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The role of endoscopy in the management of GERD

Published:April 08, 2015DOI:https://doi.org/10.1016/j.gie.2015.02.021

      Abbreviations:

      BE (Barrett’s esophagus), PPI (proton pump inhibitor), TIF (transoral incisionless fundoplication)
      This is one of a series of statements discussing the use of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. In preparing this guideline, a search of the medical literature from January 1990 to August 2014 was performed by using PubMed. Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When limited or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts. Guidelines for appropriate use of endoscopy are based on a critical review of the available data and expert consensus at the time the guidelines are drafted. Further controlled clinical studies may be needed to clarify aspects of this guideline. This guideline may be revised as necessary to account for changes in technology, new data, or other aspects of clinical practice. The recommendations were based on reviewed studies and were graded on the strength of the supporting evidence (Table 1).
      • Guyatt G.H.
      • Oxman A.D.
      • Vist G.E.
      • et al.
      GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.
      Table 1GRADE system for rating the quality of evidence for guidelines
      Adapted from Guyatt et al.
      • Guyatt G.H.
      • Oxman A.D.
      • Vist G.E.
      • et al.
      GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.
      Quality of evidenceDefinitionSymbol
      High qualityFurther research is very unlikely to change our confidence in the estimate of effect.⊕⊕⊕⊕
      Moderate qualityFurther research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.⊕⊕⊕○
      Low qualityFurther research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.⊕⊕○○
      Very low qualityAny estimate of effect is very uncertain.⊕○○○
      This guideline is intended to be an educational device to provide information that may assist endoscopists in providing care to patients. This guideline is not a rule and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment. Clinical decisions in any particular case involve a complex analysis of the patient’s condition and available courses of action. Therefore, clinical considerations may lead an endoscopist to take a course of action that varies from these guidelines. This guideline replaces our previous document on the role of endoscopy in GERD.
      • Lichtenstein D.R.
      • Cash B.D.
      • Davila R.
      • et al.
      Role of endoscopy in the management of GERD.
      GERD is a condition that develops when reflux of stomach contents causes troublesome symptoms (eg, heartburn and regurgitation) or adverse events (eg, erosive esophagitis).
      • Vakil N.
      • van Zanten S.V.
      • Kahrilas P.
      • et al.
      The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus.
      • DeVault K.R.
      • Castell D.O.
      Updated guidelines for the diagnosis and treatment of gastroesophageal reflux disease.
      • Jones R.
      • Galmiche J.P.
      Review: what do we mean by GERD?–definition and diagnosis.
      In a recent systematic review, the prevalence of GERD in the United States was estimated to be 18% to 28%, when GERD was defined as at least weekly heartburn and/or acid regurgitation.
      • El-Serag H.B.
      • Sweet S.
      • Winchester C.C.
      • et al.
      Update on the epidemiology of gastro-oesophageal reflux disease: a systematic review.
      Outpatient visits for the evaluation of GERD have increased significantly over time.
      • Friedenberg F.K.
      • Hanlon A.
      • Vanar V.
      • et al.
      Trends in gastroesophageal reflux disease as measured by the National Ambulatory Medical Care Survey.
      It is also the most common indication for EGD in the United States.
      • Peery A.F.
      • Dellon E.S.
      • Lund J.
      • et al.
      Burden of gastrointestinal disease in the United States: 2012 update.
      In addition to its impact on quality of life,
      • Becher A.
      • El-Serag H.
      Systematic review: the association between symptomatic response to proton pump inhibitors and health-related quality of life in patients with gastro-oesophageal reflux disease.
      the numerous adverse events of chronic GERD, such as esophageal stricture formation, Barrett’s metaplasia, and esophageal adenocarcinoma, necessitate adequate diagnosis and treatment of this common entity.

