Does magnifying endoscopy improve the diagnosis of erosive esophagitis?

Linked color imaging improves visibility of reflux esophagitis

Background

With more prevalent gastroesophageal reflux disease comes increased cases of Barrett's esophagus and esophageal adenocarcinoma. Image-enhanced endoscopy using linked-color imaging (LCI) differentiates between mucosal colors. We compared LCI, white light imaging (WLI), and blue LASER imaging (BLI) in diagnosing reflux esophagitis (RE).

Methods

Consecutive RE patients (modified Los Angeles [LA] classification system) who underwent esophagogastroduodenoscopy using WLI, LCI, and BLI between April 2017 and March 2019 were selected retrospectively. Ten endoscopists compared WLI with LCI or BLI using 142 images from 142 patients. Visibility changes were scored by endoscopists as follows: 5, improved; 4, somewhat improved; 3, equivalent; 2, somewhat decreased; and 1, decreased. For total scores, 40 points was considered improved visibility, 21–39 points was comparable to white light, and < 20 points equaled decreased visibility. Inter- and intra-rater reliabilities (Intra-class Correlation Coefficient [ICC]) were also evaluated. Images showing color differences (ΔE*) and L* a* b* color values in RE and adjacent esophageal mucosae were assessed using CIELAB, a color space system.

Results

The mean age of patients was 67.1 years (range: 27–89; 63 males, 79 females). RE LA grades observed included 52 M, 52 A, 24 B, 11 C, and 3 D. Compared with WLI, all RE cases showed improved visibility: 28.2% (40/142), LA grade M: 19.2% (10/52), LA grade A: 34.6% (18/52), LA grade B: 37.5% (9/24), LA grade C: 27.3% (3/11), and LA grade D: 0% (0/3) in LCI, and for all RE cases: 0% in BLI. LCI was not associated with decreased visibility. The LCI inter-rater reliability was “moderate” for LA grade M and “substantial” for erosive RE. The LCI intra-rater reliability was “moderate–substantial” for trainees and experts. Color differences were WLI: 12.3, LCI: 22.7 in LA grade M; and WLI: 18.2, LCI: 31.9 in erosive RE (P < 0.001 for WLI vs. LCI).

Conclusion

LCI versus WLI and BLI led to improved visibility for RE after subjective and objective evaluations. Visibility and the ICC for minimal change esophagitis were lower than for erosive RE for LCI. With LCI, RE images contrasting better with the surrounding esophageal mucosa were more clearly viewed.

What is the role of endoscopy and oesophageal biopsies in the management of GERD?

Gastroesophageal reflux disease (GERD) is a diagnosis applicable to "all individuals who are exposed to the risk of physical complications from gastroesophageal reflux, or who experience clinically significant impairment of health related well being (quality of life) due to reflux related symptoms, after adequate reassurance of the benign nature of their symptoms". It remains, predominantly, a symptom-based diagnosis, confirmed clinically by a response to acid suppression therapy although it is accompanied by demonstrable increases in acid exposure on esophageal pH-metry and by endoscopic and histological changes. Standard white light endoscopy permits diagnosis of erosive reflux disease (ERD) which, if present, should be graded for severity using the Los Angeles classification system. However, the role of endoscopy in clinical practice is, primarily, to evaluate patients with persistent symptoms, despite medical therapy, or to investigate alarm features and exclude complications such as Barrett' oesophagus which should be assessed using the Prague C & M criteria. Newer endoscopic techniques allow detection of 'minimal change' GERD lesions and Barrett's oesophagus-associated dysplastic or neoplastic lesions; however, none of the newer techniques has been validated for routine clinical practice. There is an increasing recognition that histology in GERD may provide useful diagnostic information, in part to exclude other lesions, such as eosinophilic oesophagitis, intestinal metaplasia and dysplasia or malignancy and, in part, to identify changes, such as basal cell hyperplasia, papillary elongation and, most recently, dilated intercellular spaces, that are consistent with GERD. However, more widespread incorporation of histology into the clinical management of GERD will require a standardized biopsy protocol and efforts to minimise interobserver differences in the identification of GERD-related histological changes.

