Endoscopic Classification of Gastro-esophageal Reflux Disease

Abstract

Endoscopy has gained a major role in the diagnostic workup and long-term follow-up of patients with gastro-esophageal reflux disease (GERD). In a quite unique way, it allows the physician to inspect the mucosa of the upper gastrointestinal tract, thereby enabling him to identify and classify the typical reflux-induced lesions. Furthermore, it lets him detect conditions that might predispose the patient to gastro-esophageal reflux or might be an alternative explanation for the symptoms. Only through endoscopic examination biopsies can be taken to further study mucosa pathology. The finding of reflux esophagitis in a patient with typical reflux-induced symptoms is for most purposes an adequate basis for making the diagnosis of GERD. Well-informed patients are aware of the importance of their physician having actually seen and evaluated the diseased mucosa for premalignant changes and other abnormalities. The disease spectrum of GERD is immense and includes at one extreme patients with purely symptomatic disease, with no endoscopically visible abnormalities, but at the other extreme patients with severe endoscopic changes, with a potential for developing complications. The potential of endoscopy to discriminate between mild and severe disease is based on the relative stability of the course of the disease. In the majority of patients, endoscopy shows its maximum severity at the time of the first endoscopic examination. Less than 20% develop more severe reflux esophagitis with time1. After 5 years of symptomatic disease, the condition is usually very stable. The role of endoscopy in GERD also seems to vary between countries. The reason for this may be historic and is linked to workup and management in dyspeptic patients in general. In most patients with dyspeptic symptoms, symptom evaluation alone is quite insufficient for making a firm diagnosis. Therefore, even patients with typical symptoms of gastroesophageal reflux are examined with endoscopy to rule out other disease, such as peptic ulcer disease and cancer. In patients with heartburn as the predominant gastrointestinal symptom, other pathology is found only infrequently and presumably less frequently as peptic ulcer disease and gastric cancer are becoming less prevalent. In a recent study of 573 patients with heartburn as main symptom, only 20 patients (3%) had peptic ulcers and no patient had cancer. This speaks against routinely doing upper endoscopy in patients strongly suspected of having GERD, due to limited diagnostic gain and some discomfort for the patient. Nevertheless, endoscopy should be performed routinely in patients above the age of 40–50 and in patients with weight loss or dysphagia, as the possibility of cancer is clearly higher2. Therefore, endoscopy should still be the basis for diagnosis in most GERD patients. The increase in the incidence of Barrett’s esophagus and esophageal and proximal gastric adenocarcinoma should lead to more frequent use of early endoscopy, possibly a “once in a lifetime” endoscopy that may detect metaplasia at an early stage and constitute a basis for the long-term management of the individual patient. As will be discussed later, it can be difficult to detect metaplasia in an area of extensive reflux esophagitis. In this setting, the option for taking biopsies is unique for endoscopy, which although of disputed importance in uncomplicated GERD, is very important once a stricture or possible metaplasia is encountered.