      Indications for endoscopic evaluation

      A diagnosis of GERD can be made based on symptoms
      • Vakil N.
      • van Zanten S.V.
      • Kahrilas P.
      • et al.
      The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus.
      and confirmed by a favorable response to antisecretory medical therapy.
      • Vakil N.
      • van Zanten S.V.
      • Kahrilas P.
      • et al.
      The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus.
      • Katz P.O.
      • Gerson L.B.
      • Vela M.F.
      Guidelines for the diagnosis and management of gastroesophageal reflux disease.
      • Numans M.E.
      • Lau J.
      • de Wit N.J.
      • et al.
      Short-term treatment with proton-pump inhibitors as a test for gastroesophageal reflux disease: a meta-analysis of diagnostic test characteristics.
      It is important to note that epigastric pain can be the major symptom of GERD.
      • Vakil N.
      • van Zanten S.V.
      • Kahrilas P.
      • et al.
      The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus.
      If the patient’s history is consistent with typical or uncomplicated GERD, an initial trial of empiric medical therapy is appropriate before consideration of endoscopy in most patients.
      • Venables T.L.
      • Newland R.D.
      • Patel A.C.
      • et al.
      Omeprazole 10 milligrams once daily, omeprazole 20 milligrams once daily, or ranitidine 150 milligrams twice daily, evaluated as initial therapy for the relief of symptoms of gastro-oesophageal reflux disease in general practice.
      Endoscopy at presentation should be considered in patients who have symptoms suggestive of complicated disease (eg, dysphagia, unintentional weight loss, hematemesis) or those with multiple risk factors for Barrett’s esophagus (BE).
      • Lundell L.R.
      • Dent J.
      • Bennett J.R.
      • et al.
      Endoscopic assessment of oesophagitis: clinical and functional correlates and further validation of the Los Angeles classification.
      • Wo J.M.
      • Mendez C.
      • Harrell S.
      • et al.
      Clinical impact of upper endoscopy in the management of patients with gastroesophageal reflux disease.
      • Lieberman D.A.
      • Oehlke M.
      • Helfand M.
      Risk factors for Barrett's esophagus in community-based practice. GORGE consortium. Gastroenterology Outcomes Research Group in Endoscopy.
      • Shaheen N.J.
      • Weinberg D.S.
      • Denberg T.D.
      • et al.
      Upper endoscopy for gastroesophageal reflux disease: best practice advice from the clinical guidelines committee of the American College of Physicians.
      • Evans J.A.
      • Early D.S.
      • Fukami N.
      • et al.
      The role of endoscopy in Barrett's esophagus and other premalignanct conditions of the esophagus.
      Risk factors for BE include older than 50 years of age, male sex, white race, a family history of BE or esophageal adenocarcinoma, prolonged reflux symptoms, smoking, and obesity.
      • Evans J.A.
      • Early D.S.
      • Fukami N.
      • et al.
      The role of endoscopy in Barrett's esophagus and other premalignanct conditions of the esophagus.
      In addition, failure to respond to appropriate antisecretory medical therapy should prompt evaluation with EGD and consideration of other diagnostic modalities, including ambulatory pH monitoring, esophageal manometry, and/or multichannel impedance testing.
      • Fock K.M.
      • Talley N.
      • Hunt R.
      • et al.
      Report of the Asia-Pacific consensus on the management of gastroesophageal reflux disease.
