Interobserver and intraobserver variation in endoscopic assessment of GERD using the "Los Angeles" classification

Usefulness of Endoscopy for the Detection and Diagnosis of Primary Esophageal Motility Disorders and Diseases Relating to Abnormal Esophageal Motility

Esophagogastroduodenoscopy (EGD) is performed to rule out organic diseases in the diagnosis of esophageal motility disorders (EMDs). Abnormal endoscopic findings can be observed during EGD, which indicate the presence of EMDs. Several endoscopic findings at both the esophagogastric junction and esophageal body that are related to EMDs have been reported. Gastroesophageal reflux disease (GERD) and eosinophilic esophagitis (EoE) could be detected during EGD, and these diseases are often associated with abnormal esophageal motility. Image-enhanced endoscopy (IEE) could improve the detection of these diseases during EGD. Although no report has been published previously on the potential usefulness of IEE in the endoscopic diagnosis of EMDs, IEE can be used to detect disorders that can be associated with abnormal esophageal motility.

Quality of upper GI endoscopy: a prospective cohort study on impact of endoscopist education

BACKGROUND AND AIMS

Guidelines on quality of upper GI (UGI) endoscopy have been proposed by the British Society of Gastroenterology (BSG) and European Society of Gastrointestinal Endoscopy (ESGE). However, these guidelines have not been evaluated in clinical practice. We aimed to measure the impact of endoscopist education on the quality of gastroscopy based on these guidelines and the association between compliance with guidelines and the detection of clinically significant premalignant pathology such as Barrett's esophagus (BE), esophageal squamous dysplasia, gastric intestinal metaplasia (GIM), and Helicobacter pylori.

METHODS

Endoscopists participated in a 1-hour education session on recommended performance measures and endoscopic detection of premalignant pathologies. A controlled before and after study was performed, measuring compliance with guidelines and rates of detection of pathology in control and intervention groups.

RESULTS

Over 2 years, 2719 procedures were performed: 1412 in the control group and 1307 in the intervention group. The proportion of procedures complying with guidelines was higher in the intervention group. The use of biopsy sampling protocols (eg, management of precancerous conditions of the stomach, 52% vs 91%; P = .007) and standardized terminology (eg, Forrest classification, 24% vs 68%; P < .001) was significantly higher. Detection of H pylori was higher in the intervention group (5.5% vs 9.8%, P = .003). Minimum inspection time of 7 minutes was associated with detection of BE (7.4% vs 2.0%, P < .001).

CONCLUSIONS

A simple endoscopist education session enhanced the quality of UGI endoscopy by improving compliance with BSG and ESGE recommendations and increasing the detection of clinically significant pathology. A minimum inspection time of 7 minutes was associated with increased diagnostic yield and may be a feasible quality indicator for clinical practice.

The Hill's Classification Is Useful to Predict the Development of Postoperative Gastroesophageal Reflux Disease and Erosive Esophagitis After Laparoscopic Sleeve Gastrectomy

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is one of the commonest bariatric procedures. However, it is associated with postoperative gastroesophageal reflux disease (GERD) and erosive esophagitis (EE). This study aims to assess the impact of various preoperative clinical and endoscopic characteristics on the development of postoperative GERD and EE.

METHODS

This study is a single-institution retrospective cohort study involving all patients who underwent LSG. A univariate and multivariate analysis was performed to identify preoperative parameters that were significantly associated with the development of postoperative GERD and EE, at up to 1-year follow-up.

RESULTS

At up to 1-year follow-up, out of 127 patients, only preoperative endoscopic presence of a hiatal hernia noted on axial length (p=0.024) and the Hill's classification of the gastroesophageal junction (p<0.001) were significantly associated with the development of postoperative GERD. Similarly, at 1-year follow-up endoscopy, the presence of a hiatal hernia (p=0.041) and the Hill's classification (p=0.001) were associated with postoperative EE. On the multivariate analysis, compared to patients with a Hill's I flap valve, Hill's II patients were more likely to develop postoperative GERD (OR 7.13, 95% CI: 1.69-29.98, p=0.007), and Hill's III patients were more likely to develop postoperative GERD (OR 20.84, 95% CI: 3.98-109.13, p<0.001) and EE (OR 34.49, 95% CI: 1.08-1105.36, p=0.045). All patients with Hill's IV developed postoperative GERD and EE in this study.

CONCLUSION

Postoperative GERD and EE remain an important limitation following LSG. Proper preoperative assessment using the Hill's classification can help to accurately predict patients at risk of postoperative GERD and EE.

Definition of Mucosal Breaks in the Era of Magnifying Endoscopy with Narrow-Band Imaging

Background

Gastroesophageal reflux disease is diagnosed endoscopically based on the presence of mucosal breaks. However, mucosal breaks can be judged differently depending on the endoscopist, even in the same image. We investigated how narrow-band imaging (NBI) and magnified endoscopy affect the judgment of mucosal breaks.

Methods

A total of 43 consecutive patients were enrolled who had suspected mucosal breaks on white-light images (WLI) and underwent nonmagnified NBI (N-NBI) and magnified NBI (M-NBI) by a single endoscopist. From WLI, N-NBI, and M-NBI, 129 image files were created. Eight endoscopists reviewed the image files and judged the presence of mucosal breaks.

Results

The 8 endoscopists determined mucosal breaks were present in 79.4 ± 9.5% (67.4%-93.0%) on WLI, and 76.7 ± 12.7% (53.5%-90.7%) on N-NBI. However, the percentage of mucosal breaks on M-NBI was significantly lower at 48.8 ± 17.0% (18.6%-65.1%) (p < 0.05). Intraclass correlation between observers was 0.864 (95% CI 0.793-0.918) for WLI and 0.863 (95% CI 0.791-0.917) for N-NBI but was lower for M-NBI at 0.758 (95% CI 0.631-0.854).

Conclusion

Rates of detection and agreement for mucosal breaks on WLI and N-NBI were high among endoscopists. However, these rates were lower on M-NBI.

The role of endoscopy in the management of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) is a common disease that may cause a huge economic burden. Endoscopy is performed not only to rule out other organic diseases but also to diagnose reflux esophagitis or Barrett's esophagus. Non‐erosive GERD (non‐erosive reflux disease [NERD]) is called endoscopy‐negative GERD; however, GERD‐related findings could be obtained through histological assessment, image‐enhanced endoscopy, and new endoscopic modalities in patients with NERD. Moreover, endoscopy is useful to stratify the risk for the development of GERD. In addition, endoscopic treatments have been developed. These techniques could significantly improve patients’ quality of life as well as symptoms.

Efficacy of Vonoprazan for Refractory Reflux Esophagitis after Esophagectomy

BACKGROUND

Refractory reflux esophagitis (RRE), unresponsive to conventional proton-pump inhibitors (PPIs), is a complication in esophagectomy with gastric pull-up. Vonoprazan (VPZ), a novel potassium-competitive acid blocker, has been available in Japan since 2015. Here, we investigated the efficacy of VPZ on PPI-resistant RRE after esophagectomy with gastric pull-up.

METHODS

This was a single-center retrospective study. We used the revised Los Angeles (r-LA) classification based on the Los Angeles classification and the modified Los Angeles classification to evaluate abnormal forms of mucosal breaks such as lateral spreading consistently. Patients who underwent esophagectomy with gastric pull-up and had RRE grade B-D as per the r-LA classification, despite using standard-dose PPIs or double dose of rabeprazole, were included. Sixteen patients who switched to VPZ (20 mg/day) and 14 patients who continued PPIs were assigned to the VPZ and PPI groups, respectively. Endoscopic observations were reviewed by 3 endoscopists using the r-LA classification to ensure consistent diagnosis, while the treatment arm and patient information were blinded to evaluators. We defined mucosal breaks that improved by at least one grade after treatment as improved mucosa and recovery to grade M or N as mucosal healing.

