In patients with atypical symptoms or symptoms over and above those of typical reflux, endoscopy may also have utility in ruling out alternative diseases, such as peptic ulcer disease, eosinophilic esophagitis and complications like adenocarcinoma. Eosinophilic esophagitis, also known as primary eosinophilic esophagitis or idiopathic eosinophilic esophagitis, occurs in adults and in children and represents a subset of eosinophilic gastroenteritis with an isolated severe esophageal eosinophilia. Patients with eosinophilic esophagitis present with symptoms similar to those of gastroesophageal reflux but may be less responsive to antireflux medication. The importance of recognizing this entity, especially in children is underscored by the need for different treatment approaches, e.g., dietary restriction or corticosteroids and in preventing unnecessary fundoplication . Dyspepsia and GERD may overlap and sometimes they may be difficult to distinguish by symptoms alone. Many patients with upper gastrointestinal symptoms have significant anxiety about their diagnosis, including fear of cancer, and that some of that anxiety and anxiety-related impairment of quality of life could be improved with the knowledge of a normal upper endoscopy .
An additional benefit of endoscopy in GERD patients is that it provides the opportunity for therapeutic stricture dilation, as well as biopsy confirmation of any tumors or Barrett esophagus. It can also identify the subset of patients who may need future surveillance, although this is controversial. An index endoscopy for GERD may also obviate need for future screening procedures as BE is almost always diagnosed at its full extent at the first endoscopy  and rarely, if ever, develops after a normal endoscopy. Therefore, those who respond to a treatment trial and have no erosive esophagitis or BE on the initial endoscopy would be able to enter a maintenance treatment program with no further fears of significant pathology.
However, any new onset of gastrointestinal symptoms including reflux symptoms, in patients older than 60-65 years also requires further investigation (i.e., endoscopy) as do patients with dysphagia, weight loss, anemia, and atypical symptoms , , .
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