Endoscopy is commonly performed for the diagnosis and management of gastroesophageal reflux disease (GERD). Endoscopy allows the physician to evaluate esophageal mucosa for evidence of esophagitis and Barrett esophagus, to obtain mucosal biopsies for evaluation of such conditions as eosinophilic esophagitis and diagnosis and grading of Barrett esophagus, and to apply various therapies. In a patient with suboptimal response to GERD therapy, endoscopy excludes other etiologies as a cause of patients’ symptoms. Newer endoscopic therapies for GERD are available or are in development. Advances in imaging techniques in development will improve the diagnostic yield of endoscopy and may replace the need for mucosal biopsies.
Key points
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Endoscopy is the mainstay diagnostic and therapeutic tool in the management of GERD.
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Endoscopy is recommended for the evaluation of medically refractory or atypical GERD, patients with alarm symptoms of dysphagia, anemia or weight loss, for diagnosis and surveillance of Barrett esophagus in patients with chronic GERD, and for application of such therapies as esophageal dilation or ablation.
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Newer imaging techniques in development will further improve the accuracy and use of endoscopy in management of GERD.
Introduction
Gastroesophageal reflux disease (GERD) is one of the most common conditions encountered in primary care and gastroenterology practices. Almost 40% of the US population suffers from occasional heartburn and up to 20% of patients report bothersome symptoms on at least a weekly basis. Heartburn or indigestion is the commonest symptom of GERD and accounts for nearly 2 million outpatient clinic visits, with dysphagia accounting for additional 1 million visits. GERD is the leading diagnosis for gastrointestinal disorders in outpatient clinic visits in the United States accounting for almost 9 million visits in the year 2009, with Barrett esophagus accounting for an additional 500,000 visits. Endoscopy is commonly performed for the diagnosis and management of GERD, with reflux symptoms (24%) and dysphagia (20%) being the commonest indications.
The prevalence of GERD and use of endoscopy for management of GERD are rising. In a systemic analysis, El-Serag reported an increasing prevalence of GERD over the last two decades. Analysis of CORI and CMMS databases shows an increased use of endoscopy partially accounted for by rising prevalence of GERD.
This article discusses the appropriate indications for endoscopy in patients with GERD and highlights newer imaging technologies that may improve utility and outcomes of endoscopy in management of GERD.
Introduction
Gastroesophageal reflux disease (GERD) is one of the most common conditions encountered in primary care and gastroenterology practices. Almost 40% of the US population suffers from occasional heartburn and up to 20% of patients report bothersome symptoms on at least a weekly basis. Heartburn or indigestion is the commonest symptom of GERD and accounts for nearly 2 million outpatient clinic visits, with dysphagia accounting for additional 1 million visits. GERD is the leading diagnosis for gastrointestinal disorders in outpatient clinic visits in the United States accounting for almost 9 million visits in the year 2009, with Barrett esophagus accounting for an additional 500,000 visits. Endoscopy is commonly performed for the diagnosis and management of GERD, with reflux symptoms (24%) and dysphagia (20%) being the commonest indications.
The prevalence of GERD and use of endoscopy for management of GERD are rising. In a systemic analysis, El-Serag reported an increasing prevalence of GERD over the last two decades. Analysis of CORI and CMMS databases shows an increased use of endoscopy partially accounted for by rising prevalence of GERD.
This article discusses the appropriate indications for endoscopy in patients with GERD and highlights newer imaging technologies that may improve utility and outcomes of endoscopy in management of GERD.
Esophagogastroduodenoscopy or upper endoscopy
High-definition, high-resolution flexible video endoscopy has become the standard of endoscopic care in the United States. Esophagogastroduodenoscopy allows for excellent view of the mucosal details and allows for obtaining photographs, video recordings, and tissue sampling using biopsy and brush cytology. Endoscopy also allows for application of therapies, such as esophageal dilation, Barrett ablation, and endoscopic resection of preneoplastic and early neoplastic lesions. Most esophagogastroduodenoscopy procedures in the United States are performed using conscious sedation or procedural sedations. However, data suggest that unsedated, thin-scope esophagogastroduodenoscopy can be safely and successfully performed in carefully selected patients.
Advances in imaging technology are expanding the accuracy of traditional white light endoscopy. High-definition (>850,000 pixel density), high-magnification (>115×) endoscopes using 1080p technology allow one to see mucosal details with greater resolution improving its diagnostic accuracy. Electronic or virtual chromoendoscopy is replacing traditional chromoendoscopy using dye, which was cumbersome and messy.
