Is conventional endoscopic identification of non-erosive reflux disease adequate?

Non-erosive reflux disease is defined as the presence of troublesome reflux-associated symptoms in the absence of mucosal breaks at endoscopy. Given the fact that the majority of patients with reflux symptoms will have a normal endoscopy, efforts are underway to determine if new endoscopic techniques can identify changes heretofore invisible at the time of standard white light endoscopy. However, for any new endoscopic technology to be useful, the grading system it uses must be accurate, reproducible, easy to remember and easy to interpret. These requirements represent a high bar indeed for any new approach to non-erosive reflux disease. Current techniques under investigation include high-resolution endoscopy, magnification endoscopy, chromoendoscopy, narrow-band imaging and confocal endomicroscopy. All of these new technologies can identify minimal abnormalities heretofore not seen with traditional white light endoscopy. All of these new techniques allow for more detailed imaging of the esophagus in gastroesophageal reflux disease patients which makes this field ripe for re-examination. The most exciting findings to date are with narrow-band imaging and confocal endomicroscopy. However, studies to date are small and require validation in larger numbers of patients by larger number of endoscopists. Furthermore, it is essential that we do not repeat the mistakes of the past as poor interobserver agreement has already been shown for minimal change esophagitis, albeit with more primitive technology.