A normal gastroscopy is an important and generally reassuring finding. It shows that no ulcer, marked oesophagitis, mass or other important structural condition visible at endoscopy has been found.
But:
A normal endoscopy does not mean your symptoms are not real, or that there is no problem at all with your digestive system. Endoscopy can show only some of the conditions of the digestive system.
If the endoscopy is normal, why do symptoms continue?
One of the most commonly encountered causes is functional dyspepsia. In these patients, despite a normal endoscopy, symptoms such as stomach pain or burning, bloating after meals, early fullness, a feeling of fullness in the stomach, nausea and belching can continue.
The problem here is not a visible sore or mass; it can relate to the stomach’s movements, its emptying, its sensitivity and the interaction between the brain and the gut.
Could it be reflux?
Yes.
In a substantial proportion of patients with reflux, no oesophagitis is seen at endoscopy. This can be called non-erosive reflux disease (NERD).
Where reflux is suspected but the endoscopy is normal, 24-hour pH or pH-impedance measurement may be needed in selected patients. This test helps assess whether reflux into the oesophagus really is occurring.
Could it be H. pylori?
A normal-looking endoscopy does not rule out H. pylori infection.
H. pylori can be investigated by biopsy, a urea breath test or a stool H. pylori antigen test.
Depending on the type of test, proton pump inhibitors, antibiotics and bismuth can affect the result, so the medicines you take before the test should be discussed with your doctor.
Could there be a problem with the stomach emptying?
Where early fullness + prolonged fullness after meals + nausea + vomiting are prominent in particular, delayed emptying of the stomach (gastroparesis) can be considered.
A gastroscopy shows the inside of the stomach but does not measure how fast it empties. Gastric emptying tests can be done in patients who need them.
Could it be a condition of the gallbladder or pancreas?
It could. A gastroscopy is not an examination that assesses the gallbladder, the whole of the liver or the pancreas.
Depending on the nature of the symptoms, ultrasound, blood tests, CT or MRI, MRCP and, where needed, EUS may be used.
But not everyone with a normal endoscopy needs a CT, an MRI or an EUS. Tests should be chosen according to the patient’s symptoms and examination findings.
Could it be irritable bowel syndrome?
Where upper gastrointestinal symptoms are accompanied by abdominal pain, bloating, constipation, diarrhoea or a change in bowel habit in particular, irritable bowel syndrome (IBS) can also be considered.
Functional dyspepsia and IBS can be present together in the same person.
What if the biopsies are normal too?
That is possible.
A normal endoscopy plus normal biopsies helps rule out some important structural and microscopic conditions; but it does not rule out functional dyspepsia, NERD and some motility disorders.
So the conclusion “everything is normal, therefore there is nothing wrong with me” is not correct.
The better question is: “Given the nature of my symptoms, which condition should be looked into next?”
Does every patient need more tests?
No.
Having CT, MRI, endoscopy and laboratory tests one after another unnecessarily does not always help.
It is more appropriate to carry out targeted investigation, weighing age, the nature and duration of the symptoms, the medicines being taken, physical examination, family history and the tests already done.
When is reassessment particularly important?
Reassessment is needed, despite a normal endoscopy, if there is
Difficulty swallowing or food sticking · gastrointestinal bleeding · unexplained iron deficiency or anaemia · recurring or persistent vomiting · unintended weight loss · symptoms that keep worsening.
In brief
- A normal endoscopy Is a good finding.
- A normal endoscopy Does not mean "there is no cause for your symptoms".
- Burning or acid taste Endoscopy-negative reflux can be considered.
- Early fullness / fullness after meals Functional dyspepsia or a stomach emptying disorder can be assessed.
- Bloating + a change in bowel habit IBS and other bowel problems can be considered.
- A normal endoscopy Does not on its own rule out H. pylori.
- What matters Is not having more tests but choosing the right test for the right symptom.
This is not enough to make a diagnosis
If symptoms continue despite a normal endoscopy, the type and duration of the symptoms, the medicines being taken, any biopsy results and the tests already done all have to be weighed together in deciding the next step.
Sources
- Prof. Ali Tüzün İnce, MD