RESULTS

The percentage of patients with improved mucosa in the VPZ and PPI groups was 81.3 and 14.3%, respectively (p < 0.001). The rate of mucosal healing was 68.8 and 7.1%, respectively (p = 0.001).

CONCLUSION

VPZ significantly improved PPI-resistant RRE after esophagectomy with gastric pull-up.

Multichannel impedance monitoring for distinguishing nonerosive reflux esophagitis with minor changes on endoscopy in children

Objectives:

There are reports describing the relationship between baseline impedance level and esophageal mucosal integrity at endoscopy, such as erosive and nonerosive reflux esophagitis. However, many children with symptoms of gastroesophageal reflux disease have normal findings or minor changes on esophagogastroduodenoscopy. We aimed to examine whether modest changes at esophagogastroduodenoscopy can be evaluated and correlated with esophageal multichannel intraluminal impedance monitoring.

Methods:

Patients (ages 0–17 years) with upper gastrointestinal symptoms who underwent combined esophagogastroduodenoscopy and multichannel intraluminal impedance monitoring at the Women’s and Children’s Hospital, Adelaide, Australia, between 2014 and 2016 were retrospectively studied and the following data were collected and used for analysis: demographics, multichannel intraluminal impedance data, included baseline impedance. Endoscopic findings were classified by modified Los Angeles grading, Los Angeles N as normal, Los Angeles M as with minimal change such as the erythema, pale mucosa, or friability of the mucosa following biopsy. Patients on proton pump inhibitor were excluded.

Results:

Seventy patients (43 boys; 61%) were enrolled with a mean age of 7.9 years (range 10 months to 17 years). Fifty-one patients (72.9%) were allocated to Los Angeles N, while Los Angeles M was evident in 19 patients (27.1%). Statistically significant differences were observed in the following parameters: frequency of acid and nonacid reflux and baseline impedance in channels 5 and 6. The median values of the data were 18.3 episodes, 16.0 episodes, 2461.0 Ω, 2446.0 Ω in Los Angeles N, 36.0 episodes, 31.0 episodes, 2033.0 Ω, 2009.0 Ω in Los Angeles M, respectively.

Conclusion:

Lower baseline impedance is helpful in predicting minimal endoscopic changes in the lower esophagus. A higher frequency of acid and nonacid reflux episodes was also predictive of minimal endoscopic change in the lower esophagus.

A Deep Learning Model for Classification of Endoscopic Gastroesophageal Reflux Disease

Gastroesophageal reflux disease (GERD) is a common disease with high prevalence, and its endoscopic severity can be evaluated using the Los Angeles classification (LA grade). This paper proposes a deep learning model (i.e., GERD-VGGNet) that employs convolutional neural networks for automatic classification and interpretation of routine GERD LA grade. The proposed model employs a data augmentation technique, a two-stage no-freezing fine-tuning policy, and an early stopping criterion. As a result, the proposed model exhibits high generalizability. A dataset of images from 464 patients was used for model training and validation. An additional 32 patients served as a test set to evaluate the accuracy of both the model and our trainees. Experimental results demonstrate that the best model for the development set exhibited an overall accuracy of 99.2% (grade A-B), 100% (grade C-D), and 100% (normal group) using narrow-band image (NBI) endoscopy. On the test set, the proposed model resulted in an accuracy of 87.9%, which was significantly higher than the results of the trainees (75.0% and 65.6%). The proposed GERD-VGGNet model can assist automatic classification of GERD in conventional and NBI environments and thereby increase the accuracy of interpretation of the results by inexperienced endoscopists.

Erosive Tooth Wear and Erosive Esophagitis in Children: An Observational Study in Porto Alegre, Brazil

The aim of this study was to establish and compare the prevalence and severity of erosive tooth wear (ETW) in children with and without erosive esophagitis. Children aged 5-12 years, scheduled for upper digestive endoscopy at the Pediatric Gastroenterology Service of the Children's Hospital Santo Antonio, Porto Alegre, Brazil, were eligible to participate in this study. Patients who presented erosive esophagitis at endoscopy were defined as gastroesophageal reflux disease (GERD) carriers, and the severity was described according to the Los Angeles classification. The oral cavity examination was performed by a trained and calibrated dentist and ETW was classified using the Basic Erosive Wear Examination (BEWE) index. Parents/guardians answered a questionnaire about the patients' diets and frequency of consumption of acidic foods and beverages. A total of 110 children were included in the study. Erosive esophagitis was observed in 24 patients (21.8%) and all of them (100%) presented ETW, showing a statistically significant association between these 2 conditions (p < 0.05). Among children who did not present with erosive esophagitis (n = 86), 54 (64.3%) had an ETW risk level of none according to their BEWE scores (0-2). The results of this study showed a statistically significant association between erosive esophagitis and ETW, thus it can be concluded that it is important to recognize groups at risk of ETW and act together with medical professionals to ensure adequate oral health for these patients.

Gender Specific Differences in Prevalence and Risk Factors for Gastro-Esophageal Reflux Disease

BACKGROUND

Gender-related factors might play an important role in the development of reflux esophagitis (RE) and symptomatic gastro-esophageal reflux disease (GERD). We aimed to evaluate the prevalence and risk factors for RE and symptomatic GERD and determine whether gender specific differences exist.

METHODS

This study was conducted on a health cohort consisting of 10,158 participants who underwent comprehensive health screening. Lifestyles and gastrointestinal symptoms were investigated using a self-reported structured questionnaire. Questionnaires about menstrual status were added for the women.

RESULTS

The prevalence of RE in men was significantly higher than that in women (10.6% vs. 2.0%, P < 0.001); however, symptomatic GERD showed predominance in women (6.2% vs. 2.5%, P < 0.001). Although the prevalence of RE gradually increased with the duration of menopause stratified by decade (P = 0.007), that of symptomatic GERD rapidly increased across the menopausal transit in women. Apart from common risk factors of obesity and current smoking for RE, over 70 years of age in women and hiatal hernia and hypertriglyceridemia in men were significant risk factors. In symptomatic GERD, high somatization was a common risk factor. Excessive alcohol drinking was a significant risk factor in men, but not in women.

CONCLUSION

This study showed a predominance of RE in men, but a predominance of symptomatic GERD in women. In women, dynamic increase in the prevalence of GERD is closely related to the menopause conditions and its duration. There are specific risk factors for RE and symptomatic GERD according to gender differences.

Management of gastroesophageal reflux disease

Gastroesophageal reflux disease (GERD) continues to be one of the most prevalent gastrointestinal tract disorders. Management of GERD is individualized for each patient depending on severity of symptoms, complications of GERD and patient/physician preference. The different management options include life style modification, pharmacological therapy, minimally invasive procedures and surgery. The final decision regarding management should be made based on an individualized patient centered approach on a case-by-case basis in consultation with a multidisciplinary team including primary care physician, gastroenterologist and surgeon. We provide a comprehensive review for the management of GERD.

Upper gastrointestinal bleeding caused by severe esophagitis: a unique clinical syndrome

BACKGROUND

We have recognized a unique clinical syndrome in patients with upper gastrointestinal bleeding who are found to have severe esophagitis.

AIM

We aimed to more clearly describe the clinical entity of upper gastrointestinal bleeding in patients with severe esophagitis.

METHODS

We conducted a retrospective matched case-control study designed to investigate clinical features in patients with carefully defined upper gastrointestinal bleeding and severe esophagitis. Patient data were captured prospectively via a Gastrointestinal Bleeding Healthcare Registry, which collects data on all patients admitted with gastrointestinal bleeding. Patients with endoscopically documented esophagitis (cases) were matched with randomly selected controls that had upper gastrointestinal bleeding caused by other lesions.

