Role of endoscopy in the management of GERD GUIDELINE

GUIDELINE
Role of endoscopy in the management of GERD
This is one of a series of statements discussing the use
of gastrointestinal endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this
text. In preparing this guideline, a search of the medical
literature was performed using PubMed, supplemented
by accessing the ‘‘related articles’’ feature of PubMed.
Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When little or no data exist
from well-designed prospective trials, emphasis is given
to results from large series and reports from recognized
experts. Guidelines for appropriate use of endoscopy
are based on a critical review of the available data
and expert consensus at the time the guidelines are
drafted. Further controlled clinical studies may be
needed to clarify aspects of this guideline. This guideline
may be revised as necessary to account for changes in
technology, new data, or other aspects of clinical practice. The recommendations were based on reviewed studies and were graded on the strength of the supporting
evidence (Table 1).1 This guideline is intended to be an
educational device to provide information that may assist endoscopists in providing care to patients. This guideline is not a rule and should not be construed as
establishing a legal standard of care or as encouraging,
advocating, requiring, or discouraging any particular
treatment. Clinical decisions in any particular case involve a complex analysis of the patient’s condition and
available courses of action. Therefore, clinical considerations may lead an endoscopist to take a course of action that varies from these guidelines. This guideline
supplements and replaces our previous document on
the role of endoscopy in GERD.2
Gastroesophageal reflux disease (GERD) is a condition
that develops when reflux of stomach contents causes
troublesome symptoms (eg, heartburn and regurgitation)
or complications (eg, erosive esophagitis).3-5 In a recent
systematic review, the prevalence of GERD in the Western
world was estimated to be 10% to 20%, with GERD defined as at least weekly heartburn and/or acid regurgitation.3,4 GERD is the third most common GI disorder in
the United States, affecting 19 million adults and accounting for 4,590,000 outpatient visits and 96,000 hospitalizations annually.6 The annual economic impact of GERD
was estimated to be $9.3 billion in 2000.7 Greater than
60% of this burden is related to the cost of antisecretory
medications.8 In addition to quality of life issues, the
numerous complications of chronic GERD, such as esophageal stricture formation, Barrett’s metaplasia, and esophageal adenocarcinoma, necessitate adequate diagnosis and
treatment of this common entity.
INDICATIONS FOR ENDOSCOPIC EVALUATION
Copyright ª 2007 by the American Society for Gastrointestinal Endoscopy
0016-5107/$32.00
doi:10.1016/j.gie.2007.05.027
A diagnosis of GERD can be made based on a history of
classic symptoms3 and favorable response to antisecretory
medical therapy.2,3 It is important to note that epigastric
pain can be the major symptom of GERD.3 If the patient’s
history is typical for uncomplicated GERD, an initial trial of
empiric medical therapy is appropriate prior to endoscopy
in most patients.9 Endoscopy at presentation should be
considered in patients who have symptoms suggestive of
complicated disease or those at risk for Barrett’s esophagus.10-12 Failure to respond to appropriate antisecretory
medical therapy or the presence of other clinical signs
suggestive of complicated GERD should prompt evaluation with EGD and consideration of other diagnostic modalities, including ambulatory pH monitoring, esophageal
manometry, and multichannel impedance testing.13
The indications for EGD in patients with GERD are
listed in Table 2. Endoscopy should also be considered
in the evaluation and management of patients with suspected extra-esophageal manifestations of GERD who
present with symptoms such as choking, coughing, and
hoarseness.14 Additionally, EGD may be necessary for
the detection or exclusion of erosive esophagitis, peptic
strictures, esophageal cancer, gastric outlet obstruction,
and other potentially significant upper-GI tract findings.