      The indications for EGD in patients with GERD are listed in Table 2. EGD may be necessary to detect erosive esophagitis, peptic strictures, esophageal cancer, gastric outlet obstruction, and other potentially significant upper GI tract findings. Additionally, EGD is often performed as part of the preoperative evaluation of patients being considered for antireflux surgery or for the placement of wireless esophageal pH monitoring devices
      • Chotiprashidi P.
      • Liu J.
      • Carpenter S.
      • et al.
      ASGE Technology Status Evaluation Report: wireless esophageal pH monitoring system.
      and is an inherent part of various endoscopic antireflux procedures. Endoscopy is often performed in the evaluation of patients with suspected extraesophageal manifestations of GERD who present with symptoms such as choking, coughing, hoarseness, asthma, laryngitis, chronic sore throat, or dental erosions.
      • Poelmans J.
      • Feenstra L.
      • Demedts I.
      • et al.
      The yield of upper gastrointestinal endoscopy in patients with suspected reflux-related chronic ear, nose, and throat symptoms.
      Given that the majority of these patients will not have endoscopic evidence of erosive esophagitis, especially when taking empiric medical therapy for GERD, the routine use of EGD to evaluate extraesophageal symptoms of GERD is not recommended.
      • Richter J.E.
      Extraesophageal presentations of gastroesophageal reflux disease.
      • El-Serag H.B.
      • Lee P.
      • Buchner A.
      • et al.
      Lansoprazole treatment of patients with chronic idiopathic laryngitis: a placebo-controlled trial.
      • Koufman J.A.
      Laryngopharyngeal reflux is different from classic gastroesophageal reflux disease.
      • Koufman J.A.
      • Belafsky P.C.
      • Bach K.K.
      • et al.
      Prevalence of esophagitis in patients with pH-documented laryngopharyngeal reflux.
      • Gralnek I.M.
      • Dulai G.S.
      • Fennerty M.B.
      • et al.
      Esomeprazole versus other proton pump inhibitors in erosive esophagitis: a meta-analysis of randomized clinical trials.
      • Ronkainen J.
      • Aro P.
      • Storskrubb T.
      • et al.
      High prevalence of gastroesophageal reflux symptoms and esophagitis with or without symptoms in the general adult Swedish population: a Kalixanda study report.
      Evidence is also lacking to support the routine use of EGD in patients with uncomplicated GERD who are responsive to medical therapy. There is a paucity of outcomes research to suggest that early or even once-in-a-lifetime EGD has a favorable effect on the management, course, or health-related quality of life of patients with typical symptoms of GERD without alarm features (dysphagia, odynophagia, weight loss, bleeding, or anemia).
      • Katz P.O.
      • Gerson L.B.
      • Vela M.F.
      Guidelines for the diagnosis and management of gastroesophageal reflux disease.
      Table 2Indications for endoscopy in patients with GERD
      GERD symptoms that are persistent or progressive despite appropriate medical therapy
      Dysphagia or odynophagia
      Involuntary weight loss >5%
      Evidence of GI bleeding or anemia
      Finding of a mass, stricture, or ulcer on imaging studies
      Screening for Barrett’s esophagus in selected patients (as clinically indicated)
      Persistent vomiting (7-10 days)
      Evaluation of patients before or with recurrent symptoms after endoscopic or surgical antireflux procedures
      Placement of wireless pH monitoring

