GERD: Endoscopic Assessment

Abstract

Symptom evaluation and endoscopic assessment are the interrelated key components of the diagnostic work up in patients with gastroesophageal reflux symptoms. Symptoms according to the new global definition of gastroesophageal reflux disease (GERD) include esophageal as well as extraesophageal syndromes and syndromes with and without esophageal injury. Symptom assessment needs to be careful and can best be obtained by validated questionnaires, which not only are helpful to direct the diagnosis but are also useful to assess the benefit of therapeutic measures. The endoscopic reports need to include: (a) the description of grade and extension of esophagitis (Los Angeles classification), (b) the description of the extent of columnar lined metaplastic epithelium whether Barrett esophagus or gastric metaplasia only (Prague classification), (c) the location of the gastroesophageal junction from the incisors and whether supradiaphragmatic or infradiaphragmatic, and (d) presence and size of hiatal hernia. Biopsies for histologic assessment are critical for the diagnosis of preneoplastic and neoplastic changes (Barrett eophagus). Moreover, with the application of molecular markers biopsies aid to the diagnosis of GERD. The first question always discussed in every meeting and critically important in the every days clinical life is whether endoscopy at least once in a life time needs to be performed and whether in all patients with gastroesophageal symptoms or if it can be limited to selected patients at risk on the basis of their clinical history. There are good reasons to recommend the endoscopic assessment in those patients who have a symptomatic relapse after a course of successful therapy and those who do not respond to therapy with adequate dosing of proton pump inhibitors. However, there are also good reasons to perform endoscopy already at the first presentation in specialist settings so that a firm diagnosis and distinction between erosive reflux disease and nonerosive reflux disease can be reached and for excluding premalignant or even malignant lesions in the upper gastrointestinal tract. Apart from the important reassurance of patients and doctors endoscopy allows better planning of the dosing of proton pump inhibitor for the initial and long-term therapy. Among issues raised against the frequent use of endoscopy a frequent one is that 70% of patients have no endoscopic abnormalities and, therefore, the clinical impact may be minimal or none. So what to do and how to go around the conflicting interest of scoping versus nonscoping? There are good chances for reconciliation of careful symptom and endoscopical assessment. The correct assignment of nonerosive reflux disease remains a major challenge and endoscopy with its advanced technology can contribute to better characterize this most frequent condition within the spectrum of GERD. The application of molecular markers such as interleukin-8, cyclooxygenase 2, capsaicin receptors, etc. and gene array analysis of the esophageal mucosa offers the chance of identifying inflammation in the esophagus in the absence of mucosal breaks. The methods for reconciliation of endoscopy and clinical assessment are there and the potential for progress in GERD is high, their translation and transfer into clinical practice need to be set in place.