It has been proposed that a baseline EGD should be
performed in patients with GERD requiring continuous
acid-suppressive therapy, especially after recurrence of
symptoms upon withdrawal of successful medical therapy.15 Such a recommendation is not universally accepted,
however, and one must also consider associated drawbacks of EGD, such as the potential physical risks, financial costs, and limited access to the procedure. There is
also a paucity of outcomes research to suggest that early
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Volume 66, No. 2 : 2007 GASTROINTESTINAL ENDOSCOPY 219
Role of endoscopy in the management of GERD
TABLE 1. 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
1Cþ
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, et al. Moving from evidence to action: grading recommendationsda qualitative approach. In: Guyatt G, Rennie D,
editors. Users’ guides to the medical literature. Chicago: AMA Press; 2002. p. 599-608.
TABLE 2. Indications for endoscopy in patients
with GERD
GERD symptoms that are persistent or progressive
despite appropriate medical therapy
features.4 Endoscopy is often performed as part of the
preoperative evaluation of patients being considered for
antireflux surgery, for the placement of a wireless esophageal pH monitoring system (as described in a recent technology status evaluation report), and is an inherent part of
various endoscopic antireflux procedures.16
Dysphagia or odynophagia
Involuntary weight loss O5%
Evidence of GI bleeding or anemia
Finding of a mass, stricture, or ulcer on imaging studies
DIAGNOSIS AND CLASSIFICATION OF GERD
or even once-in-a-lifetime EGD has a favorable effect upon
the management, course, or health-related quality of life
of patients with typical symptoms of GERD without alarm
Patients with reflux esophagitis have endoscopic and/or
histopathologic changes of esophageal mucosal injury and
inflammation. The presence of typical findings of reflux
esophagitis on endoscopy is diagnostic of GERD with
a specificity of 90% to 95%.17,18 At least 50% of patients
with reflux symptoms have normal esophageal endoscopic findings (nonerosive reflux disease [NERD]) or uncomplicated GERD.3,19 Furthermore, GERD symptoms do
not correlate with the degree of underlying esophageal
damage. Because of these observations, current recommendations are to initiate empiric antisecretory therapy
in patients with typical GERD symptoms in the absence
of alarm features.3
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Evaluation of patients with suspected extra-esophageal
manifestations of GERD
Screening for BE in selected patients (as clinically
indicated)
Persistent vomiting
Evaluation of patients with recurrent symptoms after
endoscopic or surgical antireflux procedures
Role of endoscopy in the management of GERD
TABLE 3. The modified Los Angeles classification
of GERD
TABLE 4. The modified Savary-Miller classification
of GERD
Grade
Grade
Description
A
One (or more) mucosal break no longer
than 5 mm that does not extend between
the tops of 2 mucosal folds
B
One (or more) mucosal break more
than 5 mm that does not extend between
the tops of 2 mucosal folds
C
One (or more) mucosal break that
is continuous between the tops of 2
or more mucosal folds but that involves less
than 75% of the circumference
D
One (or more) mucosal break that involves
at least 75% of the esophageal circumference
There are several classification systems for grading the
endoscopic severity of erosive reflux esophagitis and
associated complications20 (Tables 3 and 4). These classification systems have been primarily used in clinical trials to
study the efficacy of medical therapy as treatment of reflux
esophagitis. However, these systems are useful in clinical
practice for documenting disease severity. Currently, the
most commonly used systems are the Los Angeles
classification (Table 3) and the Savary-Miller classification
(Table 4), with the latter being used predominantly in Europe. The Los Angeles classification has several advantages. First, it has been shown to be reliable, with good
intra- and inter-observer agreement when tested among
expert and inexperienced endoscopists.20 Second, when
using this system, the severity of esophagitis has been
demonstrated to correlate with the extent of esophageal
acid exposure determined by 24-hour pH monitoring.21
These 2 systems avoid the use of erythema as a descriptor
due to its nonspecific language. It is strongly recommended that the endoscopist describe the extent of endoscopic abnormalities, either through the use of an
accepted grading system or by a detailed description of
the endoscopic findings.
When esophagitis is defined endoscopically, biopsy
specimens of the mucosa should be obtained under the
following circumstances: underlying immunocompromised state, irregular or deep ulceration present, proximal
distribution of esophagitis, presence of a mass lesion or
nodularity, an irregular or malignant-appearing stricture.