      Diagnosis and classification of GERD induced esophageal inflammation

      Patients with reflux esophagitis have endoscopic and/or histopathologic changes of esophageal mucosal injury and inflammation. The presence of typical findings of reflux esophagitis on EGD such as erythema, erosions, ulceration, peptic strictures, and BE is diagnostic of GERD with a specificity as high as 95%.
      • Moayyedi P.
      • Talley N.J.
      Gastro-oesophageal reflux disease.
      • Richter J.E.
      Diagnostic tests for gastroesophageal reflux disease.
      However, at least 50% of patients with reflux symptoms have normal esophageal endoscopic findings (nonerosive reflux disease) or uncomplicated GERD.
      • Vakil N.
      • van Zanten S.V.
      • Kahrilas P.
      • et al.
      The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus.
      • Ronkainen J.
      • Aro P.
      • Storskrubb T.
      • et al.
      High prevalence of gastroesophageal reflux symptoms and esophagitis with or without symptoms in the general adult Swedish population: a Kalixanda study report.
      In addition, dyspepsia is a diagnosis often confused with GERD. Furthermore, the severity of GERD symptoms does not correlate with the degree of underlying esophageal damage, supporting current recommendations to initiate empiric antisecretory therapy in patients with typical GERD symptoms in the absence of alarm features.
      • Katz P.O.
      • Gerson L.B.
      • Vela M.F.
      Guidelines for the diagnosis and management of gastroesophageal reflux disease.
      • Kahrilas P.J.
      • Shaheen N.J.
      • Vaezi M.F.
      • et al.
      American Gastroenterological Association Medical Position Statement on the management of gastroesophageal reflux disease.
      There are several classification systems for grading the endoscopic severity of erosive reflux esophagitis and associated adverse events.
      • Rath H.C.
      • Timmer A.
      • Kunkel C.
      • et al.
      Comparison of interobserver agreement for different scoring systems for reflux esophagitis: impact of level of experience.
      These classification systems have been primarily used in clinical trials to study the efficacy of medical therapy of reflux esophagitis. However, these systems are useful in clinical practice for documenting disease severity. Currently, the most commonly used systems are the Los Angeles classification and the Savary-Miller classification (Table 3). The Los Angeles classification has been shown to be reliable, with good intra- and interobserver agreement when tested among expert and inexperienced endoscopists.
      • Lundell L.R.
      • Dent J.
      • Bennett J.R.
      • et al.
      Endoscopic assessment of oesophagitis: clinical and functional correlates and further validation of the Los Angeles classification.
      • Rath H.C.
      • Timmer A.
      • Kunkel C.
      • et al.
      Comparison of interobserver agreement for different scoring systems for reflux esophagitis: impact of level of experience.
      When using this system, the severity of esophagitis has been demonstrated to correlate with the extent of esophageal acid exposure determined by 24-hour pH monitoring.
      • Kahrilas P.J.
      • Pandolfino J.E.
      Review article: oesophageal pH monitoring–technologies, interpretation and correlation with clinical outcomes.
      Table 3The Los Angeles and Savary-Miller classifications of esophagitis
      ClassificationGradeDescription
      Los AngelesAOne (or more) mucosal break no longer than 5 mm that does not extend between the tops of 2 mucosal folds
      BOne (or more) mucosal break >5 mm that does not extend between the tops of 2 mucosal folds
      COne (or more) mucosal break that is continuous between the tops of ≥2 mucosal folds but that involves <75% of the circumference
      DOne (or more) mucosal break that involves at least 75% of the esophageal circumference
