Interobserver agreement on classifying endoscopic diagnoses of nonerosive esophagitis

Background and study aims: The majority of patients with gastroesophageal reflux disease in Japan have low-grade esophagitis, including minimal changes. A modified Los Angeles classification of esophagitis, consisting of erosive esophagitis (grades A - D) and nonerosive esophagitis (grades M and N) has been proposed and is in clinical use in Japan. However, it is unclear whether nonerosive esophagitis with only undemarcated mucosal discoloration (grade M) is clinically significant, since interobserver variations in classification have not been investigated. The aim of the present study was therefore to evaluate interobserver variance and diagnostic agreement in the diagnosis of nonerosive esophagitis (grades M and N).
Materials and methods: A total of 84 endoscopists were enrolled to assess the grade of esophagitis in 30 patients by viewing endoscopic images of the gastroesophageal junction. The images were projected onto a screen, and all of the endoscopists reviewed them concurrently. The diagnosis was selected from the following three categories in the modified Los Angeles classification: grades N, M, or A. The endoscopists were grouped according to their experience, whether they had a board license, and whether they had received specialist training in esophagitis. The kappa coefficient of reliability was calculated.
Results: The kappa coefficient of reliability for all the endoscopists in the diagnosis of cases of grade M and N nonerosive esophagitis was unacceptably low at 0.22 (95 % CI, 0.21 - 0.24). Endoscopists with a board license and those who had completed a special esophagitis diagnostic course had slightly higher kappa values (0.26; 95 % CI, 0.23 - 0.30 and 0.29; 95 % CI, 0.26 - 0.32), respectively.
Conclusions: Interobserver agreement on the endoscopic diagnosis of nonerosive esophagitis (grades M and N) is too low to be of clinical value.

References

• 1 Moayyedi P, Axon A TR. Review article: gastro-oesophageal reflux disease - the extent of the problem.  Aliment Pharmacol Ther. 2005;  22 (Suppl 1) 11-19
• 2 Carlsson R, Dent J, Watts R. et al . Gastro-oesophageal reflux disease in primary care: an international study of different treatment strategies with omeprazole. International GORD Study Group.  Eur J Gastroenterol Hepatol. 1998;  10 119-124
• 3 Lind T, Havelund T, Carlsson R. et al . Heartburn without oesophagitis: efficacy of omeprazole therapy and features determining therapeutic response.  Scand J Gastroenterol. 1997;  32 974-979
• 4 Martinez S D, Malagon I B, Garewal H S. et al . Non-erosive reflux disease (NERD): acid reflux and symptom patterns.  Aliment Pharmacol Ther. 2003;  17 537-545
• 5 Quigley E M. Non-erosive reflux disease: part of the spectrum of gastro-oesophageal reflux disease, a component of functional dyspepsia, or both?.  Eur J Gastroenterol Hepatol. 2001;  13 (Suppl 1) S13-S18
• 6 Fujiwara Y, Higuchi K, Watanabe Y. et al . Prevalence of gastroesophageal reflux disease and gastroesophageal reflux disease symptoms in Japan.  J Gastroenterol Hepatol. 2005;  20 26-29
• 7 Mishima I, Adachi K, Arima N. et al . Prevalence of endoscopically negative and positive gastroesophageal reflux disease in the Japanese.  Scand J Gastroenterol. 2005;  40 1005-1009
• 8 Okamoto K, Iwakiri R, Mori M. et al . Clinical symptoms in endoscopic reflux esophagitis: evaluation in 8031 adult subjects.  Dig Dis Sci. 2003;  48 2237-2241
• 9 Miwa H, Minoo T, Hojo M. et al . Oesophageal hypersensitivity in Japanese patients with non-erosive gastro-oesophageal reflux diseases.  Aliment Pharmacol Ther. 2004;  20 (Suppl 1) 112-117
• 10 Nakamura T, Shirakawa K, Masuyama H. et al . Minimal change oesophagitis: a disease with characteristic differences to erosive oesophagitis.  Aliment Pharmacol Ther. 2005;  21 (Suppl 2) 19-26
• 11 Amano K, Adachi K, Katsube T. et al . Role of hiatus hernia and gastric mucosal atrophy in the development of reflux esophagitis in the elderly.  J Gastroenterol Hepatol. 2001;  16 132-136
• 12 Inamori M, Togawa J, Nagase H. et al . Clinical characteristics of Japanese reflux esophagitis patients as determined by Los Angeles classification.  J Gastroenterol Hepatol. 2003;  18 172-176
• 13 Fujimoto K, Iwakiri R, Okamoto K. et al . Characteristics of gastroesophageal reflux disease in Japan: increased prevalence in elderly women.  J Gastroenterol. 2003;  38 (Suppl 15) 3-6
• 14 Armstrong D, Bennett J R, Blum A L. et al . The endoscopic assessment of esophagitis: a progress report on observer agreement.  Gastroenterology. 1996;  111 85-92
• 15 Lundell L R, Dent J, Bennett J R. et al . Endoscopic assessment of oesophagitis: clinical and functional correlates and further validation of the Los Angeles classification.  Gut. 1999;  45 172-180
• 16 Hoshihara Y, Hoshimoto M. Endoscopic classification of reflux esophagitis [in Japanese with English abstract].  Nippon Rinsho. 2000;  58 1808-1812
• 17 Bytzer P, Havelund T, Hansen J M. Interobserver variation in the endoscopic diagnosis of reflux esophagitis.  Scand J Gastroenterol.. 1993;  28 119-125
• 18 Vieth M, Fiocca R, Haringsma J. et al . Radial distribution of dilated intercellular spaces of the esophageal squamous epithelium in patients with reflux disease exhibiting discrete endoscopic lesions.  Dig Dis. 2004;  22 208-212
• 19 Caviglia R, Ribolsi M, Maggiano N. et al . Dilated intercellular spaces of esophageal epithelium in nonerosive reflux disease patients with physiological esophageal acid exposure.  Am J Gastroenterol. 2005;  100 543-548
• 20 Narayani R I, Burton M P, Young G S. Utility of esophageal biopsy in the diagnosis of nonerosive reflux disease.  Dis Esophagus. 2003;  16 187-192
• 21 Zentilin P, Savarino V, Mastracci L. et al . Reassessment of the diagnostic value of histology in patients with GERD, using multiple biopsy sites and an appropriate control group.  Am J Gastroenterol. 2005;  100 2299-2306
• 22 Kiesslich R, Kanzler S, Vieth M. et al . Minimal change esophagitis: prospective comparison of endoscopic and histological markers between patients with non-erosive reflux disease and normal controls using magnifying endoscopy.  Dig Dis. 2004;  22 221-227