In these situations, forceps biopsy and/or brush cytology
specimens are necessary to exclude other diagnoses, including infectious etiologies and malignancy. Historically,
follow-up EGD for patients with GERD with esophagitis
was reserved for patients whose symptoms failed to respond to medical therapy, those who had severe esophagitis or an esophageal ulcer, or for those who needed
additional biopsy to clarify a diagnosis. It has recently
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Lesion
I
Single or isolated erosive lesion, oval or linear,
but affecting only 1 longitudinal fold
II
Multiple erosive lesions, noncircumferential,
affecting more than 1 longitudinal fold,
with or without confluence
III
Circumferential erosive lesions
IV
Chronic lesions including ulcer(s), stricture(s),
and/or short esophagus, alone or associated
with lesions of grades I to III
V
Columnar epithelium in continuity with the
Z line, noncircular, star-shaped, or
circumferential, alone or associated with
lesions grades I to IV
been suggested, however, that there may be a role for repeat EGD after adequate medical therapy has achieved
mucosal healing in patients with esophagitis, specifically
to exclude Barrett’s esophagus (BE).22
COMPLICATIONS OF GERD
Peptic strictures
The endoscopic evaluation and management of peptic
strictures is discussed in another guideline.23
BE
BE is a condition in which the squamous epithelium of
the distal esophagus is replaced by an abnormal columnar
epithelium known as specialized intestinal metaplasia.24
BE can be found in 10% to 15% of patients undergoing
EGD for GERD.25 Recommendations outlining the role
of EGD for screening and surveillance for BE have recently
been published,26 and the practice of screening and surveillance of BE remains a contentious issue. A landmark
modeling study showed that a strategy of endoscopic
screening for BE in 50-year-old white males with GERD followed by subsequent endoscopic surveillance for those
with dysplasia was associated with acceptable costs per
quality-adjusted life year saved.27 Several other modeling
studies reached similar conclusions regarding screening
for this specific population but differed regarding the
cost effectiveness of additional surveillance in patients
with nondysplastic BE.28,29 Widespread screening of the
entire population with GERD would not be feasible given
both the high prevalence of GERD in the Western world
and the presence of many asymptomatic individuals
harboring BE.28 However, there appear to be factors associated with BE that may allow for the selection of
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Role of endoscopy in the management of GERD
individuals for screening EGD, including a prolonged history of GERD symptoms (O5 years), white race, male sex,
older age (O50 years), and family history of BE and/or adenocarcinoma of the esophagus.25,26
Endoscopy is the most accurate tool for the detection
and diagnosis of BE. In order to determine the presence
of BE endoscopically, the squamocolumnar junction and
the gastroesophageal junction must be clearly identified.
While proximal displacement of the squamocolumnar
junction relative to the gastroesophageal junction is suggestive of BE, this endoscopic appearance of salmoncolored mucosa or an irregular Z line, either alone or in
combination, is not sufficient to make the diagnosis.3 Biopsy specimens should always be obtained for histopathologic confirmation of columnar epithelium. The optimal
number of biopsies necessary to identify intestinal metaplasia is not known, but it is generally accepted that multiple biopsy specimens should be obtained in all areas of
suspected BE.30 The presence of erosive esophagitis may
impair the accurate histopathologic detection of Barrett’s
epithelium and dysplasia.22 Multiple trials have demonstrated that an 8-week treatment duration is adequate to
achieve mucosal healing in most patients with erosive esophagitis treated with proton-pump inhibitors (PPIs).31-34
A recently published trial involving 172 patients with
esophagitis who did not have BE identified on initial
EGD noted that, after therapy with PPIs (mean 11 weeks;
range 8-16 weeks), BE was identified in 12%.22 Recommendations from this trial included pretreatment with
acid suppressive agents for patients with GERD symptoms
who were undergoing EGD for BE screening, and consideration of repeat endoscopy after healing for those patients with esophagitis on index endoscopy. Care should
be taken to avoid obtaining biopsy specimens from
a normal-appearing squamocolumnar junction or from the
proximal cardia because biopsy specimens from these
areas may demonstrate intestinal metaplasia, which can
be present at these locations and provide a false diagnosis
of BE.35,36 The finding of intestinal metaplasia of the
gastroesophageal junction or cardia does not appear to
confer the same (if any) malignant potential as does
long-segment (R 3cm) BE, and there is no current evidence to support surveillance endoscopic examinations
in these patients.3,27,37 In patients with BE with no evidence of dysplasia on initial endoscopy, a repeat endoscopy should be performed within the next year. If no
dysplasia is confirmed, these patients are considered to
be at low risk to have their condition progress and/or
develop cancer. Therefore, the interval for additional
surveillance has been recommended to be every 3 years.
