Can gastro‑oesophageal reflux disease be visualized on upper endoscopy?

Can GERD Be Visualized on Upper Endoscopy?

Yes, GERD can be visualized on endoscopy, but only 15–50% of patients with GERD will show visible findings—the majority (50–85%) have "nonerosive reflux disease" (ENRD) with completely normal-appearing mucosa despite genuine acid reflux symptoms. 1, 2

What Endoscopy Can and Cannot Show

Visible GERD Findings (When Present)

Endoscopy can identify the following complications and tissue changes when they exist:

• Erosive esophagitis – mucosal breaks graded A through D on the Los Angeles classification, with grades B–D considered severe 1, 3
• Esophageal ulceration – deeper mucosal injury beyond simple erosions 2
• Strictures – narrowing from chronic scarring 1, 2
• Barrett's esophagus – metaplastic columnar epithelium replacing normal squamous lining, present in ~10% of chronic GERD patients 1
• Hiatal hernia – anatomic defect often associated with reflux 4

What Endoscopy Misses

• 50–85% of symptomatic GERD patients have normal endoscopy (ENRD), meaning absence of visible findings does not rule out GERD 1, 2
• Non-erosive changes like erythema or edema are unreliable and should be ignored 2
• Endoscopy does not measure acid exposure or prove a causal link between reflux and symptoms 5

When Endoscopy Is Actually Indicated

The American College of Physicians provides clear thresholds—endoscopy is not a first-line diagnostic test for typical GERD symptoms 1:

Absolute Indications (Do Endoscopy Now)

• Alarm symptoms – dysphagia, GI bleeding, anemia, weight loss, or recurrent vomiting, regardless of age or gender 1, 6
• PPI failure – typical GERD symptoms persisting after 4–8 weeks of twice-daily PPI therapy 1, 6
• Severe erosive esophagitis – follow-up endoscopy after 2 months of PPI therapy to confirm healing and rule out Barrett's esophagus 1, 6, 3
• Recurrent dysphagia in patients with known esophageal stricture 1

Conditional Indications (Consider Endoscopy)

• Screening for Barrett's/adenocarcinoma – men >50 years with chronic GERD (>5 years) plus multiple risk factors (nocturnal reflux, hiatal hernia, elevated BMI, tobacco use, intra-abdominal fat) 1, 6
• Surveillance – patients with known Barrett's esophagus without dysplasia every 3–5 years; more frequently if dysplasia is present 1, 6

When Endoscopy Is NOT Indicated

• Typical GERD symptoms without alarm features – treat empirically with PPI for 4–8 weeks first 1, 6
• Women of any age or men <50 years for routine screening, due to very low cancer incidence 1, 6
• After one negative screening – if initial endoscopy shows no Barrett's or cancer, repeat endoscopy is not needed 1, 6
• Asymptomatic patients with prior stricture – endoscopy is symptom-driven 1

Key Clinical Pitfalls

• Do not assume normal endoscopy excludes GERD – the majority of GERD is endoscopy-negative, and diagnosis rests on symptoms and PPI response 1, 2, 7
• Do not perform "routine" endoscopy in uncomplicated GERD – this exposes patients to procedural risk (perforation, cardiovascular events ~0.01–0.1%) without improving outcomes 8
• Do not add upper endoscopy just because colonoscopy is scheduled – 10–40% of such "convenience" endoscopies are non-indicated 8
• Do not repeat endoscopy after healing of erosive esophagitis unless Barrett's is found – the 7-year risk of stricture, Barrett's, or cancer after healing is only 1.9%, 0%, and 0.1% respectively 6, 3

Practical Algorithm

1. Patient presents with heartburn/regurgitation:

   • Alarm symptoms present? → Endoscopy now 1, 6
   • No alarm symptoms? → Start twice-daily PPI for 4–8 weeks 1

2. After 4–8 weeks of PPI:

   • Symptoms resolved? → Continue PPI at lowest effective dose; no endoscopy needed 1
   • Symptoms persist? → Endoscopy indicated 1, 6

3. If endoscopy shows severe erosive esophagitis (LA grade B–D):

   • Repeat endoscopy after 2 months of PPI to confirm healing and rule out Barrett's 1, 6, 3
   • If healed and no Barrett's → no further routine endoscopy 6, 3

4. If Barrett's esophagus found:

   • No dysplasia → surveillance every 3–5 years 1, 6
   • Dysplasia present → more frequent surveillance 1, 6

5. Screening consideration (men >50 with chronic GERD >5 years + risk factors):

   • One-time endoscopy may be considered after shared decision-making and assessment of life-limiting comorbidities 1, 6
   • If negative → no repeat screening 1, 6