Frequency of Endoscopic Findings in GERD
The majority of GERD patients (50-80%) have normal endoscopy findings, while only 20-50% demonstrate erosive esophagitis, and gastritis findings are variable but less commonly the primary pathology. 1
Esophagitis Prevalence in GERD
Erosive esophagitis is found in only 20-50% of symptomatic GERD patients, meaning 50-80% have endoscopy-negative reflux disease (ENRD) despite typical symptoms 1
Among patients undergoing endoscopy for GERD symptoms, approximately 40-60% have no visible esophageal erosions and are classified as having "endoscopy-negative reflux disease" 2
Histologic evidence of esophagitis is more sensitive than endoscopic findings alone, with studies showing histologic esophagitis in 58.4% of GERD patients versus endoscopic esophagitis in 68.1%, and combined evaluation detecting esophagitis in 82% 3
In specialized populations with esophageal atresia repair, endoscopic esophagitis rates are higher (8-19% in adults, 20-49% in adolescents), with histologic esophagitis even more prevalent (25-51% in adults, 44-61% in adolescents) 1
Gastritis Findings in GERD
Gastritis is not a primary endoscopic feature of GERD, though it may coexist as a separate pathology 4
In one Middle Eastern study, 36% of GERD patients had endoscopic esophagitis, and active corpus gastritis due to H. pylori was actually associated with protection against severe erosive esophagitis 5
The relationship between gastritis and GERD is complex: patients with severe esophagitis (≥grade II) less frequently had active gastritis (15/45 vs. 55/98; p=0.02) and lower H. pylori density compared to those without esophagitis 5
Clinical Implications
Endoscopy cannot rule out GERD, as the absence of erosions does not exclude clinically significant reflux disease requiring treatment 1, 2
When endoscopy is performed, complete evaluation should document erosive esophagitis using standardized grading (Los Angeles classification), hiatal hernia presence, and Barrett's esophagus screening 1, 6
Histologic evaluation increases diagnostic sensitivity: nearly all patients with severe endoscopic changes show histologic esophagitis, but 43.7% of patients with normal-appearing mucosa also have histologic evidence of inflammation 3
In patients with typical GERD symptoms and normal endoscopy, ambulatory pH monitoring (preferably 96-hour wireless) is needed to objectively confirm reflux and guide long-term therapy decisions 1
Important Caveats
Los Angeles grade A esophagitis is not diagnostic of GERD, as it can be seen in healthy asymptomatic volunteers 1
Endoscopy is primarily indicated for alarm symptoms (dysphagia, bleeding, anemia, weight loss), refractory symptoms despite 4-8 weeks of twice-daily PPI therapy, or screening for Barrett's esophagus in high-risk patients 1, 6
The presence of gastritis should prompt evaluation for H. pylori and NSAID use as separate etiologies rather than being attributed to GERD itself 4, 5