RESULTS

Epidemiologic features in patients with esophagitis were similar to those with other causes of upper gastrointestinal bleeding. However, hematemesis was more common in patients with esophagitis 86% (102/119) than in controls 55% (196/357) (p < 0.0001), while melena was less common in patients with esophagitis 38% (45/119) than in controls 68% (244/357) (p < 0.0001). Additionally, the more severe the esophagitis, the more frequent was melena. Patients with esophagitis had less abnormal vital signs, lesser decreases in hematocrit, and lesser increases in BUN. Both pre- and postRockall scores were lower in patients with esophagitis compared with controls (p = 0.01, and p < 0.0001, respectively). Length of hospital stay (p = 0.002), rebleeding rate at 42 days (p = 0.0007), and mortality were less in patients with esophagitis than controls. Finally, analysis of patients with esophagitis and cirrhosis suggested that this group of patients had more severe bleeding than those without cirrhosis.

CONCLUSIONS

We have described a unique clinical syndrome in patients with upper gastrointestinal bleeding who have erosive esophagitis. This syndrome is manifest by typical clinical features and is associated with favorable outcomes.

Fecal calprotectin one year after ileocaecal resection for Crohn's disease--a comparison with findings at ileocolonoscopy

BACKGROUND AND AIMS

Ileocaecal resection for Crohn's disease is commonly performed. The severity of endoscopic lesions in the anastomotic area one year postoperatively is considered to reflect the subsequent clinical course. Fecal calprotectin (FC) has been shown to correlate with the findings at ileocolonoscopy in Crohn's disease. The objectives of this study were to assess whether the concentration of FC reflects the endoscopic findings one year after ileocaecal resection and to evaluate the variation of FC in individual patients during 6months prior to the ileocolonoscopy.

METHODS

Thirty patients with Crohn's disease and ileocaecal resection performed within one year were included. Stool samples were delivered monthly until an ileocolonoscopy was performed one year postoperatively.

RESULTS

One year after surgery the median values of FC were not significantly different between the patients in endoscopic remission (n=17) and the patients with an endoscopic recurrence (189 (75-364) vs 227 (120-1066)μg/g; p=0.25). However, most patients with low values were in remission and all patients with high (>600μg/g) calprotectin values had recurrent disease. The variability of the FC concentration was most pronounced in patients with diarrhea.

CONCLUSIONS

We found no statistical difference in the concentrations of calprotectin between patients in endoscopic remission and patients with a recurrent disease one year after ileocaecal resection for Crohn's disease. However, among the minority of patients with low or high values, FC indicated remission and recurrence, respectively. There was significant variation of the fecal calprotectin concentrations over time, which affects the utility of calprotectin in clinical practice.

Endoscopic experience improves interobserver agreement in the grading of esophagitis by Los Angeles classification: conventional endoscopy and optimal band image system

Background/Aims

Interobserver variation by experience was documented for the diagnosis of esophagitis using the Los Angeles classification. The aim of this study was to evaluate whether interobserver agreement can be improved by higher levels of endoscopic experience in the diagnosis of erosive esophagitis.

Methods

Endoscopic images of 51 patients with gastroesophageal reflux disease (GERD) symptoms were obtained with conventional endoscopy and optimal band imaging (OBI). Endoscopists were divided into an expert group (16 gastroenterologic endoscopic specialists guaranteed by the Korean Society of Gastrointestinal Endoscopy) and a trainee group (individuals with fellowships, first year of specialty training in gastroenterology). All endoscopists had no or minimal experience with OBI. GERD was diagnosed using the Los Angeles classification with or without OBI.

Results

The mean weighted paired κ statistics for interobserver agreement in grading erosive esophagitis by conventional endoscopy in the expert group was better than that in the trainee group (0.51 vs 0.42, p<0.05). The mean weighted paired k statistics in the expert group and in the trainee group based on conventional endoscopy with OBI did not differ (0.42, 0.42).

Conclusions

Interobserver agreement in the expert group using conventional endoscopy was better than that in the trainee group. Endoscopic experience can improve the interobserver agreement in the grading of esophagitis using the Los Angeles classification.

Vegetarianism as a protective factor for reflux esophagitis: a retrospective, cross-sectional study between Buddhist priests and general population

BACKGROUND/AIMS

Several risk factors for reflux esophagitis, such as smoking, alcohol consumption, obesity, and metabolic syndrome, are recognized. But vegetarianism as a protective factor for reflux esophagitis has not been reported. The aim of this study is to elucidate the protective effect of vegetarianism for reflux esophagitis.

METHODS

This is a cross-sectional study that compared the prevalence of reflux esophagitis of 148 Buddhist priests, who are obligatory vegetarians with that of age- and sex-matched controls who underwent health checkups in a health promotion center.

RESULTS

The prevalence of reflux esophagitis was higher in the control group than in the Buddhist priest group (21.6 vs 12.2 %). Weight, body mass index, waist circumference, waist-to-hip ratio, and abdominal adipose tissue area were higher and high density lipoprotein (HDL) cholesterol and total cholesterol were lower in the Buddhist priest group. The prevalence of metabolic syndrome was higher in the Buddhist priest group than the control group (30.4 vs 17.6 %). In univariate analysis, male sex (odds ratio [OR] = 3.325; 95 % confidence interval [CI], 1.659-6.666), current smoking (OR = 3.37; 95 % CI, 1.439-7.881), alcohol consumption (OR = 2.75; 95 % CI, 1.375-5.481), waist circumference (OR = 1.99; 95 % CI, 1.062-3.739), negative for Helicobacter pylori IgG antibody (OR = 1.89; 95 % CI, 1.018-3.491) and non-vegetarianism (OR = 1.99; 95 % CI, 1.062-3.739) were associated with reflux esophagitis. According to multivariate analysis, male sex (OR = 3.44; 95 % CI, 1.698-6.970), non-vegetarianism (OR = 2.08; 95 % CI, 1.086-3.974) and negative H. pylori IgG antibody (OR = 1.96; 95 % CI, 1.039-3.712) were significantly associated with reflux esophagitis.

CONCLUSIONS

A non-vegetarian diet is associated with reflux esophagitis.

Recent advances in noncardiac chest pain in Korea

Gastroesophageal reflux disease (GERD) is the most common cause of noncardiac chest pain (NCCP) and is present in up to 60% of patients with NCCP in Western countries. In Korea, after a reasonable cardiac evaluation, GERD is reported to underlie 41% of NCCP cases. Typical reflux symptoms are frequent in Korean patients suffering from NCCP. Therefore, a careful history of the predominant symptoms, including heartburn and acid regurgitation, is relatively indicative of the GERD diagnosis in Korea. In Korea, in contrast to Western countries, patients aged 40 years and over who have been diagnosed with NCCP but who are without alarming features should undergo endoscopy to exclude gastric cancer or peptic ulcers because of the higher prevalence of peptic ulcer disease and gastric cancers in the region. In a primary care setting, in the absence of any alarming symptoms, a symptomatic response to a trial of a proton pump inhibitor (PPI) is sufficient for the presumptive diagnosis of GERD. In addition, the optimal duration of a PPI test may be at least 2 weeks, as GERD symptoms tend to be less frequent or atypical in Korean patients than in patients from Western countries. In patients diagnosed with GERD-related NCCP, long-term therapy (more than 2 months) with double the standard dose of a PPI is required to alleviate symptoms. Esophageal dysmotility is relatively uncommon, and pain modulators seem to offer significant improvement of chest pain control in non-GERD-related NCCP. Most traditionally available tricyclics or heterocyclics have many undesirable effects. Therefore, newer drugs with fewer side effects (for example, the serotonin - norepinephrine reuptake inhibitors) may be needed.

Esophagitis in a high H. pylori prevalence area: severe disease is rare but concomitant peptic ulcer is frequent

Background

Few data are available on the prevalence of erosive and severe esophagitis in Western countries.

Objective

To retrospectively determine the prevalence and the factors predicting erosive esophagitis and severe esophagitis in a large series of endoscopies in Spain.

