Gastroesophageal reflux disease: endoscopy, duration of treatment, and choice of PPI.

Neil R. Greenspan, MD, FACG  When is endosCopy indiCAted in the diAgnosis And folloW-up of gAstro-esophAgeAl reflux diseAse (gerd)? In the Montreal definition based on a consensus of experts, GERD was defined as “a condition that develops when the reflux of stomach contents causes troublesome symptoms and/or complications. ” It is important to note that the diagnosis may be symptom-based and made independent of endoscopy and other diagnostic testing. Patients diagnosed with GERD, therefore, will include patients with erosive esophagitis as well as those with nonerosive reflux disease (NERD). Patients with NERD may account for two-thirds of all patients with GERD and, as they will appear normal endoscopically, the sensitivity of endoscopy for making the diagnosis of GERD is low. Endoscopy does play a significant role in excluding other serious disorders such as esophageal or gastric cancer in a patient presenting with reflux-like symptoms. The concept of “alarm” signs or symptoms comes in to play here. Although not supported by literature, it is certainly appropriate to consider endoscopy in any patient presenting with reflux and dysphagia, odynophagia, weight loss, abdominal mass, GI bleeding or anemia. The issue of GERD, Barrett’s esophagus and esophageal cancer remains controversial. Carcinoma of the esophagus is a clinically important disease. Worldwide esophageal cancer is diagnosed in almost a half a million people annually where it is the sixth leading cause of death in men (ninth leading in women). The incidence of adenocarcinoma of the esophagus is rising rapidly in the United States and other “Western” countries. Over the period from 1976-1987, the incidence of adenocarcinoma of the esophagus in US white males increased more rapidly than that of any other cancer. With its incidence increasing almost 20% annually, adenocarcinoma has replaced squamous cell carcinoma as the most prevalent type of esophageal cancer in this population. The prognosis of esophageal adenocarcinoma is strongly associated with the stage at diagnosis. According to Surveillance Epidemiology and End Results (SEER) data from 2005, one-year survival in patients with local, regional, and distant (metastatic) disease were 68%, 54%, and 28%, respectively. The five-year survival for esophageal cancers confined to the mucosa (T1m, N0, M0) may approach 90%. Therefore, there is great interest in identifying risk factors for esophageal cancer and focusing screening and surveillance efforts on populations at high risk for esophageal cancer. A large population-based Swedish study showed that the relative risk of esophageal cancer may be more than seven-fold greater in patients with recurrent reflux when compared to patients without reflux. The more frequent, more severe, and longer-lasting the symptoms of reflux, the greater the risk. While this may make GERD patients appear to be a good target population for endoscopic esophageal cancer screening, enthusiasm for devoting limited health-care dollars on this effort is tempered by the realization that the majority of patients with adenocarcinoma of the esophagus do not report a history of reflux. Additionally, only a small percentage of all patients with reflux ever develop esophageal adenocarcinoma. Like adenocarcinoma, GERD is a strongly associated with Barrett’s esophagus. It is well accepted that Barrett’s esophagus, defined as metaplasia of esophageal mucosa and presumably related to chronic exposure to acid, is a pre-malignant condition for adenocarcinoma of the esophagus. The risk estimated to be about 0.5% annually is substantially higher in patients with low or high grade dysplasia. There are controversies in the diagnosis of Barrett’s esophagus and dysplasia that are beyond the scope of this article. The American College of Gastroenterology has published guidelines addressing the management of patients with Barrett’s esophagus. In addition, a variety of exciting new ablative therapies and endoscopic mucosal resection techniques for Barrett’s esophagus with dysplasia or early adenocarcinoma have been developed. These can eliminate dysplastic epithelium and, under acid suppression, permit restoration of squamous mucosa. The fact remains however, that at this time, no endoscopic screening protocol for Barrett’s has been shown to improve survival by preventing deaths from esophageal cancer.