Guideline:
Role of endoscopy in the management of GERD
Bibliographic Source(s)
- Standards of Practice Committee Lichtenstein DR Cash BD Davila R Baron TH Adler DG Anderson MA Dominitz JA Gan SI Harrison ME 3rd Ikenberry SO Qureshi WA Rajan E Shen B Zuckerman MJ Fanelli RD Van Guilder T. Role of endoscopy in the management of GERD. Gastrointest Endosc 2007 Aug;66(2):219-24. [41 references] PubMed
Guideline Status
This is the current release of the guideline.
Guideline Category
Diagnosis
Evaluation
Management
Treatment
Intended Users
Physicians
Guideline Objective(s)
To discuss the use of endoscopy for the diagnosis and management of gastroesophageal reflux disease (GERD) and Barrett's esophagus (BE)
Target Population
Patients with gastroesophageal reflux disease (GERD) and Barrett's esophagus (BE)
Interventions and Practices Considered
- Esophagogastroduodenoscopy (EGD)
- Biopsy
- Classification of gastroesophageal reflux disease (GERD) according to an accepted grading scale (the Los Angeles classification or the Savary-Miller classification) or detailed description of endoscopic findings
- Endoscopic antireflux therapy for selected patients
Major Outcomes Considered
- Accuracy and specificity of diagnostic tests
- Incidence and economic impact of gastroesophageal reflux disease (GERD)
- Cost-effectiveness of endoscopic evaluation screening and/or treatment
- Safety of endoscopic procedures
Methods Used to Collect/Select Evidence
Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
In preparing this guideline a search of the medical literature was performed using PubMed supplemented by accessing the "related articles" feature of PubMed. Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When little or no data exist from well-designed prospective trials emphasis is given to results from large series and reports from recognized experts.
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus (Committee)
Rating Scheme for the Strength of the Evidence
Not applicable
Methods Used to Analyze the Evidence
Systematic Review
Description of the Methods Used to Analyze the Evidence
Not stated
Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
Guidelines for appropriate utilization of endoscopy are based on a critical review of the available data and expert consensus.
Rating Scheme for the Strength of the Recommendations
Grades of Recommendation*
| Grade of Recommendation | Clarity of Benefit | Methodologic Strength/ Supporting Evidence | Implications |
|---|---|---|---|
| 1A | Clear | Randomized trials without important limitations | Strong recommendation; can be applied to most clinical settings |
| 1B | Clear | Randomized trials with important limitations (inconsistent results nonfatal methodologic flaws) | Strong recommendation; likely to apply to most practice settings |
| 1C+ | Clear | Overwhelming evidence from observational studies | Strong recommendation; can apply to most practice settings in most situations |
| 1C | Clear | Observational studies | Intermediate-strength recommendation; may change when stronger evidence is available |
| 2A | Unclear | Randomized trials without important limitations | Intermediate-strength recommendation; best action may differ depending on circumstances or patients' or societal values |
| 2B | Unclear | Randomized trials with important limitations (inconsistent results nonfatal methodologic flaws) | Weak recommendation; alternative approaches may be better under some circumstances |
| 2C | Unclear | Observational studies | Very weak recommendation; alternative approaches likely to be better under some circumstances |
| 3 | Unclear | Expert opinion only | Weak recommendation; likely to change as data become available |
*Adapted from Guyatt G Sinclair J Cook D Jaeschke R Schunemann H Pauker S. Moving from evidence to action: grading recommendations—a qualitative approach. In: Guyatt G Rennie D eds. Users' guides to the medical literature. Chicago: AMA Press; 2002. p. 599-608.
Cost Analysis
Published cost analyses were reviewed.
A landmark modeling study showed that a strategy of endoscopic screening for Barrett's esophagus (BE) in 50-year-old white males with gastroesophageal reflux disease (GERD) followed by subsequent endoscopic surveillance for those with dysplasia was associated with acceptable costs per quality-adjusted life year saved. Several other modeling studies reached similar conclusions regarding screening for this specific population but differed regarding the cost effectiveness of additional surveillance in patients with nondysplastic BE.
Method of Guideline Validation
Internal Peer Review
Description of Method of Guideline Validation
This document was reviewed and approved by the Governing Board of the American Society for Gastrointestinal Endoscopy.
Major Recommendations
Recommendations were graded on the strength of the supporting evidence (Grades 1A-3). Definitions of the recommendation grades are presented at the end of the "Major Recommendations" field.
Summary
- Gastroesophageal reflux disease (GERD) can be diagnosed on the basis of typical symptoms without the need for diagnostic testing including endoscopy (1C).
- In patients with uncomplicated GERD an initial trial of empiric medical therapy is appropriate (1C).
- Endoscopy is recommended for patients who have symptoms suggesting complicated GERD or alarm symptoms (2A).
