoring may be a better test vs endoscopy in this situation), or for patients with erosive esophagitis and/or strictures on an initial endoscopic exam who will need follow-up to evaluate for underlying Barrett's esophagus that may have been missed on the initial exam (ie, because the presence of mucosal erosions/ulcerations may have obscured the identification of underlying Barrett's disease).

Screening for Barrett's esophagus in patients with GERD who are at an increased risk for development of this lesion (ie, those individuals with GERD symptoms of greater than 5 years' duration, especially among white men) has been recommended by many authorities.[3] Unfortunately, there is little evidence at this time to indicate that screening for Barrett's esophagus results in the prevention of Barrett's-related esophageal cancer. Indeed, some experts have begun to question the validity of the recommendation for screening all patients with chronic GERD for Barrett's esophagus.[4] However, performing surveillance endoscopy in patients found to have Barrett's esophagus through an endoscopic screening program has been associated with detection of early-stage, curable cancer and improved survival.

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