Upper endoscopy is the procedure of choice to detect the severity of mucosal injury, document esophageal healing, and rule out Barrett's esophagus, esophageal cancer, and other esophageal or GI causes of reflux-type symptoms. Endoscopy (with biopsy) of the esophageal mucosa is indicated for patients who are unresponsive or refractory to potent antisecretory drug therapy or in those with dysphagia, odynophagia, or GI bleeding, to rule out esophageal cancer; in patients with long-standing GERD, to rule out Barrett's esophagus; and in patients with atypical symptoms, when the response to empirical therapy is difficult to evaluate. Esophageal strictures can be detected by endoscopy in most cases, but certain strictures (e.g., esophageal webs) are best evaluated by barium swallow. It is important to recognize that a normal endoscopy does not rule out symptomatic GERD and the presence of esophagitis does not always indicate that esophagitis is the cause of the patient's symptoms. Additional tests, such as 24-h esophageal pH monitoring, may be necessary to correlate symptoms with the presence of acid in the esophagus, aid in the diagnosis, and help guide therapy.
Barrett's esophagus is a histologic diagnosis that, at the time of endoscopy, is recognized by the displacement of the squamocolumnar junction or Z line (the boundary between the pale pink squamous esophageal mucosa and the deep red columnar gastric mucosa) into the lumen of the esophagus. Barrett's esophagus is also suspected when deep-red patches of columnar epithelium exist within the lighter squamous mucosa. Most cases of dysplasia, however, occur in the absence of an endoscopically visible lesion. If Barrett's esophagus is confirmed, periodic endoscopic suveillance with biopsy is indicated to monitor for the development of dysplasia. The optimal frequency of endoscopic surveillance in patients WithOUt dysplasia has yet to be determined but recommendations range from every 18 to 24 months to every 5 years. If dysplasia is present more intense monitoring (e.g., every 6 to 12 months) or esophageal resection is needed, depending On a number of factors induding the age of the patient and the grade (low versus high) of dysplasia.
Radiographic Studies
Barium radiography rarely shows free GER of the contrast agent and thus is less useful for the diagnosis of GERD. Although a double-contrast barium esophagogram may be used to rule out esophageal ulcers, with certain types of esophageal strictures (e.g., esophageal webs), hiatal hernia, or extrinsic compression, radiography fails to detect most cases of esophagitis or Barrett's esophagus so endoscopy is preferred. A normal radiograph rarely predudes the need for subsequent endoscopy, whereas an initial endoscopic examination rarely requires additional testing before proceeding with treatment.