Design

Retrospective observational study. A multivariate analysis was performed to determine variables predicting severe esophagitis.

Setting

Databases of 29 Spanish endoscopy units.

Patients

Patients submitted to a diagnostic endoscopy during the year 2005.

Interventions

Retrospective review of the databases.

Main Outcome Measurements

Esophagitis severity (graded according to the Los Angeles classification) and associated endoscopic findings.

Results

Esophagitis was observed in 8.7% of the 93,699 endoscopies reviewed. Severe esophagitis (LA grade C or D) accounted for 22.5% of cases of the disease and was found in 1.9% of all endoscopies. Incidences of esophagitis and those of severe esophagitis were 86.2 and 18.7 cases per 100,000 inhabitants per year respectively. Male sex (OR 1.89) and advanced age (OR 4.2 for patients in the fourth age quartile) were the only variables associated with severe esophagitis. Associated peptic ulcer was present in 8.8% of cases.

Limitations

Retrospective study, no data on individual proton pump inhibitors use.

Conclusions

Severe esophagitis is an infrequent finding in Spain. It occurs predominantly in males and in older individuals. Peptic ulcer disease is frequently associated with erosive esophagitis.

Causes of, and therapeutic approaches for, proton pump inhibitor-resistant gastroesophageal reflux disease in Asia

Proton pump inhibitors (PPIs) are the most widely used drugs for treatment of gastroesophageal reflux disease. However, approximately 20% of patients with reflux esophagitis and 40% of those with nonerosive reflux diseases complain of troublesome symptoms, even during treatment with PPIs. In patients with reflux esophagitis, dose escalation and co-administration with a histamine H(2)-receptor antagonist are potential approaches, since the major cause of PPI resistance is incomplete suppression of gastric acid secretion. On the other hand, for patients with nonerosive reflux disease, switching from PPIs to pain modulators is often necessary for improvement of symptoms, since 25% of patients with nonerosive reflux disease have symptoms not caused by gastroesophageal acid reflux. Therapeutic approaches for PPI-resistant patients with reflux esophagitis and nonerosive reflux diseases are considered according to pathogenesis.

Lack of utility of transabdominal ultrasound in the detection of gastroesophageal reflux disease-induced esophagitis in comparison with endoscopy

BACKGROUND

Although upper gastrointestinal (GI) tract endoscopy is the investigation of choice for patients with suspected gastroesophageal reflux disease (GERD)-induced esophagitis, it is associated with complications and significant patient discomfort. The aim of the current study was to compare the accuracy of transabdominal ultrasonography with upper GI tract endoscopy in the detection of GERD-induced esophagitis.

MATERIALS AND METHODS

In this descriptive study, 350 patients (mean age, 41.41 ± 14.52 years) referred to a gastroenterologist with symptoms suggestive of GERD were enrolled. The esophageal wall thickness was measured with transabdominal ultrasonography, and patients were subsequently assessed by upper GI endoscopy, representing the criterion standard in the diagnostic evaluation for GERD-induced esophagitis.

RESULTS

Endoscopic evaluation identified 100 patients with esophagitis (case group), and 250 subjects were reported to have normal endoscopic findings (control group). The wall thickness was significantly higher in the case group compared with the control (P < 0.0001).In the receiver operating characteristic analysis, only 2 cutoff points had a positive predictive value (PPV) greater than 50%. The cutoff point of 2.7 mm had 38% sensitivity, 91% specificity, 63% PPV, and 79% negative predictive value in the detection of GERD. Its positive and negative likelihood ratios were 4.32 and 0.68, respectively.

CONCLUSIONS

According to the identified sensitivity/specificity, low PPV and positive likelihood ratio, and relatively high negative likelihood ratio, we failed to find the transabdominal ultrasound effective in the detection of GERD-induced esophagitis.

Assessment of gastroesophageal reflux disease by serodiagnosis of Helicobacter pylori-related chronic gastritis stage

AIM: To evaluate the association of Helicobacter pylori (H.pylori)-related chronic gastritis stage with upper gastrointestinal symptoms and gastroesophageal reflux disease (GERD).

METHODS: Subjects underwent upper gastrointestinal endoscopy, a questionnaire using a frequency scale for symptoms of GERD (FSSG), and measurements of serum H.pylori-antibody and pepsinogen (PG) levels. They were classified into the following 4 groups in terms of H.pylori-related chronic gastritis stage: Group A (n = 219), H.pylori(-)PG(-); Group B (n = 310), H.pylori(+)PG(-); Group C (n = 279), H.pylori(+)PG(+); and Group D (n = 17), H.pylori(-)PG(+).

RESULTS: Reflux esophagitis occurred in 30.6% of Group A, 14.5% of Group B, 6.8% of Group C, and 0% of Group D (P < 0.001). Scores for acid reflux symptoms decreased significantly with chronic gastritis stage (from Group A to D) (P < 0.05), while scores for dysmotility symptoms did not differ significantly. The prevalence of non-erosive reflux disease (NERD) did not differ among groups. However, in subjects with GERD, the prevalence of NERD tended to increase with chronic gastritis stage (P = 0.081).

CONCLUSION: Acid reflux symptoms and the prevalence of reflux esophagitis can be assessed by measuring both serum H.pylori-antibody and PG levels.

A double-blind, controlled study comparing lafutidine with placebo and famotidine in Japanese patients with mild reflux esophagitis

PURPOSE

This randomized, double-blind, controlled study examined whether lafutidine is superior to placebo and non-inferior to famotidine in terms of healing rates as assessed by endoscopy in Japanese patients with mild reflux esophagitis. Safety and improvement in symptoms of heartburn were also assessed.

METHODS

Patients with an endoscopic diagnosis of grade A or B reflux esophagitis according to the Los Angeles classification were randomly assigned to receive lafutidine (20 mg/day), famotidine (40 mg/day), or placebo for 8 weeks.

RESULTS

Of the 584 patients enrolled in the study, 447 were diagnosed to have grade A or B reflux esophagitis by the Endoscopic Assessment Committee. Healing rates at 8 weeks were 71.0% (115/162) in the lafutidine group, 61.4% (86/140) in the famotidine group, and 9.7% (14/145) in the placebo group. Lafutidine was thus demonstrated to be superior to placebo and non-inferior to famotidine. As compared with placebo, lafutidine significantly improved symptoms of heartburn.

CONCLUSIONS

Lafutidine has a high endoscopic healing rate and improves symptoms of heartburn in patients with mild reflux esophagitis. Lafutidine is considered a promising treatment option for mild reflux esophagitis.

Lack of correlation between a self-administered subjective GERD questionnaire and pathologic GERD diagnosed by 24-h esophageal pH monitoring

INTRODUCTION

Self-reported reflux symptoms do not always correspond to pathologic gastroesophageal reflux disease (GERD). We evaluated whether GERD-related symptoms in the self-reported Mayo-GERD questionnaire (GERDQ) were correlated with current gold standard definitions of pathologic GERD.

METHODS

Three hundred thirty-six consecutive consenting individuals with GERD symptoms referred for 24-h esophageal pH monitoring completed a baseline GERDQ. Univariate and multivariate analyses identified questions that were most associated with percent total time pH<4 at distal probe (DT) >4% or DeMeester score (DS) >or=14.7, two accepted definitions of pathologic GERD. A risk score was created from these analyses, followed by generation of receiver operating characteristic curves and determination of C-statistics, sensitivity, and specificities at various cut points, with prespecified minimal values of each that would be required to meet the definition of "potential clinical utility."