However, on the basis of decision analysis models, the
more appropriate interval may be 5 years.26
Reassessment of the cost effectiveness of screening and
surveillance for BE will need to be performed if new technologies, such as unsedated endoscopy with small-caliber
endoscopesdpreviously shown to be reliable for screen-
ing for BE38 and to prevent loss of work days39dand/or
wireless capsule endoscopy (WCE), prove to be as accurate as standard EGD and biopsy for the diagnosis of BE
and dysplasia. The precise role of these technologies for
diagnosing or managing Barrett’s epithelium, however,
remains unclear at this time.40
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ENDOSCOPIC ANTIREFLUX PROCEDURES
The endoluminal treatment of GERD is evolving and may
have the potential to decrease the need for long-term antisecretory medications in selected patients. Most studies of
endoluminal therapies for GERD have involved small numbers of PPI-dependent patients and have provided relatively
limited follow-up information, so the durability of these
therapies remains in question. Additionally, both shortand long-term safety issues surrounding the endoluminal
devices continue to be a concern, and the economics of
their use are unknown. A technical review on the use of
endoscopic therapies for GERD was recently published.41
The new endoscopic antireflux techniques represent a rapidly evolving area of GI endoscopy, but additional research is
needed before they can be widely recommended. Appropriate patient selection and endoscopist experience should be
carefully considered before pursuing these therapies. It is
important that patients and practitioners alike be aware of
the limitations in the evidence that exist with these devices
at the present time.
SUMMARY
d
d
d
d
d
d
d
d
d
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
BE (2C).
Biopsy must be performed to confirm endoscopicallysuspected 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
Role of endoscopy in the management of GERD
1. Guyatt G, Sinclair J, Cook D, et al. Moving from evidence to action:
grading recommendationsda qualitative approach. In: Guyatt G, Rennie D, editors. Users’ guides to the medical literature. Chicago: AMA
Press; 2002. p. 599-608.
2. American Society for Gastrointestinal Endoscopy. The role of endoscopy in the management of GERD: guidelines for clinical application.
Gastrointest Endosc 1999;49:834-5.
3. Vakil N, van Zanten SV, Kahrilas P, et al. The Montreal definition and
classification of gastroesophageal reflux disease: a global evidencebased consensus. Am J Gastroenterol 2006;101:1900-20.
4. DeVault KR, Castell DO. Updated guidelines for the diagnosis and
treatment of gastroesophageal reflux disease. Am J Gastroenterol
2005;100:190-200.
5. Jones R, Galmiche JP. Review: what do we mean by GERD? Definition
and diagnosis. Aliment Pharmacol Ther 2005;22(Suppl. 1):2-10.
6. Russo MW, Wei JT, Thiny MT, et al. Digestive and liver diseases statistics, 2004. Gastroenterology 2004;126:1448-53.
7. Frank L, Kleinman L, Ganoczy D, et al. Upper gastrointestinal symptoms in North America: prevalence and relationship to healthcare utilization and quality of life. Dig Dis Sci 2000;45:809-18.
8. Sandler RS, Everhart JE, Donowitz M, et al. The burden of selected digestive diseases in the United States. Gastroenterology 2002;122:
1500-11.
