Upper endoscopy, also known as EGD (for esophago-gastro-duodenoscopy), is a procedure which allows direct examination of the lining of the esophagus (food pipe), the stomach and the first part of the small intestine (duodenum). When combined with ultrasound it is known as upper EUS.

What are reasons for doing an upper endoscopy (EGD) ?

EGD is a very versatile procedure and there are many reasons to do one:

  • Upper abdominal complaints (symptoms) that are not getting better
  • Serious symptoms such as loss of appetite and loss of weight
  • Trouble swallowing and painful swallowing
  • Persistent vomiting
  • GI bleeding
  • When x-rays show an abnormality and a direct look is required
  • GI bleeding
  • When cirrhosis causes enlargement of esophageal veins (esophageal varices)
  • and many more.

One of the more common reasons to perform an EGD is longstanding acid reflux which may lead to a precancerous condition known as Barrett’s esophagus. Here are the known risk factors:

Risk factors for the precancerous condition known as Barrett’s esophagus:

  • Longstanding heartburn, acid reflux, or regurgitation (GERD)
  • Obesity
  • Age (more common in the older population)
  • Ethnicity (more common among Caucasians)
  • Gender (more common among males)
  • History of smoking
Barrett’s esophagus is the replacement of the lining of the lower esophagus by a type of lining that is precancerous.

When you have one or more of these conditions screening for Barrett’s esophagus is recommended and is easily performed by performing an upper endoscopy. Most patients with Barrett’s esophagus do not require special treatment other than strong acid suppression, but repeat endoscopies every 3 – 5 years are recommended to make sure the Barrett’s mucosa has not become dysplastic (unstable – a step away from cancer).

Learn more about upper endoscopy (EGD) 

GERD – Gastroesophageal reflux disease – Acid reflux

Once you have been diagnosed with GERD (gastroesophageal reflux disease) there are several treatment options of which the so-called proton pump inhibitors have been the most popular ones.

Reflux of gastric contents is promoted by many factors and in some cases simple lifestyle modifications is all which is needed.

Proton pump inhibitors currently available:

omeprazole (Prilosec, Prilosec OTC), lansoprazole (Prevacid, Prevacid IV, Prevacid 24-Hour), dexlansoprazole (Dexilent, Dexilent Solutab), rabeprazole (Aciphex, Aciphex Sprinkle), pantoprazole (Protonix), esomeprazole (Nexium, Nexium IV, Nexium 24 HR), omeprazole/sodium bicarbonate (Zegerid, Zegerid OTC).

Are proton pump inhibitors (PPIs) dangerous?

Proton pump inhibitors have recently come under attack with the evidence for harm caused by PPIs being generally of low or very low quality. In 2017 the American Gastroenterological Association has the following advice to prescribers (Gastroenterology 2017;152:706–715) (abridged):

  1. Patients with GERD and acid-related complications (ie, erosive esophagitis or peptic stricture) should take a PPI for short-term healing, maintenance of healing, and long-term symptom control.
  2. Patients with uncomplicated GERD who respond to short-term PPIs should subsequently attempt to stop or reduce them. Patients who cannot reduce PPIs should consider ambulatory esophageal pH/impedance monitoring before committing to lifelong PPIs to help distinguish GERD from a functional syndrome. The best candidates for this strategy may be patients with predominantly atypical symptoms or those who lack an obvious predisposition to GERD (eg, central obesity, large hiatal hernia).
  3. Patients with Barrett’s esophagus and symptomatic GERD should take a long-term PPI.
  4. Asymptomatic patients with Barrett’s esophagus should consider a long-term PPI.
  5. Patients at high risk for ulcer-related bleeding from NSAIDs should take a PPI if they continue to take NSAIDs.
  6. The dose of long-term PPIs should be periodically reevaluated so that the lowest effective PPI dose can be prescribed to manage the condition.

The list above is not meant to constitute medical advice but illustrates that the decision to use or not use PPIs needs to be highly individualized. Patients should consult their primary care physician or gastroenterologist when making decisions related to proton pump inhibitor use.

What about surgical or endoscopic anti-reflux treatment?

The proton pump inhibitors do not abolish the reflux as such, instead, they only take the acid out of the equation. Some patients continue to have bothersome symptoms from reflux of gastric contents or, and this is increasingly more the case, do not want to take proton pump inhibitors long term.

Restoration of a natural anti-reflux barrier is currently only possible by antireflux interventions combined with hiatoplasty and necessitates a laparoscopic approach, specifically the Nissen fundoplication surgery.

A Nissen fundoplication is a surgical procedure where the top of the stomach (fundus) is freed from its attachments and then wrapped (plicated) around the lower end of the esophagus to create a reflux barrier.

Newer alternative techniques to the generally accepted fundoplication are laparoscopic implantation of the LINX® device (currently available) or the EndoStim® system (currently undergoing trials in the US), and various endoscopic antireflux procedures, such as radiofrequency energy treatment, plication and implantation techniques aimed at augmentation of the gastroesophageal valve.

 

The Linx system consist of magnetic beads that are wrapped around the lower end of the esophagus. The beads work as magnetic sphincter muscle that opens when food goes down the esophagus but closes again once the food is through preventing reflux (figure from patent drawing).
The Linx magnetic beads for GERD.

The LINX® System is a small flexible band of interlinked titanium beads with magnetic cores. The magnetic attraction between the beads is intended to help the LES (lower esophageal sphincter) resist opening to gastric pressures, preventing reflux from the stomach into the esophagus. LINX is designed so that swallowing forces temporarily break the magnetic bond, allowing food and liquid to pass normally into the stomach. The magnetic attraction of the device is designed to close the LES immediately after swallowing, restoring the body’s natural barrier to reflux.

Learn more about reflux disease (GERD)
Learn more about LINX®

Where can I get independent advice about surgical anti-reflux procedures?

When surgical anti-reflux procedures are considered, patients should see a gastroenterologist who is familiar with the latest technologies and can give independent advice and perform pre-op endoscopic evaluation.

Dr. Klaus Gottlieb in Templeton, CA, has authored or co-authored the following papers relevant to GERD and Linx (magnetic band):

Gottlieb, Klaus T., et al. “Magnets in the GI tract.” Gastrointestinal Endoscopy 78.4 (2013): 561-567.

Wang A, Pleskow DK, Banerjee S, Barth BA, Bhat YM, Desilets DJ, Gottlieb KT, Maple JT, Pfau PR, Siddiqui UD, Tokar JL. “Esophageal function testing”. Gastrointestinal Endoscopy. 2012 Aug 1;76(2):231-43.

Gottlieb, Klaus T., et al. “Monitoring equipment for endoscopy.” Gastrointestinal Endoscopy 77.2 (2013): 175-180.

Siddiqui UD, Banerjee S, Barth B, Chauhan SS, Gottlieb KT, Konda V, Maple JT, Murad FM, Pfau PR, Pleskow DK, Tokar JL. “Tools for endoscopic stricture dilation”. Gastrointestinal endoscopy. 2013 Sep 1;78(3):391-404.