      Savary-Miller1Single erosion above the gastroesophageal mucosal junction
      2Multiple, noncircumferential erosions above the gastroesophageal mucosal junction
      3Circumferential erosion above the mucosal junction
      4Chronic change with esophageal ulceration and associated stricture
      5Barrett's esophagus with histologically confirmed intestinal differentiation within the columnar epithelium.
      When esophagitis is encountered endoscopically, tissue samples of the esophageal mucosa should be obtained under the following circumstances: underlying immunocompromised state, the presence of irregular or deep ulceration, proximal distribution of esophagitis, the presence of an esophageal mass lesion or nodularity, bullous changes suggestive of esophageal pemphigus vulgaris, visible changes of eosinophilic esophagitis (rings, linear furrows, white plaques, fragile mucosa), changes of esophageal dessicans superficialis, or an irregular or malignant-appearing esophageal stricture. In these situations, forceps tissue samples and/or brush cytology specimens are necessary to exclude other diagnoses, including infectious etiologies and malignancy. Tissue sampling has also been recommended in patients with dysphagia without evidence of erosive esophagitis to evaluate for eosinophilic esophagitis.
      • Kahrilas P.J.
      • Shaheen N.J.
      • Vaezi M.F.
      • et al.
      American Gastroenterological Association Medical Position Statement on the management of gastroesophageal reflux disease.
      However, routine sampling of the esophagus or gastroesophageal junction in patients with heartburn and a normal findings on endoscopy are not recommended.
      • Takubo K.
      • Honma N.
      • Aryal G.
      • et al.
      Is there a set of histologic changes that are invariably reflux associated?.
      Historically, follow-up EGD for patients with GERD and esophagitis has been reserved for patients whose symptoms fail to respond to medical therapy, those who had severe esophagitis or an esophageal ulcer, or those who needed additional biopsies to clarify a diagnosis such as BE or BE-associated dysplasia because the presence of erosive esophagitis may impair the accurate histopathologic detection of BE and dysplasia.
      • Takubo K.
      • Honma N.
      • Aryal G.
      • et al.
      Is there a set of histologic changes that are invariably reflux associated?.
      • Hanna S.
      • Rastogi A.
      • Weston A.P.
      • et al.
      Detection of Barrett's esophagus after endoscopic healing of erosive esophagitis.
      Multiple trials have demonstrated that 8 weeks of proton pump inhibitor (PPI) treatment is adequate to achieve mucosal healing in most patients with erosive esophagitis due to GERD.
      • Castell D.O.
      • Kahrilas P.J.
      • Richter J.E.
      • et al.
      Esomeprazole (40 mg) compared with lansoprazole (30 mg) in the treatment of erosive esophagitis.
      • Richter J.E.
      • Kahrilas P.J.
      • Sontag S.J.
      • et al.
      Comparing lansoprazole and omeprazole in onset of heartburn relief: results of a randomized, controlled trial in erosive esophagitis patients.
      • Labenz J.
      • Armstrong D.
      • Lauritsen K.
      • et al.
      Esomeprazole 20 mg vs. pantoprazole 20 mg for maintenance therapy of healed erosive oesophagitis: results from the EXPO study.
      Upon healing of erosive esophagitis, BE can be identified in as many as 12% of these patients.
      • Takubo K.
      • Honma N.
      • Aryal G.
      • et al.
      Is there a set of histologic changes that are invariably reflux associated?.
      • Rodriguez S.
      • Mattek N.
      • Lieberman D.
      • et al.
      Barrett's esophagus on repeat endoscopy: should we look more than once?.
      • Modiano N.
      • Gerson L.B.
      Risk factors for the detection of Barrett's esophagus in patients with erosive esophagitis.

