Ultrathin endoscopy without sedation: is this the future of esophagology?

Abstract

The use of endoscopy in patients with gastroesophageal reflux disease (GERD) is constantly evolving. Current guidelines emphasize empiric treatment of patients with symptoms consistent with GERD and reserve endoscopy for those with symptoms suggestive of complications (warning symptoms) and those who have sufficient duration of symptoms to warrant screening for Barrett's esophagus (BE) (1). Although relatively cost-effective, this approach has its limitations. For example, the symptoms of GERD are not nearly as specific as many believe. When GERD symptoms and response to a short course of high dose proton pump inhibitor (PPI) were compared with a gold standard of ambulatory pH testing, the false negative rate was actually quite high (2). In addition, most of the studies used to validate empiric therapy use a full or even increased dose of PPI twice a day for the therapeutic trial (3), whereas clinical practice seems to favor a longer trial of single dose PPI. GERD symptoms do not distinguish between erosive esophagitis and nonerosive disease. It is clear that more severe grades of esophagitis require more complete acid suppression for healing (4), although some experts contend that this information is not necessary to guide therapy (5). It is possible that empiric therapy results in many patients with mild GERD or perhaps without GERD at all being given a course of overly expensive medications. Even more importantly, patients who fail an empiric trial are occasionally subjected to more invasive surgical or endoscopic therapy for GERD without a confirmed diagnosis. Delaying endoscopy until after a course of reflux therapy has been suggested (but not demonstrated in any fully published study) to improve the ability to diagnose BE (6). On the other hand, endoscoping after a course of therapy might actually represent a lost opportunity to confirm the GERD diagnosis (assuming that many patients would have esophagitis on an initial endoscopy that heals when the endoscopy is delayed until after a therapeutic trial). A few patients with typical GERD symptoms might also have other problems, including infectious esophagitis, cardiac disease, and rarely, esophageal malignancies, the diagnosis of which might be delayed if the initial approach is an empiric trial. Finally, there are data from the dyspepsia literature which suggest that many patients with upper GI symptoms have significant anxiety about their diagnosis, including fear of cancer, and that some of that anxiety and anxiety-related impairment of quality of life could be improved with the knowledge of a normal upper endoscopy (7).