Role of endoscopy in the management of GERD.

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.

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