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Guideline Summary
Guideline Title
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 External Web Site Policy
Guideline Status

This is the current release of the guideline.

The American Society for Gastrointestinal Endoscopy (ASGE) reaffirmed the currency of the guideline in 2011.

Scope

Disease/Condition(s)
  • Gastroesophageal reflux disease (GERD)
  • Complications of GERD such as Barrett's esophagus (BE)
Guideline Category
Diagnosis
Evaluation
Management
Treatment
Clinical Specialty
Family Practice
Gastroenterology
Internal Medicine
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
  1. Esophagogastroduodenoscopy (EGD)
  2. Biopsy
  3. 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
  4. 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

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

2007 Guideline

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.

2011 Reaffirmation

A search of medical databases (PubMed, MEDLINE) and annual meeting proceedings from 1990 to 2011 was conducted by one to two Standards of Practice Committee members.

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

2007 Guideline

Guidelines for appropriate utilization of endoscopy are based on a critical review of the available data and expert consensus.

2011 Reaffirmation

A search of medical databases and annual meeting proceedings was conducted by one to two Standards of Practice Committee members with discussion and voting regarding novelty and informative value of new publications since the previous version of the guideline.

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.

Recommendations

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

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified for each recommendation (see "Major Recommendations").

Benefits/Harms of Implementing the Guideline 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

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.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
Living with Illness
IOM Domain
Effectiveness

Identifying Information and Availability

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 External Web Site Policy
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2007 Aug (reaffirmed 2011)
Guideline Developer(s)
American Society for Gastrointestinal Endoscopy - Medical Specialty Society
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.

The American Society for Gastrointestinal Endoscopy (ASGE) reaffirmed the currency of the guideline in 2011.

Guideline Availability

Electronic copies: Available from the American Society for Gastrointestinal Endoscopy Web site External Web Site Policy.

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. The currency of the guideline was reaffirmed by the developer in 2011 and this summary was updated by ECRI Institute on October 16, 2012.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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