The endoscopic assessment of esophagitis: A progress report on observer agreement
Abstract
BACKGROUND & AIMS: The study and management of reflux esophagitis require an endoscopic classification system founded on esophageal lesions that can be reproducibly identified. The aim of this study was to investigate interobserver agreement for the identification of endoscopic lesions typical of reflux esophagitis. METHODS: Paired comparisons of observers' descriptions were obtained. Seventeen endoscopists assessed 100 still images, and 42 endoscopists, including 13 endoscopists in training, assessed 23 endoscopic video recordings. In a third, ancillary study, using a simpler evaluation sheet, 219 gastroenterologists recorded their assessments of 20 still images. RESULTS: The agreement between endoscopists was similar for still images and video recordings. Agreement between experienced endoscopists was acceptable to good for recognition of minimal changes (erythema, friability, mucosal edema; kappa = 0.46 to kappa = 0.8), mucosal breaks (discretely, demarcated areas of slough or erythema; kappa = 0.84), and complications (ulceration, kappa = 0.92; stricturing, kappa = 0.80; columnar metaplasia, kappa = 0.81), although there was poor agreement when the circumferential extent and number of mucosal breaks were assessed. However, total circumferential extent of the mucosal break had a kappa value of 0.59. Agreement between inexperienced endoscopists was poor for recognition of minimal changes but was good for recognition of complications (kappa, 0.70-0.90). CONCLUSIONS: Endoscopists can identify mucosal breaks confined to a mucosal fold and lesions that extend throughout the esophageal circumference. Complications of reflux disease can be reproducibly recorded. Criteria for assessing the number of mucosal breaks and their radial extent must be defined more clearly, as must the features of minimal change esophagitis. (Gastroenterology 1996 Jul;111(1):85-92)
References (0)
Cited by (995)
Expression of epidermal growth factor receptor (EGFR) in systemic sclerosis patients (SSc) and gastro-oesophageal reflux disease (GORD)
2024, Immunology LettersSystemic sclerosis (SSc) affects the connective tissue and leads to an abnormal fibrotic process in the skin and internal organs. Epidermal Growth Factor Receptor (EGFR) is able to induce cell proliferation and differentiation, and its expression is increased in SSc patients with pulmonary artery hypertension and in skin biopsies in patients with scleroderma. To date, no data on esophageal expression of EGFR are available in SSc patients. We aimed to evaluate whether the pro-fibrogenic pathways of SSc may affect EGFR expression in the esophagus.
A retrospective analysis included patients with SSc and control subjects suffering from gastroesophageal reflux symptoms. Endoscopic assessment and histopathologic analyses were performed in all subjects and the presence of microscopic esophagitis was used to distinguish patients with normal esophageal mucosa and subjects with non-erosive reflux disease. EGFR expression was measured in all subjects.
A total of 35 patients with SSc were included, while the control group included 67 non-SSc patients. EGFR expression at the Z-line was higher in SSc patients than non-SSc patients in absence of microscopic esophagitis (median 65 %, IQR 56–71 % vs 42 %, IQR 37–54 %, p < 0.001). Microscopic esophagitis was found in 60 % of patients with SSc and 62.7 % of control patients, and EGFR expression was significantly higher in patients presenting microscopic esophagitis both in SSc and non-SSc patients.
The EGFR hyperexpression may be due to SSc and/or reflux-related damage in patients with microscopic esophagitis. Further studies are warranted to answer open questions and provide a possible role of EGFR in terms of diagnosis, prognosis, and therapy.
AGA Clinical Practice Update on High-Quality Upper Endoscopy: Expert Review
2024, Clinical Gastroenterology and HepatologyThe purpose of this Clinical Practice Update (CPU) Expert Review is to provide clinicians with guidance on best practices for performing a high-quality upper endoscopic exam.
