Endoscopy of the esophagus in gastroesophageal reflux disease: are we losing sight of symptoms? Another perspective

Abstract

Gastroesophageal reflux disease (GERD) is an extremely common chronic disorder associated with impaired quality of life and huge economic burden. Recently, an International Consensus Group developed a global definition of GERD (The Montreal Definition): a condition that develops when the reflux of stomach contents causes troublesome symptoms and/or complications. The traditional endoscopy-based classification of GERD patients into one of three groups - non-erosive reflux disease, erosive esophagitis, and Barrett's esophagus - is fraught with several limitations. Due to the lack of a gold standard, GERD is a symptom-based diagnosis, and hence symptom evaluation will remain the primary means by which treatment decisions are made for patients with suspected GERD. We propose that patients reporting the predominant GERD-like symptoms (GERS) in the primary care setting be classified based upon their response to an empiric trial of acid suppressive therapy: complete response to acid suppressive therapy, partial response to acid suppressive therapy, and no response to acid suppressive therapy. Given the limitations of objective medical testing, implementation of our proposed new symptom-based classification of patients with GERS would guide primary care physicians on when to refer patients to a gastroenterologist, which in turn could help in better resource utilization. Validation of this proposed classification by well-designed prospective multicenter studies is awaited.

Reflux and sex

“…However, these results should be seen in the context of an emerging consensus that de-emphasizes the utility of endoscopy or other invasive testing in the diagnosis of reflux disease [8,320]. The resulting guidelines were published about 5 years ago and may thus not be reflected in reports of diagnostic approaches that cover a longer time period.…”

“…Alternative tests, such as ambulatory pH studies, similarly have relatively low sensitivity and specificity [5][6][7]. Five years ago, a consensus conference thus concluded that 'GER[D] is a symptom-based diagnosis, and hence symptom evaluation will remain the primary means by which treatment decisions are made for patients with suspected GER[D]' [8]. However, diagnostic testing remains a common and even increasing practice [9][10][11].…”

Evolving issues in the management of reflux disease?

“…When symptoms persist, the PPI can be stopped for 1 week after which esophagogastroduodenoscopy, 24 h esophageal and gastric pH metry and Helicobacter pylori testing are performed to confirm erosive esophagitis or NERD. Although endoscopy with biopsy is probably the best diagnostic method, endoscopy for all patients is impractical and a symptom-based approach to patients with predominant GERD-like symptoms has been proposed [63]. In patients not responding to a PPI (correctly used), it is important to question whether they should be on or off a PPI for 24 h pH metry.…”

Endoscopic Therapies for Gastroesophageal Reflux Disease: Back in the Game?

“…[17][18][19][20][21] Acid, weakly acidic reflux, and visceral hypersensitivity all cause heartburn, but do not respond in the same way to acid-reducing therapies. Extra-esophageal symptoms of GERD do not respond with the same regularity to PPIs and surgery as heartburn.…”