RESULTS

Forty-nine percent of patients were found to have pathologic GERD; half the patients (not necessarily those with pathologic GERD) described suffering from severe or very severe heartburn or acid regurgitation in the past year. Univariate logistic regression analysis identified six of 22 key GERD questions that were significantly related to DT or DS, in addition to age and gender. Three questions (duration of symptoms, nocturnal heartburn, hiatal hernia) along with age and gender remained significant in multivariate analyses. A risk score (RS) was created from these five questions separately for DT and DS. For DT, the C-statistic for RS was 0.75, and at the optimal cut point of >or=6 that maximizes sensitivity (SS) and specificity (SP), SS was 68% and SP was 72%. For DS, the C-statistic was 0.73, and at the optimal cut point, SS was 82%and SP 60%. When considering other cut points, the rare extreme case of very low RS (<or=2) was strongly predictive of lack of pathologic GERD: for DT, SS 100%/SP 18%, negative predictive value (NPV) 100%; and for DS, SS 97%, SP 25%, NPV 88%. However, only 10-15% of patients referred for pH testing had RS scores of <or=2.

CONCLUSION

Self-reported prolonged history of GERD-like symptoms, nocturnal heartburn, history of a hiatus hernia, and male gender were associated with abnormal 24-h esophageal pH monitoring. However, these factors lack clinical utility to predict pathologic GERD in patients referred for pH testing. We found that 51% of patients with severe GERD symptoms do not have true pathological GERD on objective testing. The clinical implications of this study are significant in that treatment with acid-suppressing medication in such patients would be inappropriate.

The use of frequency scale for the symptoms of GERD in assessment of gastro-oesophageal reflex symptoms in asthma

In adult asthmatics the incidence of gastro-oesophageal reflux disease (GERD) reportedly ranges from 34% to 89%. Oesophageal pH monitoring and endoscopy are not required in the patient with typical GERD symptoms before the initiation of a therapeutic trial. Diagnosis of GERD on the basis of history is the simplest and quickest method, placing no demand on patients. Recently, a new questionnaire (FSSG; Frequency Scale for the Symptoms of GERD) was produced to evaluate the severity and the therapeutic response of GERD. The FSSG (F-scale) was used to assess the GERD in subjects with persistent moderate to severe asthma treated with anti-inflammatory asthma medication. In the present study, 27.4% of the patients with asthma had symptoms suggestive of GERD. There is significant correlation between GERD symptom (F-scale score) and severity of cough and sputum. The observations suggested that reflux symptoms, not gastric dysmotility symptoms, significantly associated with severity of cough, not of sputum. It is the first such study to use a FSSG as incidence of GERD symptoms in asthmatics and examine the relationship between F-scale score and asthmatic symptoms.

Epidemiology and clinical characteristics of GERD in the Japanese population

We reviewed articles on the epidemiology and clinical characteristics of gastroesophageal reflux disease (GERD) in Japan to clarify these features of GERD in this country. Although the definition of GERD depends on the individual study, the prevalence of GERD has been increasing since the end of the 1990s. The reasons for the increase in the prevalence of GERD may be due to increases in gastric acid secretion, a decrease in the Helicobacter pylori infection rate, more attention being paid to GERD, and advances in the concept of GERD. More than half of GERD patients had non-erosive reflux disease, and the majority (87%) of erosive esophagitis was mild type, such as Los Angeles classification grade A and grade B. There were several identified risk factors, such as older age, obesity, and hiatal hernia. In particular, mild gastric atrophy and absence of H. pylori infection influence the characteristics of GERD in the Japanese population. We also discuss GERD in the elderly; asymptomatic GERD; the natural history of GERD; and associations between GERD and peptic ulcer disease and H. pylori eradication. We examined the prevalence of GERD in patients with specific diseases, and found a higher prevalence of GERD, compared with that in the general population, in patients with diabetes mellitus, those with obstructive sleep apnea syndrome, and those with bronchial asthma. We provide a comprehensive review of GERD in the Japanese population and raise several clinical issues.

Metabolic risk factors associated with erosive esophagitis

BACKGROUND AND AIM

Our aim was to determine associations between metabolic risk factors and erosive esophagitis.

METHODS

In this retrospective case-control study, diagnosis of erosive esophagitis was based on the Los Angeles classification. Endoscopic findings in subjects with erosive esophagitis were reviewed by two experienced endoscopists and those with agreement of diagnosis were enrolled for study. Body mass index (BMI), abdominal girdle, blood pressure, and serum triglyceride, glucose, and beta-lipoprotein levels were compared between individuals with and without erosive esophagitis. Multivariate binary logistic regression analysis was used to identify independent metabolic risk factors associated with erosive esophagitis.

RESULTS

Between October 2004 and April 2006, 518 of 4206 subjects who underwent endoscopic examination were diagnosed as having erosive esophagitis. After expert review, 427 (male : female = 365:62) individuals met the study criteria of having erosive esophagitis (10.5%). Compared with age- and gender-matched controls, patients with erosive esophagitis had significantly higher BMI, abdominal girdle, blood pressure, and triglyceride levels, and lower levels of high density lipoprotein (HDL) cholesterol (P < 0.05). More subjects with metabolic syndrome had erosive esophagitis than without metabolic syndrome (OR: 1.76, 95% CI: 1.27-2.44, P = 0.001). Multivariate logistic regression analysis revealed that central obesity (OR: 1.41, 95% CI: 05-1.89, P = 0.023) and hypertriglyceridemia (OR: 1.57, 95% CI: 1.19-2.13, P = 0.004) were significantly associated with erosive esophagitis.

CONCLUSIONS

Obesity and hypertriglyceridemia, which are key components of metabolic syndrome, are moderate independent risk factors for erosive esophagitis.

[Clinical and endoscopic outcome after Nissen fundoplication for gastroesophageal reflux disease]

CONTEXT

The surgical treatment of gastroesophageal reflux disease is indicated in patients with a chronic condition when proton pump inhibitors therapy is ineffective or when symptoms are persistently recurrent. Fundoplication failure occurrence has been detected in some patients and highlights a needing of monitoring esophageal post-surgical condition since that clinical symptoms are not sensitive enough for indicating fundoplication failure.

AIMS

To identify the frequency of a disrupted wrap in the postoperative period and to evaluate esophageal complications related with gastroesophageal reflux recurrence in children and adolescents.

METHODS

The study was cross-sectional, prospective and descriptive, including 45 patients (16 months-16.9 years) who had undergone Nissen fundoplication in a school hospital. Twenty six patients (57.8%) were neurologically impaired. Upper gastrointestinal endoscopy was performed in order to determine fundoplication integrity, endoscopic and histopathological esophageal condition. Upper gastrointestinal endoscopies were performed from 12 up to 30 months after surgery.

RESULTS

Patent wrap was identified in 41 patients (91.1%). Recurrent peptic esophagitis was found in 6 of 45 patients, 2 of which required a second fundoplication and other two had Barrett esophagus. Endoscopic peptic esophagitis was associated with a defective wrap (P = 0.005). Conclusions - Fundoplication was effective for treating esophagitis, even in patients with previous esophageal stenosis. Endoscopic follow up may detect surgery failure in children undergone anti-reflux surgery even in asymptomatic patients.

Validation of structured scoring using the LA classification for esophagitis and endoscopically suspected Barrett's esophagus in a tertiary Asian endoscopy center

AIM

To determine the inter-observer agreement and validity of the LA Classification in scoring the severity of esophagitis in Asian patients.

METHODS

Video endoscopy clips were selected from 45 consecutive patients participating in reflux studies. The videos were viewed by endoscopists who then independently scored the presence, severity and distribution of esophagitis, including endoscopically suspected Barrett's esophagus (ESBE). Each video was discussed and a consensus on findings reached. Kappa (k) correlation was calculated to describe inter-observer agreement.