The best practice advice statements presented herein were developed from a combination of available evidence from published literature, guidelines, and consensus-based expert opinion. No formal rating of the strength or quality of the evidence was carried out, which aligns with standard processes for American Gastroenterological Association (AGA) Institute CPUs. These statements are meant to provide practical, timely advice to clinicians practicing in the United States. This Expert Review was commissioned and approved by the American Gastroenterological Association (AGA) Institute Clinical Practice Updates (CPU) Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership, and underwent internal peer review by the CPU Committee and external peer review through standard procedures of Clinical Gastroenterology & Hepatology.
Endoscopists should ensure that upper endoscopy is being performed for an appropriate indication and that informed consent clearly explaining the risks, benefits, alternatives, sedation plan, and potential diagnostic and therapeutic interventions is obtained. These elements should be documented by the endoscopist before the procedure.
Endoscopists should ensure that adequate visualization of the upper gastrointestinal mucosa, using mucosal cleansing and insufflation as necessary, is achieved and documented.
A high-definition white-light endoscopy system should be used for upper endoscopy instead of a standard-definition white-light endoscopy system whenever possible. The endoscope used for the procedure should be documented in the procedure note.
Image enhancement technologies should be used during the upper endoscopic examination to improve the diagnostic yield for preneoplasia and neoplasia. Suspicious areas should be clearly described, photodocumented, and biopsied separately.
Endoscopists should spend sufficient time carefully inspecting the foregut mucosa in an anterograde and retroflexed view to improve the detection and characterization of abnormalities.
Endoscopists should document any abnormalities noted on upper endoscopy using established classifications and standard terminology whenever possible.
Endoscopists should perform biopsies for the evaluation and management of foregut conditions using standardized biopsy protocols.
Endoscopists should provide patients with management recommendations based on the specific endoscopic findings (eg, peptic ulcer disease, erosive esophagitis), and this should be documented in the medical record. If recommendations are contingent upon histopathology results (eg, H pylori infection, Barrett’s esophagus), then endoscopists should document that appropriate guidance will be provided after results are available.
Endoscopists should document whether subsequent surveillance endoscopy is indicated and, if so, provide appropriate surveillance intervals. If the determination of surveillance is contingent on histopathology results, then endoscopists should document that surveillance intervals will be suggested after results are available.
Esophagitis, reflux esophagitis, and gastroesophageal reflux disease
2024, Medicine (Spain)La esofagitis se define como la presencia de un proceso inflamatorio a nivel de diferentes capas del esófago. Es una patología frecuente, con gran variedad de causas, siendo la esofagitis por reflujo la más común. La enfermedad por reflujo gastroesofágico (ERGE) se define como la aparición de síntomas o lesiones secundarias al reflujo patológico mantenido, siendo las relajaciones transitorias del esfínter esofágico inferior el principal mecanismo precipitante. Clínicamente puede dar lugar a manifestaciones típicas (pirosis y regurgitación), así como a manifestaciones extraesofágicas. Es una enfermedad crónica y de curso generalmente benigno, aunque puede dar lugar a complicaciones como la esofagitis o el esófago de Barrett y riesgo de evolución a adenocarcinoma de esófago. La ERGE en la práctica clínica es diagnosticada empíricamente y tratada basándose en los síntomas registrados por el clínico, aunque en ocasiones precisa de la realización de una endoscopia digestiva alta y otras pruebas complementarias para el diagnóstico y descartar complicaciones. El tratamiento se basa en una combinación de medidas higiénico-dietéticas y la administración de inhibidores de la bomba de protones, siendo en alguna ocasión necesario recurrir a la cirugía.
Esophagitis is defined as the presence of inflammatory disease in different layers of the esophagus. It is a common disease that has a wide variety of causes, with reflux esophagitis being the most frequent. Gastroesophageal reflux disease (GERD) is defined as the onset of symptoms or lesions secondary to sustained pathological reflux. The main triggering mechanism is transient relaxation of the lower esophageal sphincter. Clinically, it can give rise to typical manifestations (pyrosis and regurgitation) as well as extraesophageal manifestations. It is a chronic disease with a generally benign course, although it can lead to complications such as esophagitis or Barrett's esophagus and risk of progression to esophageal adenocarcinoma. In clinical practice, GERD is diagnosed empirically and treated based on the symptoms recorded by the clinician, although performing an upper gastrointestinal endoscopy and other additional tests are sometimes required for diagnosis and to rule out complications. Treatment is based on a combination of hygienic-dietary measures and medical treatment based on proton pump inhibitors. On some occasions, resorting to surgical treatment may be required.