      Adverse events of GERD

      Peptic strictures

      The endoscopic evaluation and management of peptic strictures is discussed in another ASGE guideline.
      • Pasha S.F.
      • Acosta R.D.
      • Chandrasekhara V.
      • et al.
      The role of endoscopy in the evaluation and management of dysphagia.

      Barrett’s esophagus

      BE is a premalignant condition in which the squamous epithelium of the distal esophagus is replaced by an abnormal columnar epithelium known as specialized intestinal metaplasia.
      • Spechler S.J.
      Barrett esophagus and risk of esophageal cancer: a clinical review.
      • Spechler S.J.
      • Sharma P.
      • Souza R.F.
      • et al.
      American Gastroenterological Association medical position statement on the management of Barrett's esophagus.
      BE is found in as many as 15% of patients undergoing EGD for GERD.
      • Wani S.
      • Sharma P.
      The rationale for screening and surveillance of Barrett's metaplasia.
      • Westhoff B.
      • Brotze S.
      • Weston A.
      • et al.
      The frequency of Barrett's esophagus in high-risk patients with chronic GERD.
      Recommendations regarding the role of EGD for screening and surveillance for BE were recently published.
      • Evans J.A.
      • Early D.S.
      • Fukami N.
      • et al.
      The role of endoscopy in Barrett's esophagus and other premalignanct conditions of the esophagus.
      The value and optimal method of screening for BE remains unclear.
      • Evans J.A.
      • Early D.S.
      • Fukami N.
      • et al.
      The role of endoscopy in Barrett's esophagus and other premalignanct conditions of the esophagus.
      Widespread screening of the entire population with GERD would not be feasible given both the high prevalence of GERD in the Western world and the presence of many asymptomatic individuals harboring BE.
      • Gerson L.B.
      • Groeneveld P.W.
      • Triadafilopoulos G.
      Cost-effectiveness model of endoscopic screening and surveillance in patients with gastroesophageal reflux disease.
      • Rex D.K.
      • Cummings O.W.
      • Shaw M.
      • et al.
      Screening for Barrett's esophagus in colonoscopy patients with and without heartburn.
      However, several factors associated with BE may facilitate the selection of at-risk individuals for screening EGD. These include white race, male sex, older age (older than 50 years of age), prolonged GERD symptoms (>5 years), a family history of BE and/or adenocarcinoma of the esophagus, nocturnal reflux symptoms, hiatal hernia, increased body mass index (BMI ≥25 kg/m2), tobacco use, and intra-abdominal distribution of fat.
      • Katz P.O.
      • Gerson L.B.
      • Vela M.F.
      Guidelines for the diagnosis and management of gastroesophageal reflux disease.
      • Shaheen N.J.
      • Weinberg D.S.
      • Denberg T.D.
      • et al.
      Upper endoscopy for gastroesophageal reflux disease: best practice advice from the clinical guidelines committee of the American College of Physicians.
      • Evans J.A.
      • Early D.S.
      • Fukami N.
      • et al.
      The role of endoscopy in Barrett's esophagus and other premalignanct conditions of the esophagus.
      • Rubenstein J.H.
      • Morgenstern J.
      • Appelman H.
      • et al.
      Prediction of Barrett's esophagus among men.
      • Kamat P.
      • Wen S.
      • Morris J.
      • et al.
      Exploring the association between elevated body mass index and Barrett's esophagus: a systematic review and meta-analysis.
      The ASGE suggests that endoscopic screening for BE be considered in select patients with multiple risk factors for BE and esophageal adenocarcinoma, but patients should be informed that there is insufficient evidence to affirm that this practice prevents cancer or prolongs life.
      • Evans J.A.
      • Early D.S.
      • Fukami N.
      • et al.
      The role of endoscopy in Barrett's esophagus and other premalignanct conditions of the esophagus.
      Given the high costs of endoscopy and limitations of using GERD symptoms to screen for BE, alternative screening methods have been sought.
      Endoscopy with tissue sampling is the most accurate tool for the detection and diagnosis of BE. To determine the presence of BE endoscopically, the squamocolumnar and gastroesophageal junctions must be clearly identified. Although proximal displacement of the squamocolumnar junction relative to the gastroesophageal junction is suggestive of BE, the endoscopic appearance of salmon-colored mucosa or an irregular Z line, either alone or in combination, is not sufficient to establish the diagnosis.
      • Spechler S.J.
      Barrett esophagus and risk of esophageal cancer: a clinical review.
      Esophageal tissue specimens should always be obtained for histopathologic confirmation of columnar epithelium when BE is suspected. The optimal number of tissue samples necessary to identify intestinal metaplasia is not known, but it is generally accepted that multiple biopsy specimens should be obtained in all areas of suspected BE.
      • Sharma P.
      • McQuaid K.
      • Dent J.
      • et al.
      A critical review of the diagnosis and management of Barrett's esophagus: the AGA Chicago Workshop.
      • Sharaf R.N.
      • Shergill A.K.
      • Odze R.D.
      • et al.
      Endoscopic mucosal tissue sampling.
      Care should be taken to avoid obtaining specimens from a normal-appearing squamocolumnar junction or from the proximal cardia because tissue samples from these areas may demonstrate intestinal metaplasia and provide a false diagnosis of BE.
      • Sharaf R.N.
      • Shergill A.K.
      • Odze R.D.
      • et al.
      Endoscopic mucosal tissue sampling.
      • Spechler S.J.
      • Zeroogian J.M.
      • Antonioli D.A.
      • et al.
      Prevalence of metaplasia at the gastro-oesophageal junction.
      • Hirota W.K.
      • Loughney T.M.
      • Lazas D.J.
      • et al.
      Specialized intestinal metaplasia, dysplasia, and cancer of the esophagus and esophagogastric junction: prevalence and clinical data.
      Patients with a negative screening EGD for BE do not need follow-up endoscopy because only 1.8% of such patients were found to have BE on repeat EGD performed within 5 years.
      • Rodriguez S.
      • Mattek N.
      • Lieberman D.
      • et al.
      Barrett's esophagus on repeat endoscopy: should we look more than once?.

