Following up on Unsymptomatic Erosive Esophagitis
Q: Mr. Smith Is a 52-Year-Old Man Who Has Never Been on PPI Therapy. After an ED Visit for Chest Pain, He Is Found to Have Grade D Erosive Esophagitis. I Have Started Omeprazole 40 mg Daily, and His Symptoms Have Resolved. Does He Need a Follow-Up Endoscopy?
A: This 52-year-old man with presumed gastroesophageal reflux disease, erosive esophagitis grade D, is referred for a question related to the need for follow-up endoscopy. In order to answer this question in the most efficient manner, there are several bits of information that would be helpful. I have been given little background on the patient. Specifically whether or not he is presenting with chest pain for the first time; whether he has heartburn, regurgitation, or any other symptom of gastroesophageal reflux disease; and/or whether he has had any other treatment for GERD. It would be unusual for a 52-year-old man to present with chest pain as his sole symptom for GERD having no other symptoms or other past intervention. Nevertheless, for the purpose of answering this question, I will assume that he has had cardiac disease ruled out, which is mandatory for a gastroenterologist managing a patient with chest pain, a thorough history taken, and as such underwent endoscopy for evaluation of the chest pain.
The use of endoscopy as an evaluative tool in patients with unexplained chest pain is, to some degree, debated. Although it appears to be the usual first diagnostic test in the community, the “yield” of this intervention is not nearly as high as it would be had this patient presented with frequent heartburn. Chest pain literature for the most part suggests that erosive esophagitis is seen in a minority, about 10% to 15%, which is in keeping with my clinical experience. A well-done study from the Veterans Administration in Tucson, Arizona, found the frequency of erosive esophagitis to be higher (35%) than other studies in the literature, and a recent report (personal communication) of a large endoscopic database found that endoscopic abnormalities are seen in 25% to 35% of patients endoscoped when noncardiac chest pain is listed as the reason for endoscopy. In addition, the finding of grade D erosive esophagitis (the most severe on the A, B, C, D grading system; Figure 1) is in my experience quite unusual in patients with noncardiac chest pain. A therapeutic trial of high dose proton pump inhibitor is the most efficient and cost-effective approach to this patient.
Although it is likely that the erosive esophagitis is due to gastroesophageal reflux disease, it would be imperative to be certain that the patient had no history of pill ingestion that might contribute to esophagitis nor any history in which one might develop infectious esophagitis that might confuse the picture. Assuming this is grade D erosive esophagitis secondary to reflux, the determination of follow-up endoscopy in my practice is based on a single question. Should this patient be screened for Barrett’s esophagus and is his initial endoscopy sufficient to rule that out? As I will discuss in other questions, the risks for Barrett’s esophagus are the following: Caucasian, male, long history of reflux symptoms (greater than 5 to 10 years), and early onset of reflux symptoms (prior to age 35). I know only that he is 52 years old. Given the absence of this history, let’s presume that he is in a high-risk category and therefore is a candidate for screening. It is clear from my own observations that a columnar lined esophagus can be obscured by severe erosive esophagitis and that inflammation on biopsy may obscure accurate interpretation of the histologic findings. There are no well-designed studies, however, that support this observation so an argument for follow-up endoscopy could not be made based purely on the available evidence or data. However, it would be my preference to electively re-endoscope the patient to be certain that he did not have Barrett’s even in the absence of any symptoms. It would not be necessary to endoscope this patient purely to document healing as there is little evidence, if any, that his disease would progress to further complications should he not heal, in the absence of Barrett’s metaplasia.
Clinicians can be comfortable that in the absence of Barrett’s, there is little reason to believe that erosive esophagitis is an independent risk for complications or will progress to Barrett’s. As such, healing itself does not need to be documented to optimally manage GERD symptoms.
Farraye FA, eds. Curbside Consultation in GERD: 49 Clinical Questions (pp 1-3) © 2008 SLACK Incorporated.
- Fass R, et al. Gastroenterology. 1998;115(1):42-49.
- Pandak WM, et al. J Clin Gastroenterol. 2002;35(4):307-314.
- For more information on the Curbside Consultation in Gastroenterology Series:
- Visit Healio.com/Books/Gastroenterology.