RESULTS

Thirty-five clips were scored (no esophagitis 20%, grade-A 54%, grade-B 23%, grade-C 3%, respectively and 10 clips were excluded for poor imaging). Excellent agreement was noted on the presence of esophagitis (mean k = 0.79, range 0.77-0.82). Fifteen patients (42%) had ESBE with a mean k of 0.48 (range 0.39-0.60). Inter-observer agreement on the LA grade was good (mean k = 0.58, range 0.55-0.63), whilst in agreement between endoscopists and consensus grading, the mean kappa rose to 0.77 (range 0.73-0.81). There was a trend of increasing agreement as viewings progressed, with superior kappa correlation after 16 cases. Evaluation of the extent of esophagitis showed good k values using the alternative approach of grouping by circumferential extent (mean k = 0.64, range 0.60-0.67) at the lower categories of severity.

CONCLUSIONS

Scoring using the LA classification for esophagitis and the concurrence on the presence of ESBE showed moderate to strong agreement amongst Asian endoscopists. Our results also suggested that an alternative method of scoring esophagitis based on proportion of circumferential involvement was reliable. A learning effect was observed and reliable scoring was achieved after 16 patients.

Endoscopic grading of reflux oesophagitis: the past, present and future

The Los Angeles Classification for diagnosis and grading of reflux oesophagitis, first discussed at the 1994 World Congress of Gastroenterology, was published in its definitive form in 1999. The product of a demanding validation process, it consistently predicts the outcome of acid suppressant therapy, correlates with oesophageal acid exposure, and is the most reproducible and practical of oesophagitis grading systems. The attributes of the classification, which enhance the specificity of communication on reflux oesophagitis, are widely recognized, as it is now by far the most widely used method for description of reflux oesophagitis. Exclusion of minimal oesophageal mucosal change is, however, regarded as a significant limitation by some users, especially in Japan. Some data suggest that minimal changes may now be recognized with modern endoscopes; if this claim can be adequately validated, formal addition of criteria for minimal change could significantly improve the sensitivity of endoscopy for reflux disease.

Clinical significance of minimal change lesions of the esophagus in a healthy Korean population: a nationwide multi-center prospective study

BACKGROUND AND AIM

At least half of the patients with typical reflux symptoms have non-erosive reflux disease (NERD). Minimal change lesions are commonly seen in the screening endoscopic examinations for individuals without clinically significant symptoms. We evaluated the correlation between minimal changes and symptoms in individuals visiting the hospital for routine health check-up by a nationwide survey in 2006.

METHODS

Upper gastrointestinal endoscopic examinations as a health check-up were performed for 25,536 patients. Among them, symptom questionnaires were given in 23,350 patients without mucosal break or Barrett's esophagus. Endoscopic findings of the lower esophagus were divided into normal or minimal changes. Minimal changes in the present study included white turbid discoloration and Z-line blurring.

RESULTS

Among a total of 25,536 subjects, reflux esophagitis was found in 2019 subjects (7.91%) and 3043 patients (11.9%) were classified as having minimal changes. History of gastroesophageal reflux disease (GERD) was more commonly found in individuals with minimal changes. Among the reflux-related symptoms, heartburn, acid regurgitation, globus sensation, and epigastric soreness were related to the minimal changes of the esophagus. Especially, individuals with globus sensation or epigastric soreness were more likely to have minimal changes compared to individuals without respective symptoms. Male gender, current smoker, history of H. pylori eradication, frequent stooping at work, hiatal hernia, and atrophic/metaplastic gastritis were found to be risk factors for minimal changes.

CONCLUSION

The minimal changes were closely related with upper gastrointestinal symptoms and had similar risk factors for GERD, suggesting that minimal changes could be considered as early endoscopic findings of GERD.

Acute nonvariceal upper gastrointestinal bleeding: endoscopic diagnosis and therapy

Acute upper gastrointestinal bleeding is a relatively common,potentially life-threatening condition that causes more than 300,000 hospital admissions and about 30,000 deaths per annum in America. Esophagogastroduodenoscopy is the procedure of choice for the diagnosis and therapy of upper gastrointestinal bleeding lesions. Endoscopic therapy is indicated for lesions with high risk stigmata of recent hemorrhage, including active bleeding, oozing, a visible vessel, and possibly an adherent clot. Endoscopic therapies include injection therapy, such as epinephrine or sclerosant injection; ablative therapy, such as heater probe or argon plasma coagulation; and mechanical therapy, such as endoclips or endoscopic banding. Endoscopic therapy reduces the risk of rebleeding,the need for blood transfusions, the requirement for surgery, and patient morbidity.

Intraobserver and interobserver consistency for grading esophagitis with narrow-band imaging

BACKGROUND

Narrow-band imaging (NBI) is a novel, noninvasive optical technique that adjusts reflected light to enhance the contrast between the esophageal mucosa and the gastric mucosa. Whether the use of this optical technique may increase consistency in describing the presence and severity of mucosal breaks remains elusive.

OBJECTIVES

We compared the intra- and interobserver variations in the endoscopic scoring of esophagitis by using conventional imaging with and without NBI.

DESIGN

Cross-sectional study of consecutive patients with reflux.

SETTING

Single center in Taiwan.

PATIENTS

Endoscopic photographs of 230 patients with gastroesophageal reflux were obtained with both methods. Images were randomly displayed twice to 7 endoscopists, who independently scored each photograph by using the Los Angeles classification.

MAIN OUTCOME MEASUREMENTS

We calculated intra- and interobserver kappa statistics to measure the consistency in interpretations.

RESULTS

With the addition of NBI, intraobserver reproducibility significantly improved with 3 of the 7 endoscopists. Interobserver reproducibility was more consistent with the combined approach than with conventional imaging alone, with an improved overall kappa value of 0.62 versus 0.45 (P < .05). Discordance between these methods was substantial in the grading of class A or B esophagitis.

LIMITATIONS

A small sample of class D esophagitis might have produced insufficient statistical power in this category.

CONCLUSIONS

Intra- and interobserver reproducibilities in grading esophagitis could be improved when NBI was applied with conventional imaging. The benefit appeared to derive from better depictions of small erosive foci.

Endoscopic ultrasound for the evaluation of Nissen fundoplication integrity: a blinded comparison with conventional testing

BACKGROUND

For patients whose symptoms develop after Nissen fundoplication, the precise mechanism of anatomic failure can be difficult to determine. The authors have previously reported the endosonographic hallmarks defining an intact Nissen fundoplication in swine and the known causes of failure. The current clinical trial tested the hypothesis that a defined set of endosonographic criteria can be applied to determine fundoplication integrity in humans.

METHODS

The study enrolled seven symptomatic and nine asymptomatic subjects at a mean of 6 years (range, 1-30 years) after Nissen fundoplication. A validated gastroesophageal reflux disease (GERD)-specific questionnaire and medication history were completed. Before endoscopic ultrasound (EUS), all the patients underwent complete conventional testing (upper endoscopy, esophagram, manometry, 24-h pH). A diagnosis was rendered on the basis of combined test results. Then EUS was performed by an observer blinded to symptoms, medication use, and conventional testing diagnoses. Because EUS and esophagogastroduodenoscopy (EGD) are uniformly performed in combination, the EUS diagnosis was rendered on the basis of previously established criteria combined with the EGD interpretation. The diagnoses then were compared to examine the contribution of EUS in this setting.

RESULTS

The technique and defined criteria were easily applied to all subjects. All symptomatic patients had heartburn and were taking proton pump inhibitors (PPI). No asymptomatic patients were taking PPI. All diagnoses established with combined conventional testing were detected on EUS with upper endoscopy. Additionally, EUS resolved the etiology of a low lower esophageal sphincter pressure in two symptomatic patients and detected the additional diagnoses of slippage in two subjects. Among asymptomatic subjects, EUS identified additional diagnoses in two subjects considered to be normal by conventional testing methods.

CONCLUSION

According to the findings, EUS is a feasible method for evaluating post-Nissen fundoplication hiatal anatomic relationships. The combination of EUS and EGD allows the mechanism of failure to be detected in patients presenting with postoperative symptoms after Nissen fundoplication.