Standard white light endoscopy uses blue, green, and red light waves, whereas the NBI technology (Olympus, Center Valley, PA), using electronic light filters, only uses blue (440–460 nm) and green (540–560 nm) wave light, eliminating the use of the red light. The narrower wavelengths highlight the superficial mucosa and blood vessels accentuating the mucosal architecture and microvasculature. The FICE system (Fuji, Wayne, NJ) and I-Scan (Pentax, Montvale, NJ) use postprocessing techniques, such as spectral analysis, or postprocessing enhancements to achieve electronic chromoendoscopy.
Full-spectrum endoscopy (FUSE; EndoChoice, Atlanta, GA) allows for a 245-degree field of view compared with the 160-degree field of view of traditional upper endoscopy and may improve the diagnostic yield of upper endoscopy.
Confocal laser endomicroscopy and optical coherence tomography
Confocal laser endomicroscopy and optical coherence tomography (OCT) use lasers to penetrate to a certain depth below the surface and magnify the images obtained to evaluate deeper structures. Two catheter-based technologies for confocal laser endomicroscopy (Cellvizio; Mauna Kea Technologies, Paris, France) and OCT (NvisionVLE; Ninepoint Medical, Cambridge, MA) have been approved by the Food and Drug Administration for use in the United States.
The Cellvizio probe-based confocal laser endomicroscopy system uses a 7F catheter confocal miniprobe, which is passed down the working channel of the upper endoscope and a low-power blue laser light (wave length 488 nm) passed through a fiberoptic bundle for tissue illumination after application of fluorescence agents (topical Acriflavine hydrochloride and Cresyl Violet, and systemic fluorescein) to obtain confocal images (∼1000 × magnification) of the mucosa fixed image plane depth of 55 to 65 μm that are streamed at a frame rate of 12 frames per second.
OCT uses a technique called interferometry that measures the path length of reflected light and processes the information for image generation, a technique similar to an ultrasound that uses sound waves. The NvisionVLE OCT or volumetric laser endomicroscopy uses a balloon catheter that passes through a 2.8-mm or larger scope channel and performs volumetric laser interferometry based on frequency domain OCT to faster, real-time, high-resolution imaging. It provides resolution to 10 mm and imaging depth down to 3 mm, real-time resolution of 7 μm, scanning over a 6-cm length of esophagus for a period of 90 seconds and allowing for the visualization of tissue layers including the esophageal mucosa, submucosa, and muscularis propria.
Wireless capsule endoscopy
Esophageal capsule endoscopy was approved by the Food and Drug Administration in 2004 for the evaluation of the esophagus in patients with GERD and suspected Barrett esophagus. Esophageal capsule endoscopy uses a video capsule endoscope with camera at both ends (height, 11 mm; width, 26 mm; weight, 3.7 g) that takes images of the esophagus at 18 frames per seconds. Esophageal capsule endoscopy allowed for unsedated outpatient evaluation of the esophagus with moderate sensitivity and specificity for the evaluation of Barrett esophagus. However, because of cost and need for mucosal biopsy for the diagnosis of Barrett esophagus, it is not widely used. A tethered multiuse string capsule using the small bowel capsule endoscope was developed to overcome some of the issues of traditional esophageal capsule endoscopy but interest in the technology has waned.
Gastroesophageal reflux disease
Montreal Consensus Conference defines GERD as a condition that develops when there is reflux of stomach contents into the esophagus causing troublesome symptoms, complications, or both. Presence of mucosal damage and positive endoscopic findings are not a prerequisite for the diagnosis of GERD. GERD can accurately be diagnosed by history of classical symptoms of heartburn and/or regurgitation and a positive response to antisecretory therapy. Almost two-thirds of patients with GERD have nonerosive disease and a normal endoscopy. Los Angeles classification ( Table 1 ) is most commonly used to classify the grade of erosive esophagitis in the United States, whereas the Savary-Miller classification is more commonly used in Europe. Los Angeles classification has been shown to have good intraobserver and interobserver agreement among experienced and inexperienced endoscopists and correlates well with the amount of esophageal acid exposure and complications of GERD. However, neither of the classifications accurately predicts symptom severity.
| Grade | Endoscopic Description |
|---|---|
| A | One or more mucosal break <5 mm that does not extend between the tops of two mucosal folds |
| B | One or more mucosal break ≥5 mm that does not extend between the tops of two mucosal folds |
| C | One or more mucosal break that is continuous between the tops of two or more mucosal folds but that involves <75% of the circumference |
| D | One or more mucosal break that involves ≥75% of the esophageal circumference |
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