      Endoluminal antireflux procedures

      Endoluminal therapies for GERD have been used for more than a decade. The techniques used have included delivery of thermal energy intended to constrict the lower esophageal sphincter, intramural injection of bulking agents to augment lower esophageal sphincter pressures, and mechanical alterations of the gastroesophageal junction to mimic results achieved with surgical fundoplication.
      • Louis H.
      • Devière J.
      Ensocopic-endoluminal therapies. A critical appraisal.
      • Yew K.C.
      • Chuah S.K.
      Antireflux endoluminal therapies: past and present.
      • Auyang E.D.
      • Carter P.
      • Rauth T.
      • et al.
      SAGES clinical spotlight review: endoluminal treatments for gastroesophageal reflux disease (GERD).
      • Falk G.W.
      • Fennerty M.B.
      • Rothstein R.I.
      AGA Institute technical review on the use of endoscopic therapy for gastroesophageal reflux disease.
      Several devices and/or techniques have been abandoned due to a lack of efficacy or durability or for safety reasons. Currently, there are 2 endoluminal GERD therapies used in the United States: the Stretta procedure (Mederi Therapeutics, Greenwich, Conn) and transoral incisionless fundoplication (TIF) (Endogastric Solutions, Redmond, Wash).
      • Auyang E.D.
      • Carter P.
      • Rauth T.
      • et al.
      SAGES clinical spotlight review: endoluminal treatments for gastroesophageal reflux disease (GERD).
      The Stretta procedure received initial U.S. Food and Drug Administration approval in 2000. This technique uses radiofrequency energy delivery to the distal esophagus and appears to reduce GERD by decreasing tissue compliance and reducing transient lower esophageal relaxations.
      • Auyang E.D.
      • Carter P.
      • Rauth T.
      • et al.
      SAGES clinical spotlight review: endoluminal treatments for gastroesophageal reflux disease (GERD).
      A recent meta-analysis of 18 studies involving 1441 patients found significant improvement in heartburn and GERD quality of life scores after the Stretta procedure.
      • Perry K.A.
      • Banerjee A.
      • Melvin W.S.
      Radiofrequency energy delivery to the lower esophageal sphincter reduces esophageal acid exposure and improves GERD symptoms: a systematic review and meta-analysis.
      However, although the esophageal acid exposure, as measured by the DeMeester score, was significantly reduced after treatment (44.4 vs 28.5, P = .007), it did not normalize. In addition, no significant increase in lower esophageal sphincter pressure was observed. Adverse events were infrequent and typically minor. The technique appears to durably relieve GERD symptoms for up to 10 years in the majority of patients.
      • Noar M.
      • Squires P.
      • Noar E.
      • et al.
      Long-term maintenance effect of radiofrequency energy delivery for refractory GERD: a decade later.
      • Dughera L.
      • Rotondano G.
      • De Cento M.
      • et al.
      Durability of Stretta radiofrequency treatment for GERD: results of an 8-year follow-up.
      The TIF procedure received U.S. Food and Drug Administration approval in 2007 and has undergone several device and technique modifications since the initial approval.
      • Auyang E.D.
      • Carter P.
      • Rauth T.
      • et al.
      SAGES clinical spotlight review: endoluminal treatments for gastroesophageal reflux disease (GERD).
      Most studies involving TIF have been small with short-term follow-up. The results have been variable, with poorer results observed with earlier versions of the device/technique. A systematic review of TIF that included 15 studies and 550 procedures found improved GERD health-related quality of life scores (21.9 vs 5.9, P < .0001) after the procedure.
      • Wendling M.R.
      • Melvin W.S.
      • Perry K.A.
      Impact of transoral incisionless fundoplication (TIF) on subjective and objective GERD indices: a systematic review of the published literature.
      PPI use was discontinued in 67% of patients. Limitations of the analysis of these studies include a lack of routine reporting of pH data and a mean follow-up period of only 8.3 months. Major adverse events were reported in 3.2% of patients. Most recently, 3 randomized trials with at least 6-month follow-up found that TIF was more effective than high-dose PPI therapy in eliminating troublesome regurgitation or extraesophageal symptoms of GERD.
      • Trad K.S.
      • Barnes W.E.
      • Simoni G.
      • et al.
      Transoral incisionless fundoplication effective in eliminating GERD symptoms in partial responders to proton pump inhibitor therapy at 6 months: the TEMPO randomized clinical trial.
      • Trad K.S.
      • Simoni G.
      • Barnes W.E.
      • et al.
      Efficacy of transoral fundoplication for treatment of chronic gastroesophageal reflux disease incompletely controlled with high-dose proton-pump inhibitors therapy: a randomized, multicenter, open label, crossover study.
      • Hunter J.G.
      • Kahrilas P.J.
      • Bell R.C.
      • et al.
      Efficacy of transoral fundoplication vs omeprazole for treatment of regurgitation in a randomized controlled trial.
      Endoluminal antireflux techniques represent potentially new therapeutic indications for GI endoscopy. Prospective trials comparing these therapies with existing medical and surgical options by using objective measures of GERD as the primary endpoint could be useful in further defining the clinical role of these procedures. Appropriate patient selection and endoscopist experience and training should be carefully considered before pursuing these therapies.