Clinical usefulness of subgrouping of patients with non-cardiac chest pain according to characteristic symptoms in Korea

BACKGROUND

Non-cardiac chest pain (NCCP) is a heterogeneous disorder. There is controversy about the associations between symptoms and causes in NCCP patients. The purpose of the present study was to evaluate the clinical usefulness of subgrouping according to characteristic symptoms in NCCP patients.

PATIENTS AND METHODS

Fifty-eight patients were classified into two groups, as patients with typical reflux symptoms (group I, n = 24) and those without typical reflux symptoms (group II, n = 34). They underwent upper endoscopy, manometry, and 24-h esophageal pH monitoring.

RESULTS

Twenty-four (41%) of the patients were diagnosed with gastroesophageal reflux disease (GERD) at upper endoscopy or 24-h esophageal pH monitoring. Eleven (19%) were diagnosed with GERD-associated esophageal motility disorder and 13 (22%) were diagnosed with non-GERD-associated esophageal motility disorder. The two groups did not differ significantly in age, sex, weight, smoking history, history of chronic alcoholism, or the severity, duration and frequency of symptoms. The sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratio of group I for GERD-related NCCP were significantly higher than those of group II. Group I had a higher proportion of patients with GERD-associated esophageal motility disorder (55%) than non-GERD-associated esophageal motility disorder (23%).

CONCLUSION

Typical reflux symptoms can be used to distinguish patients with GERD-related NCCP from patients with NCCP, and subgrouping according to characteristic symptoms may assist the diagnosis of these patients in Korea.

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

OBJECTIVES

A major limitation to screening and surveillance of Barrett's esophagus is the complexity, expense, and risk associated with sedation for upper endoscopy. This study examines the feasibility, accuracy, and patient acceptability of office-based unsedated endoscopy as an alternative.

METHODS

Of 274 eligible adults scheduled for endoscopic screening for gastroesophageal reflux symptoms or surveillance of Barrett's esophagus at a tertiary care center, 121 underwent unsedated small-caliber endoscopy and conventional endoscopy in a randomized crossover study. The two procedures were compared with regard to histological detection of Barrett's esophagus and dysplasia and biopsy size. Patients answered questionnaires assessing the tolerability of the procedures.

RESULTS

The prevalence of Barrett's esophagus was 26% using conventional endoscopy and 30% using unsedated endoscopy (P= 0.503). The level of agreement between the two approaches was "moderate" (kappa= 0.591). Each modality detected four cases of low-grade dysplasia with concordance on one case. The tissue samples collected with unsedated endoscopy were smaller than with conventional endoscopy (P < 0.001). The majority of subjects rated their experience with both procedures as being well tolerated with minimal or no difficulty. When asked which procedure they would prefer in the future, 71% (81/114) chose unsedated small-caliber endoscopy.

CONCLUSIONS

Office-based unsedated small-caliber endoscopy is technically feasible, well tolerated, and accurate in screening for Barrett's esophagus, despite yielding a smaller biopsy specimen. This approach bears the potential to eliminate the infrastructure and cost required for intravenous sedation in this application.

Capsule endoscopy examination--preliminary review by a nurse

Capsule endoscopy (CE) has been recommended as the method of choice for diagnostic endoscopy of the small bowel. An experienced nurse, after proper training, may contribute to the endoscopy procedures as previously described for sigmoidoscopy. The aim of this study was to evaluate the ability of an experienced gastroenterology nurse to prepare CE records for physician interpretation, by detecting abnormal thumbnails. A prospective, observational design was used. Fifty CE videos were pre-read by a specially trained gastroenterology nurse who thumbnailed the abnormalities detected for interpretation by the gastroenterologist. The nurse's description of the lesions and the calculated gastric and bowel transit times were compared to the interpretation of the videos made directly by the gastroenterologist (gold standard). The primary end point of the study was the quality of the nurse's pathology findings; the secondary end point was the cost effectiveness of this practice. There was complete agreement between the nurse and gastroenterologist for all 12 cases interpreted as normal by the gastroenterologist. In the remaining 38 cases, the nurse created 130 thumbnail selections and the physician, 99. Complete interobserver agreement was achieved for 93 of the 96 lesions categorized as "significant" by the physician (96.9%). After all relevant variables were taken into account, this approach saved dollar 324 per CE examination. The use of nurse practitioner to pre-read CE videos and prepare thumbnail selections for further assessment by the gastroenterologist appears to be safe, reliable, and cost effective.

Gastroesophageal reflux

Gastroesophageal reflux disease (GERD) is the most common disease of the gastrointestinal system. Heartburn, regurgitation, and dysphagia are the most common symptoms of GERD. However, chest pain, chronic cough, laryngitis, hoarseness, and other otolaryngologic manifestation can be the primary manifestations of the disease. Endoscopy, barium studies, and especially pH monitoring and therapeutic trials may help in establishing the diagnosis of GERD. The introduction of H2 antagonists and especially of proton pump inhibitors (PPI) has brought symptomatic relief in most patients. However, surgical procedures, especially laparoscopic fundoplication, are still required in some patients. Barrett's esophagitis is the most common complication of GERD and is associated with a high prevalence of esophageal adenocarcinoma. Whether or not treatment with either PPIs or H2 antagonists can prevent this complication is still under investigation.

Diagnosis of gastroesophageal reflux disease using a new questionnaire

BACKGROUND AND AIM

An early and accurate evaluation by a general practitioner is needed to screen out non-gastroesophageal reflux disease (GERD) patients. A recent questionnaire (QUEST) highlighted problems with specificity and complexity, so the aim of the present study was to design a simplified questionnaire.

METHODS

When admitted to hospital to undergo an upper gastrointestinal endoscopy for suspected GERD, 333 patients completed a 50-item questionnaire requiring 'yes/no' answers to different combinations of questions relating to symptoms of upper gastrointestinal tract conditions (e.g. GERD, ulcers and functional dyspepsia) and psychosomatic symptoms. The endoscopic diagnosis was then correlated with the rate of positive answers to each question.

RESULTS

Based on the analysis of the 50 items, the 8-10 questions most often answered affirmatively by each of the GERD and non-GERD groups were chosen for the simplified questionnaire. Three draft questionnaires were compiled. After calculating the sensitivity, specificity and accuracy in relation to the diagnosis of GERD and other conditions, it was found that questionnaire B (selection of persons answering 'yes' to at least one of questions 1-5 and exclusion of persons answering 'yes' to at least three of questions 7-10) had a high sensitivity, high specificity and low false positive rate.

CONCLUSION

A novel questionnaire was developed. It was designed to detect the symptoms of GERD while simultaneously excluding non-GERD patients. This simplified nine-item simplified questionnaire had a sensitivity of 79.8%, a specificity of 53.6% and an accuracy of 63.4%.

Catheter-based pH monitoring: use in evaluation of gastroesophageal reflux disease symptoms (on and off therapy)

Tube-based ambulatory pH testing has rapidly evolved in the past 3 decades to become the standard by which other diagnostic approaches to gastroesophageal reflux disease are judged. Acid exposure 5 cm above the manometrically determined lower esophageal sphincter is the standard for documentation of pathologic acid exposure of the distal esophagus. Proximal esophageal or hypopharyngeal monitoring is an evolving technique that may shed light on patients with supraesophageal symptoms. The ability to simultaneously monitor esophageal and gastric acidity (usually in patients with persistent symptoms despite therapy) is another advantage of this technique. Whether the new system that allows simultaneous pH and impedance monitoring and the system that uses an implantable tubeless monitoring capsule will supplant this older but well-established technology remains to be determined.

Clinical presentation, diagnosis, and management of gastroesophageal reflux disease

GERD is ubiquitous throughout the adult population in the United States. It commonly adversely affects quality of life and occasionally causes life-threatening complications. The new and emerging medical and endoscopic therapies for GERD and the new management strategies for BE should dramatically reduce the clinical toll of this disease on society.