9. Venables TL, Newland RD, Patel AC, et al. Omeprazole 10 milligrams
once daily, omeprazole 20 milligrams once daily, or ranitidine 150 milligrams twice daily, evaluated as initial therapy for the relief of symptoms of gastro-oesophageal reflux disease in general practice. Scand J
Gastroenterol 1997;32:965-73.
10. Lundell LR, Dent J, Bennett JR, et al. Endoscopic assessment of oesophagitis: clinical and functional correlates and further validation of the
Los Angeles classification. Gut 1999;45:172-80.
11. Wo JM, Mendez C, Harrell S, et al. Clinical impact of upper endoscopy
in the management of patients with gastroesophageal reflux disease.
Am J Gastroenterol 2004;99:2311-6.
12. Lieberman DA, Oehlke M, Helfand M. Risk factors for Barrett’s esophagus in community-based practice. GORGE consortium. Gastroenterology Outcomes Research Group in Endoscopy. Am J Gastroenterol
1997;92:1293-7.
13. Fock KM, Talley N, Hunt R, et al. Report of the Asia-Pacific consensus
on the management of gastroesophageal reflux disease. J Gastroenterol Hepatol 2004;19:357-67.
14. Poelmans J, Feenstra L, Demedts I, et al. The yield of upper gastrointestinal endoscopy in patients with suspected reflux-related chronic
ear, nose, and throat symptoms. Am J Gastroenterol 2004;99:
1419-26.
15. Dent J, Brun J, Fendrick A, et al. An evidence-based appraisal of reflux
disease management–the Genval Workshop Report. Gut 1999;
44(Suppl 2):S1-15.
16. Chotiprashidi P, Liu J, Carpenter S, et al. Wireless esophageal pH monitoring system. Gastrointest Endosc 2005;62:485-7.
17. Moayyedi P, Talley N. Gastro-oesophageal reflux disease. Lancet 2006;
367:2086-100.
18. Richter JE. Diagnostic tests for gastroesophageal reflux disease. Am J
Med Sci 2003;326:300-8.
19. Ronkainen J, Aro P, Storskrubb T, et al. High prevalence of gastroesophageal reflux symptoms and esophagitis with or without symptoms in the general adult Swedish population. A Kalixanda study
report. Scand J Gastroenterol 2005;40:275-80.
20. Rath HC, Timmer A, Kunkel C, et al. Comparison of interobserver
agreement for different scoring systems for reflux esophagitis; impact
of level of experience. Gastrointest Endosc 2004;60:44-9.
21. Kahrilas PJ, Pandolfino JE. Review article: oesophageal pH monitoringtechnologies, interpretation, and correlation with clinical outcomes.
Aliment Pharmacol Ther 2005;22(Suppl 3):2-9.
22. Hanna S, Rastogi A, Weston AP, et al. Detection of Barrett’s esophagus
after endoscopic healing of erosive esophagitis. Am J Gastroenterol
2006;101:1416-20.
23. Egan JV, Baron TH, Adler DG, et al. Esophageal dilation. Gastrointest
Endosc 2006;63:755-60.
24. Spechler SJ. Clinical practice: Barrett’s esophagus. N Engl J Med 2002;
346:836-42.
25. Wani S, Sharma P. The rationale for screening and surveillance
of Barrett’s metaplasia. Best Pract Res Clin Gastroenterol 2006;20:
829-42.
26. Hirota WK, Zuckerman MJ, Adler DG, et al. The role of endoscopy in
the surveillance of premalignant conditions of the upper GI tract. Gastrointest Endosc 2006;63:570-80.
27. Inadomi JM, Sampliner R, Lagergren J, et al. Screening and surveillance
for Barrett’s esophagus in high-risk groups: a cost utility diagnosis.
Ann Intern Med 2003;138:176-86.
28. Gerson LB, Groeneveld PW, Triadafilopoulos G. Cost-effectiveness
model of endoscopic screening and surveillance in patients with gastroesophageal reflux disease. Clin Gastro Hep 2004;2:868-79.