      Role of endoscopy in pediatric GERD

      Although most infant reflux is physiologic, there are sparse data regarding the prevalence of GERD in the pediatric population.
      • El-Serag H.B.
      • Sweet S.
      • Winchester C.C.
      • et al.
      Update on the epidemiology of gastro-oesophageal reflux disease: a systematic review.
      Guidelines from the North American Society of Pediatric Gastroenterology, Hepatology and Nutrition state that endoscopy is indicated in infants and children with GERD who fail to respond to pharmacologic therapy or as part of the initial management if symptoms of poor weight gain, unexplained anemia or fecal occult blood, recurrent pneumonia, or hematemesis exist.
      • Vandenplas Y.
      • Rudolph C.D.
      • Di Lorenzo C.
      • et al.
      Pediatric gastroesophageal reflux clinical practice guidelines: joint recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN).
      Erosive esophagitis is reported less often in infants and children with GERD than in adults with GERD, but approximately 25% of infants younger than 1 year of age undergoing upper endoscopy will have histologic evidence of esophageal inflammation.
      • Volonaki E.
      • Sebire N.J.
      • Borrelli O.
      • et al.
      Gastrointestinal endoscopy and mucosal biopsy in the first year of life: indications and outcome.
      When EGD is performed in children with suspected GERD, tissue sampling of both normal and inflamed mucosa should be performed to exclude other conditions such as eosinophilic esophagitis, gastritis, and celiac disease.
      • Lightdale J.R.
      • Gremse D.A.
      Gastroesophageal reflux: management guidance for the pediatrician.
      • Lightdale J.R.
      • Acosta R.
      • Shergill A.K.
      • et al.
      Modifications in endoscopic practice for pediatric patients.

      Summary

      • We recommend that uncomplicated GERD be diagnosed on the basis of typical symptoms without the use of diagnostic testing, including EGD. ⊕⊕⊕⊕
      • We recommend EGD for patients who have symptoms suggesting complicated GERD or alarm symptoms. ⊕⊕⊕○
      • We recommend that EGD not be routinely performed solely for the assessment of extraesophageal GERD symptoms. ⊕⊕⊕○
      • We recommend that endoscopic findings of reflux esophagitis be classified according to an accepted grading scale or described in detail. ⊕⊕⊕○
      • We suggest that repeat EGD be performed in patients with severe erosive esophagitis after at least an 8-week course of PPI therapy to exclude underlying BE or dysplasia. ⊕⊕○○
      • We recommend against obtaining tissue samples from endoscopically normal tissue to diagnose GERD or exclude BE in adults. ⊕⊕⊕○
      • We suggest that endoscopy be considered in patients with multiple risk factors for Barrett’s esophagus. ⊕○○○
      • We recommend that tissue samples be obtained to confirm endoscopically suspected Barrett’s esophagus. ⊕⊕⊕⊕
      • We suggest that endoscopic antireflux therapy be considered for selected patients with uncomplicated GERD after careful discussion with the patient regarding potential adverse effects, benefits, and other available therapeutic options. ⊕⊕○○

      Disclosure

      Dr Khashab is a consultant for and member of the advisory board of Boston Scientific, is a consultant for Olympus American, and has received research support from Cook Medical. Dr Chathadi is a consultant for Boston Scientific. Dr Muthusamy is a consultant for and has received honoraria and research support from Covidien GI Solutions. Dr Fanelli is a consultant for EndoGastric Solutions, has received royalties for unrelated inventions and product development from Cook Surgical Inc, and has minor ownership interest in Allurion Technologies Inc and Mozaic Medical Inc. All other authors disclosed no financial relationships relevant to this article.

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