Computer analysis of upper gastrointestinal endoscope images

Gastro-oesophageal reflux disease (GORD) occurs in up to 40% of adults in the West. Oesophagitis is a major determinant in the treatment of GORD but its current classification systems are subjective. In order to help to provide objective interpretation of upper gastro-intestinal (GI) endoscope examination and reduce inter-observer variability, we developed a computer image analysis system. Digital video recordings were made on patients with clinical evidence of reflux oesophagitis. Cross-sectional profiles of hue and saturation data were analysed on images from seven patients with grade B or C oesophagitis (LA grading). This analysis showed clear changes in hue (p = 0.01) and saturation (p = 0.001). These results suggest that quantification of upper GI endoscopic images is feasible and may help in objective assessment.

[Antireflux therapy--more than acid reduction?]

Because gastroesophageal reflux disease (GERD) is a motility disorder, acid reduction with proton pump inhibitors (PPI) remains a symptomatic therapy with a recurrence rate of over 90% after discontinuation of acid suppression. This "therapeutic dilemma" becomes obvious in patients not responding sufficiently to the conventional medication (therapy resistance, necessity of high PPI doses, volume reflux). In this manuscript we analyze additional factors that may play a role in the pathogenesis and interpretation of GERD. These additional factors include gastroesophageal motility and esophageal barrier functions as well as duodenogastroesophageal reflux and Helicobacter pylori infection. In addition, basic problems in interpretation of therapeutic success such as placebo effect, spontaneous remission of GERD, the role of sensory function and subjective interpretation of symptoms and the overlap between physiological and pathological reflux as well as functional disorders will be discussed.

Comparison of interobserver agreement for different scoring systems for reflux esophagitis: Impact of level of experience

BACKGROUND

The Savary-Miller, the Los Angeles, and the MUSE (metaplasia, ulcer, stricture, erosion) scoring systems have been developed to assess esophageal lesions related to GERD. Interobserver agreement for these systems was compared, with particular reference to the experience of the endoscopist.

METHODS

By using videoendoscopes, videotapes were made of the gastroesophageal junction of 60 patients who presented with symptoms suggestive of GERD. The Savary-Miller, the Los Angeles, and the MUSE systems were used to score all video clips by 9 endoscopists who were subgrouped by level of experience (3 levels, 3 endoscopists per level). Agreement was assessed by using weighted kappa statistics (kappa).

RESULTS

The Savary-Miller scoring system revealed moderate agreement for the experienced group (kappa=0.41) but performed poorly when applied by inexperienced raters (kappa=0.16). The Los Angeles system was most reproducible in all subgroups, irrespective of the level of experience (kappa=0.49 to 0.65). The MUSE scoring system was highly similar to the Los Angeles scoring system with respect to erosions and, in addition, allowed assessment of complications of GERD.

CONCLUSIONS

The Los Angeles and the MUSE scoring systems are most reliable for the assessment of erosions caused by GERD. Because of low reliability, use of the Savary-Miller scoring system is not recommended. For all scoring systems, interobserver agreement varies with the level of experience in the performance of upper endoscopy.

Safety and efficacy of long term esomeprazole therapy in patients with healed erosive oesophagitis

OBJECTIVE

To evaluate the safety and tolerability of long term treatment with esomeprazole in patients with healed erosive oesophagitis, and to describe its efficacy in the maintenance of healing.

DESIGN AND SETTING

US multicentre, noncomparative, nonblind study.

PATIENTS AND PARTICIPANTS

807 patients with endoscopically confirmed healed erosive oesophagitis.

METHODS

Patients received esomeprazole 40 mg once daily for up to 12 months. Adverse events and clinical laboratory tests were assessed over the study period. Endoscopy was performed at the final visit of the antecedent healing trials and at months 6 and 12 of the current safety trial; gastric biopsies were obtained at the initial visit of the healing trials and at the end of the safety trial.

RESULTS

80.9% of patients completed 6 months of treatment; 76.6% completed 12 months of treatment. There were no serious drug-related adverse events. Diarrhoea, abdominal pain, flatulence, and headache were the only treatment-related adverse events reported by >3% of patients. Mean changes in laboratory measures were generally small and not clinically meaningful. Plasma gastrin levels increased, as expected, and reached a plateau after 3 months. No changes in gastric histological scores were noted in the majority of patients. Evaluation of gastric biopsies revealed an overall decline in chronic inflammation and atrophy. Intestinal metaplasia findings remained essentially unchanged. Life table estimates of maintenance of healing were 93.7% [95% confidence interval (CI) 92.0 to 95.5%] at 6 months and 89.4% (95% CI 87.0 to 91.7%) at 12 months.

CONCLUSIONS

Daily treatment with esomeprazole 40 mg for up to 1 year in patients with healed erosive oesophagitis was generally well tolerated and effective. No safety concerns arose.

Endoscopically demonstrable esophageal changes after Helicobacter pylori eradication in patients with gastric disease

BACKGROUND AND AIMS

An increased prevalence of reflux esophagitis has been reported following Helicobacter pylori (H. pylori) eradication in patients with duodenal ulcers in Western countries. However, it has remained unknown whether this might also appertain to individuals with other diseases. We therefore carried out this study to determine the effect of eradicating H. pylori infection in a series of Japanese patients.

METHODS

Of a total of 203 H. pylori-positive patients successfully cured of infection, 82 cases (58 males, 24 females) with gastric disease, but not duodenal ulcers, were included in the present study; median age 56 years (range 18-80) and median follow up of 24 months (range 6-65). The patients were investigated clinically and endoscopically at regular intervals.

RESULTS

Mild reflux esophagitis developed after eradication in three of 55 (5.5%) patients formerly without this condition, while it improved after eradication in five of 27 (18.5%) patients, with the disease endoscopically diagnosed prior to eradication. The estimated incidence of esophagitis within 3 years was 4.8% after cure of infection. Short segment Barrett's esophagus developed after eradication in six of 58 (10.3%) patients who did not have it prior to the therapy, while the condition did not improve in 24 patients affected before eradication.

CONCLUSIONS

Endoscopic esophageal changes after H. pylori eradication in the present series of Japanese patients were relatively infrequent and mild. This therapeutic approach thus appears to be safe and unproblematic.

Esomeprazole improves healing and symptom resolution as compared with omeprazole in reflux oesophagitis patients: a randomized controlled trial. The Esomeprazole Study Investigators

BACKGROUND

The pharmacologic profile of the new proton pump inhibitor esomeprazole has demonstrated advantages over omeprazole that suggest clinical benefits for patients with acid-related disease.

METHODS

1960 patients with endoscopy-confirmed reflux oesophagitis (RO) were randomized to once daily esomeprazole 40 mg (n=654) or 20 mg (n=656), or omeprazole 20 mg (n=650), the standard recommended dose for RO, for up to 8 weeks in a US, multicentre, double-blind trial. The primary efficacy variable was the proportion of patients healed at week 8. Secondary variables included healing and heartburn resolution at week 4, time to first resolution and sustained resolution of heartburn, and per cent of heartburn-free days and nights. Safety and tolerability were also evaluated.

RESULTS

Significantly more patients were healed at week 8 with esomeprazole 40 mg (94.1%) and 20 mg (89.9%) vs. omeprazole 20 mg (86.9%), using cumulative life table estimates, ITT analysis (each P < 0.05). Esomeprazole 40 mg was also significantly more effective than omeprazole for healing at week 4 and for all secondary variables evaluating heartburn resolution. The most common adverse events in all treatment groups were headache, abdominal pain and diarrhoea.

CONCLUSION

Esomeprazole was more effective than omeprazole in healing and symptom resolution in GERD patients with reflux oesophagitis, and had a tolerability profile comparable to that of omeprazole.