Overlap of functional dyspepsia and GERD--diagnostic and treatment implications

GERD and functional dyspepsia are the two most prevalent upper gastrointestinal disorders. Gastro-oesophageal reflux is most commonly diagnosed using the cardinal symptoms of heartburn and regurgitation. Patients might also be diagnosed using a questionnaire, after empiric treatment with an acid suppressant, after upper endoscopy or by pH testing. Functional dyspepsia is best diagnosed using symptoms outlined by the Rome committee in conjunction with a normal upper endoscopy. Theoretically, distinguishing these two populations should be easy for all health-care providers. In reality, however, carefully separating out these two populations can be quite difficult, as substantial overlap exists epidemiologically, symptomatically and even diagnostically. This overlap renders precise diagnosis a challenge; given the limited treatment options, the primary goal is to identify those patients who will respond to acid suppressive therapy. Despite the frequency with which functional dyspepsia and GERD overlap, remarkably few studies have investigated this overlap. Most recommendations are based on data derived from separate studies of functional dyspepsia and GERD. A further limitation of existing studies is their failure to differentiate between the various diagnostic categories into which the individual presenting with heartburn might belong.

Managing gastroesophageal reflux disease in children: The role of endoscopy

Gastroesophageal reflux disease (GERD) is a growing problem in the pediatric population and recent advances in diagnostics and therapeutics have improved their management, particularly the use of esophago-gastroduodenoscopy (EGD). Most of the current knowledge is derived from studies in adults; however there are distinct features between infant onset and adult onset GERD. Children are not just little adults and attention must be given to the stages of growth and development and how these stages impact the disease management. Although there is a lack of a gold standard test to diagnose GERD in children, EGD with biopsy is essential to assess the type and severity of tissue damage. To date, the role of endoscopy in adults and children has been to assess the extent of esophagitis and detect metaplastic changes complicating GERD; however the current knowledge points another role for the EGD with biopsy that is to rule out other potential causes of esophagitis in patients with GERD symptoms such as eosinophilic esophagitis. This review highlights special considerations about the role of EGD in the management of children with GERD.

The diagnosis of gastroesophageal reflux disease

BACKGROUND

Gastroesophageal reflux disease is a highly prevalent condition that imposes a significant economic impact on the US health care system. The utility of commonly used tests for the diagnosis of gastroesophageal reflux disease has not been adequately reviewed.

METHODS

A comprehensive review of the literature was undertaken to provide an evidence-based approach to the diagnosis of gastroesophageal reflux disease. EMBASE (1980-December 2008), OVID MEDLINE, and PubMed, (1966-December 2008) were searched using "gastroesophageal reflux" and "adults" with other terms, including medications, diagnostic tests, symptoms, and epidemiologic terms. Studies were limited to human trials, English language, and full articles.

RESULTS

Heartburn is a reasonably sensitive symptom for the diagnosis of gastroesophageal reflux disease, although it does not reliably predict esophagitis. Standardized questionnaires have limited specificity, whereas the double-contrast barium swallow has a low sensitivity to diagnose gastroesophageal reflux. The role of esophageal manometry is limited to accurate placement of a pH-measuring device. pH testing has reasonable sensitivity and specificity for the diagnosis of gastroesophageal reflux disease. The sensitivity of upper endoscopy to diagnose gastroesophageal reflux is lower than that of pH tests.

CONCLUSION

The diagnosis of gastroesophageal reflux disease remains difficult. In the absence of alarm symptoms, empiric treatment with acid suppression is warranted. pH testing provides valuable information in many patients, although the clinical utility of newer tests needs to be determined. Endoscopy should not be the first test used to diagnose gastroesophageal reflux.