29. Provenzale D, Schmitt C, Wong JB. Barrett’s esophagus: a new look at
surveillance based on emerging estimates of cancer risk. Am J Gastroenterol 1999;94:2043-53.
30. Sharma P, McQuaid K, Dent J, et al. A critical review of the diagnosis
and management of Barrett’s esophagus: the AGA Chicago Workshop.
Gastroenterology 2004;127:310-30.
31. Castell DO, Kahrilas PJ, Richter JE, et al. Esomeprazole (40 mg) compared with lansoprazole (30 mg) in the treatment of erosive esophagitis. Am J Gastroenterol 2002;97:575-83.
32. Kahrilas PJ, Pandolfino JE. Review article: oesophageal pH monitoringtechnologies, interpretation and correlation with clinical outcomes.
Aliment Pharmacol Ther 2000;14:1249-58.
33. Labenz J, Armstrong D, Lauritsen K, et al. Esomeprazole 20 mg vs. pantoprazole 20 mg for maintenance therapy of healed erosive oesophagitis: results from the EXPO study. Aliment Pharmacol Ther 2005;21:
739-46.
34. Richter JE, Kahrilas PJ, Sontag SJ, et al. Comparing lansoprazole and
omeprazole in onset of heartburn relief: results of a randomized, controlled trial in erosive esophagitis patients. Am J Gastroenterol 2001;
96:3089-98.
35. Spechler SJ, Zeroogian JM, Antonioli DA, et al. Prevalence of metaplasia at the gastro-oesophageal junction. Lancet 1994;344:1533-6.
36. Hirota WK, Loughney TM, Lazas DJ, et al. Specialized intestinal metaplasia, dysplasia, and cancer of the esophagus and esophagogastric
junction: prevalence and clinical data. Gastroenterology 1999;116:
277-85.
37. Morales TG, Camargo E, Bhattacharyya A, et al. Long-term follow-up of
intestinal metaplasia of the gastric cardia. Am J Gastroenterol 2000;95:
1677-80.
38. Jobe BA, Hunter JG, Chang EY, et al. Office-based unsedated
small-caliber endoscopy is equivalent to conventional sedated endoscopy in screening and surveillance for Barrett’s esophagus: a randomized and blinded comparison. Am J Gastroenterol 2006;101:
2693-703.
39. Nietert PJ, Silverstein MD, Mokhashi MS, et al. Cost-effectiveness of
screening a population with chronic gastroesophageal reflux. Gastrointest Endosc 2003;57:311-8.
40. Mishkin DS, Chuttani R, Croffie J, et al. Wireless capsule endoscopy.
Gastrointest Endosc 2006;63:539-45.
41. Falk G, Fennerty MB, Rothstein RI. AGA institute technical review on
the use of endoscopic therapy for gastroesophageal reflux disease.
Gastroenterology 2006;131:1315-36.
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Volume 66, No. 2 : 2007 GASTROINTESTINAL ENDOSCOPY 223
careful discussion with the patient regarding potential
side effects, benefits, and other available therapeutic
options (3).
REFERENCES
Role of endoscopy in the management of GERD
Prepared by:
STANDARDS OF PRACTICE COMMITTEE
David R. Lichtenstein, MD
Brooks D. Cash, MD
Raquel Davila, MD
Todd H. Baron, MD, Chair
Douglas G. Adler, MD
Michelle A. Anderson, MD
Jason A. Dominitz, MD, MHS
Seng-Ian Gan, MD
M. Edwyn Harrison III, MD
Steven O. Ikenberry, MD
Waqar A. Qureshi, MD
Elizabeth Rajan, MD
Bo Shen, MD
Marc J. Zuckerman, MD
Robert D. Fanelli, MD, SAGES Representative
Trina VanGuilder, RN, BSN, SGNA Representative
This document is a product of the Standards of Practice Committee.
This document was reviewed and approved by the Governing Board
of the American Society for Gastrointestinal Endoscopy.
224 GASTROINTESTINAL ENDOSCOPY Volume 66, No. 2 : 2007
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