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ASGE releases new guideline on endoscopic management of GERD
The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy has released a new guideline on the role of endoscopy in the management of gastroesophageal reflux disease. Replacing the previous guideline published in 2007, this document was updated based on a critical review of data from medical literature published from January 1990 to August 2014.
Indications for EGD
The guideline recommends that diagnosis of uncomplicated GERD should be based on symptoms and response to a trial of antisecretory medical therapy. Upper endoscopic evaluation should be considered in patients who fail to respond to medical therapy, those with symptoms of complicated GERD or alarm symptoms, and those with multiple risk factors for Barrett’s esophagus (BE) and esophageal adenocarcinoma. Routine esophagogastroduodenoscopy (EGD) is not recommended solely for assessing patients with extraesophageal GERD symptoms, as most will not have endoscopic evidence of erosive esophagitis.
Diagnosis, classification of endoscopic findings
The committee recommends that endoscopic severity of erosive reflux esophagitis and related adverse events should be classified according to one of several accepted classification systems, the most common of which are the Los Angeles classification and the Savary-Miller classification. The committee recommends against routine tissue sampling in patients with heartburn and normal endoscopic findings, but does recommend tissue sampling to confirm endoscopically suspected BE. For patients with severe erosive esophagitis, repeat EGD is recommended after a minimum 8-week course of proton pump inhibitors (PPI) to exclude BE or dysplasia.
Endoluminal procedures
The guidelines suggest that for certain patients with uncomplicated GERD, endoscopic antireflux therapy may be considered after discussing potential adverse effects, benefits and therapeutic alternatives. “Endoluminal antireflux techniques represent potentially new therapeutic indications for GI endoscopy,” the authors wrote.
The two endoluminal GERD therapies currently approved in the U.S. are the Stretta procedure (Mederi Therapeutics), which “appears to durably relieve GERD symptoms for up to 10 years in the majority of patients,” and transoral incisionless fundoplication (Endogastric Solutions), which was shown to be “more effective than high-dose PPI therapy in eliminating troublesome regurgitation or extraesophageal symptoms of GERD” in recent trials.
“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,” the authors wrote. – by Adam Leitenberger
Disclosure: Muthusamy reports he is a consultant for and has received honoraria and research support from Covidien GI Solutions. Please see the guideline for a full list of all other authors’ relevant financial disclosures.