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• W2091370036 abstract "The diagnosis and grading of reflux esophagitis are important in the management of patients with gastroesophageal reflux disease (GERD). It enables the estimation of esophageal mucosal damage, the prediction of prognosis, and the monitoring of treatment response. An ideal endoscopic grading system of reflux esophagitis should have high sensitivity and specificity, which avoids the injudicious exclusion of patients at risk of disease progression, and the misdiagnosis of patients without GERD. It should also be simple and robust enough so that the interpretation can be relatively unaffected by the experience of endoscopist and endoscopic facilities. Furthermore, the classification should also be described in clearly defined and easily comprehensible terms so that precise communication among endoscopists is possible. There are over 30 different grading systems of reflux esophagitis. However, a formal development and validation process is lacking in most of these systems, and some have merely been published as secondary findings of clinical trials in patients with reflux esophagitis.1,2 There are no data on interobserver agreement, reproducibility, correlation with esophageal acid exposure, and the prediction of the treatment response rate in most of these systems. Other flaws include use of equivocal descriptions of endoscopic criteria, inclusion of minimal changes that are subjected to substantial interobserver variation, and incorporation of Barrett's esophagus in the grading system. Because of these pitfalls, further revision on the original system is inevitable and several ‘modified’ versions are established, which create further confusion and hamper their application in clinical practice. To date, the Los Angeles (LA) classification is the only system that has been established through a stringent process of development, evaluation, and validation.3 It has some distinct features compared to other grading systems. First, minimal changes of non-erosive reflux disease (NERD), such as mucosal edema, friability, and erythema are not included, as these criteria have been shown to have very poor agreement. Second, the difficulty of differentiating between ‘red streak’, ‘ulcer’, and ‘erosion’ is obviated by adoption of a collective term known as ