Why Endoscopy Is Not Always the First Step
Most cases of GERD are diagnosed based on classic symptoms - heartburn occurring two or more times per week and acid regurgitation - combined with a positive response to acid-reducing medication. Endoscopy is not routinely performed for initial diagnosis in patients with typical symptoms who respond well to treatment.
Upper endoscopy, also called EGD (esophagogastroduodenoscopy), is a procedure that allows a physician to visually examine the inside of the esophagus, stomach, and upper small intestine using a thin, flexible tube that has a camera. For GERD (gastroesophageal reflux disease), endoscopy is not a first-line diagnostic test but plays an essential role in identifying complications caused by long-term acid exposure. Upper endoscopy for GERD is indicated for patients with alarm symptoms, patients with screening criteria for Barrett's esophagus, and patients who do not respond adequately to PPI therapy, according to a review published in Clinical Endoscopy (Simadibrata et al., 2023).
However, endoscopy becomes necessary when the goal is shifted from symptom diagnosis to complication assessment, treatment planning, or other condition rule-outs that mimic GERD symptom presentation.
When Is Endoscopy Recommended for GERD?
The International Foundation for Gastrointestinal Disorders (IFFGD, 2023) and the American College of Gastroenterology suggest the following:
Alarm Symptoms Are Present
Alarm symptoms indicate that GERD has caused considerable damage to the esophagus or that the cause of the symptoms is serious. Endoscopy should be done if any of the following are present.
- Dysphagia - difficulty swallowing solid or liquid food
- Odynophagia - pain when swallowing
- Unexplained weight lossVomiting blood or passing black, tarry stools (signs of gastrointestinal bleeding)
- Persistent vomiting
- Significant loss of appetite
Barrett's Esophagus Screening Criteria Are Met
Barrett's esophagus is a pre-cancerous condition in which the normal esophageal lining is replaced by intestinal-type cells due to chronic acid exposure. Endoscopy for Barrett's esophagus screening is recommended for people who meet the following profile, according to Simadibrata et al., Clinical Endoscopy (2023).
- Male sex with chronic GERD symptoms lasting five or more years
- Age 50 or older with long-standing GERD
- Obesity, particularly with excess abdominal fat
- Family history of Barrett's esophagus or esophageal adenocarcinoma (a type of cancer)
- History of smoking
Symptoms Persist Despite PPI Therapy
When symptoms continue or worsen after four to eight weeks of standard PPI therapy, endoscopy assesses whether esophageal damage is present and looks for alternative explanations for ongoing symptoms, according to the IFFGD (2023).
Before or After Anti-Reflux Surgery
Endoscopy is performed before surgical treatment for GERD to document esophageal damage and confirm the anatomy of the gastroesophageal junction. It is also used after surgery to evaluate treatment outcomes and detect recurrence.
What Does Endoscopy Find in GERD?
During upper endoscopy, the gastroenterologist visually examines the esophageal lining in real time and looks for the following findings.
Esophagitis
Esophagitis is inflammation of the esophageal lining caused by repeated acid contact. It appears as redness, swelling, and erosions or breaks in the mucosal surface. Doctors classify its severity using the Los Angeles (LA) Classification system.
Higher grades indicate more severe acid damage and a greater risk of complications.
Barrett's Esophagus
The esophageal lining in Barrett's esophagus appears salmon-pink rather than the normal pale-pink of healthy tissue. The gastroenterologist takes multiple biopsies from the abnormal area to confirm the diagnosis and assess the degree of cellular change - called dysplasia - which determines future surveillance frequency and treatment decisions.
Esophageal Stricture
Chronic acid exposure causes repeated injury and scarring that can narrow the esophageal passage, making swallowing progressively harder. This narrowing is called a stricture and appears as a visible constriction of the esophageal lumen during the procedure.
Hiatal Hernia
A hiatal hernia is a condition that occurs when a part of the stomach slides upward through the diaphragm into the chest. It weakens the lower esophageal sphincter (the valve that prevents acid from refluxing upward) and is commonly found alongside GERD. Endoscopy identifies the size and type of hiatal hernia, which guides treatment planning.
Normal Endoscopy in GERD
A normal endoscopy does not rule out GERD. Many people with significant acid reflux have no visible esophageal damage - a condition called non-erosive reflux disease (NERD). In these cases, pH monitoring or impedance-pH testing is used to confirm whether abnormal acid exposure is causing symptoms.
What to Expect During a GERD Endoscopy
Before the Procedure
- Fast for at least six hours beforehand - typically overnight - to ensure the esophagus and stomach are clear for visualization
- Inform the doctor about all current medications, as some, such as blood thinners, may need to be temporarily stopped.
- A healthcare professional will place an intravenous (IV) line for sedation medication
During the Procedure
- Sedation is administered through the IV line to keep the patient comfortable and relaxed
- A small mouthguard is placed between the teeth to protect the endoscope
- The gastroenterologist gently passes the endoscope through the mouth and down into the esophagus, stomach, and duodenum.
- The entire process takes around 15 to 30 minutes.
- Biopsies may be taken from abnormal-appearing areas - this is painless under sedation
After the Procedure
- Patients are monitored in a recovery area for 30 to 60 minutes while sedation wears off
- An adult must accompany the patient home, as driving is not permitted on the procedure day
- Mild throat soreness and bloating are common and resolve within a few hours
- Biopsy results, if taken, are typically available within three to five business days
Risks of Upper Endoscopy
Upper endoscopy is safe and well tolerated. Serious complications are rare and may include the following.
- Mild bleeding at biopsy sites, which usually resolves without intervention
- Aspiration of stomach contents into the lungs - minimized by adequate fasting
- Perforation (a tear in the esophageal or stomach wall) - very rare but requiring immediate treatment
- Adverse reaction to sedation medications
The rate of serious complications for diagnostic upper endoscopy is less than 1 in 1,000 procedures, making it one of the safest invasive gastrointestinal procedures currently available, as cited in Simadibrata et al., Clinical Endoscopy (2023).
Conclusion
In the treatment of GERD, the role of endoscopy is important, especially in severe and chronic cases of the disease, or in cases that are resistant to treatment with anti-reflux agents. The procedure serves as proof of the level of damage to the esophagus, the existence of Barrett's esophagus, and the presence of structural abnormalities like hiatal hernias and strictures. Endoscopy also aids in the decision to perform surgery. A negative result on endoscopy does not preclude the diagnosis of GERD, and pH or impedance testing may be necessary to document the presence of acid reflux in the esophagus in the absence of visible esophageal damage.