- Endoscopic findings of reflux esophagitis should be classified according to an accepted grading scale or described in detail (3).
- Endoscopy should be considered in patients at risk for Barrett's esophagus (BE) (2C).
- Biopsy must be performed to confirm endoscopically suspected BE (2B).
- Endoscopic biopsy specimens should not be obtained from an endoscopically normal tissue to exclude BE (2B).
- For patients with established BE of any length and with no dysplasia after 2 consecutive examinations within 1 year an acceptable interval for additional surveillance is every 3 years (3).
- Endoscopic antireflux therapy may be considered for selected patients with uncomplicated GERD after careful discussion with the patient regarding potential side effects benefits and other available therapeutic options (3).
Definitions:
Grades of Recommendation*
| Grade of Recommendation | Clarity of Benefit | Methodologic Strength/ Supporting Evidence | Implications |
|---|---|---|---|
| 1A | Clear | Randomized trials without important limitations | Strong recommendation; can be applied to most clinical settings |
| 1B | Clear | Randomized trials with important limitations (inconsistent results nonfatal methodologic flaws) | Strong recommendation; likely to apply to most practice settings |
| 1C+ | Clear | Overwhelming evidence from observational studies | Strong recommendation; can apply to most practice settings in most situations |
| 1C | Clear | Observational studies | Intermediate-strength recommendation; may change when stronger evidence is available |
| 2A | Unclear | Randomized trials without important limitations | Intermediate-strength recommendation; best action may differ depending on circumstances or patients' or societal values |
| 2B | Unclear | Randomized trials with important limitations (inconsistent results nonfatal methodologic flaws) | Weak recommendation; alternative approaches may be better under some circumstances |
| 2C | Unclear | Observational studies | Very weak recommendation; alternative approaches likely to be better under some circumstances |
| 3 | Unclear | Expert opinion only | Weak recommendation; likely to change as data become available |
*Adapted from Guyatt G Sinclair J Cook D Jaeschke R Schunemann H Pauker S. Moving from evidence to action: grading recommendations—a qualitative approach. In: Guyatt G Rennie D eds. Users' guides to the medical literature. Chicago: AMA Press; 2002. p. 599-608.
Clinical Algorithm(s)
None provided
Type of Evidence supporting the Recommendations
The type of supporting evidence is identified for each recommendation (see "Major Recommendations").
Potential Benefits
Appropriate utilization of endoscopy in the diagnosis and management of patients with gastroesophageal reflux disease (GERD) and Barrett's esophagus (BE)
Potential Harms
- Drawbacks of esophagogastroduodenoscopy (EGD) include the potential physical risks financial costs and limited access to the procedure.
- Short- and long-term safety issues surrounding the endoluminal devices continue to be a concern and the economics of their use are unknown.
Qualifying Statements
- Further controlled clinical studies are needed to clarify aspects of this statement and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance to these recommendations.
- 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 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.
Description of Implementation Strategy
An implementation strategy was not provided.
IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness
Bibliographic Source(s)
- Standards of Practice Committee Lichtenstein DR Cash BD Davila R Baron TH Adler DG Anderson MA Dominitz JA Gan SI Harrison ME 3rd Ikenberry SO Qureshi WA Rajan E Shen B Zuckerman MJ Fanelli RD Van Guilder T. Role of endoscopy in the management of GERD. Gastrointest Endosc 2007 Aug;66(2):219-24. [41 references] PubMed
Adaptation
Not applicable: The guideline was not adapted from another source.
Source(s) of Funding
American Society for Gastrointestinal Endoscopy
Guideline Committee
Standards of Practice Committee
Composition of Group that Authored the Guideline
Committee Members: David R. Lichtenstein MD; Brooks D. Cash MD; Raquel Davila MD; Todd H. Baron MD Chair; Douglas G. Adler MD; Michelle A. Anderson MD; Jason A. Dominitz MD MHS; Seng-Ian Gan MD; M. Edwyn Harrison III MD; Steven O. Ikenberry MD; Waqar A. Qureshi MD; Elizabeth Rajan MD; Bo Shen MD; Marc J. Zuckerman MD; Robert D. Fanelli MD SAGES Representative; Trina VanGuilder RN BSN SGNA Representative
Financial Disclosures/Conflicts of Interest
Not stated
Guideline Status
This is the current release of the guideline.
Guideline Availability
Electronic copies: Available from the American Society for Gastrointestinal Endoscopy Web site.
Print copies: Available from the American Society for Gastrointestinal Endoscopy 1520 Kensington Road Suite 202 Oak Brook IL 60523
Availability of Companion Documents
None available
Patient Resources
None available
NGC STATUS
This NGC summary was completed by ECRI Institute on March 3 2008.
COPYRIGHT STATEMENT
This NGC summary is based on the original guideline which is subject to the guideline developer's copyright restrictions.
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