An improved guideline adherence and PPI efficacy has been accompanied by a decrease in diagnostic delay, and strictures before diagnosis of eosinophilic esophagitis in the North Denmark Region - a retrospective registry study of the DanEoE cohorts
2023, Clinics and Research in Hepatology and GastroenterologyIn the North Denmark Region an increased awareness of eosinophilic esophagitis (EoE) was observed after 2011 where a regional biopsy guideline was implemented. This resulted in an increased awareness of EoE and a 50-fold increase in the incidence of EoE patients between 2007-2017.
The aims of this study were to examine the progress in diagnostic delay, complications, PPI treatment, and follow up since 2017 in Danish patients with eosinophilic esophagitis.
This was a retrospective registry- and population-based cohort study (DanEoE2 cohort) including 346 adult patients with esophageal eosinophilia diagnosed between 2018-2021 in the North Denmark Region. The DanEoE2 cohort included all possible EoE patients by using the Danish Patho-histology registry based on the SNOMED-system. The data was analyzed and compared to the DanEoE cohort (2007-2017).
The diagnostic delay of EoE patients diagnosed between 2018-2021 in the North Denmark Region had decreased with a median of 1.5 years (5.5 (2.0;12) years versus 4.0 (1.0;12) years, p=0.03). Strictures before diagnosis had decreased 8.4 % (11.6% versus 3.2%, p=0.003). The number of patients started on high-dose PPI increased (56% versus 88%, p<0.001). An intensified awareness regarding national guidelines and follow-up was observed as an increase in the number of histological follow up (67% versus 74%, p=0.05).
Comparisons of the DanEoE cohorts showed a decrease in diagnostic delay, a decrease in stricture formation before diagnosis, and an improved guideline adherence after 2017. Future studies are needed to assess if symptomatic or histological remission on PPI treatment is more capable of predicting a patient's risk of developing complications.
Clinical Variables as Indicative Factors for Endoscopy in Adolescents with Esophageal Atresia
2023, Journal of Pediatric SurgeryGastro-esophageal reflux disease (GERD) occurs frequently in patients operated for esophageal atresia (EA). Longstanding esophagitis may lead to dysphagia, strictures, columnar metaplasia, and dysplasia with an increased risk of adenocarcinoma. Are clinical factors and non-invasive assessments reliable indicators for follow-up with endoscopy?
A follow-up study with inclusion of EA adolescents in Norway born between 1996 and 2002 was conducted. Clinical assessment with pH monitoring, endoscopy with biopsies, along with interviews and questionnaires regarding gastroesophageal reflux disease (GERD) and dysphagia were performed.
We examined 68 EA adolescents. 62% reported GERD by interview, 22% by questionnaire. 85% reported dysphagia by interview, 71% by questionnaire. 24-hour pH monitoring detected pathological reflux index (RI) (>7%) in 7/59 (12%). By endoscopy with biopsy 62 (92%) had histologic esophagitis, of whom 3 (4%) had severe esophagitis. Gastric metaplasia was diagnosed in twelve (18%) adolescents, intestinal metaplasia in only one (1.5%). None had dysplasia or carcinoma. Dysphagia and GERD were statistically correlated to esophagitis and metaplasia, but none of the questionnaires or interviews alone were good screening instruments with high combined sensitivity and specificity. A compound variable made by simply taking the mean of rescaled RI and dysphagia by interview showed to be the best predictor of metaplasia (85% sensitivity, 67% specificity).
The questionnaires and interviews used in the present study were not good screening instruments alone. However, combining dysphagia score by interview and RI may be helpful in assessing which patients need endoscopy with biopsy at each individual follow-up examination.
Level II prognostic study
Risk Factors for Mucosal Redness in the Duodenal Bulb as Detected via Linked Color Imaging
2024, Diagnostics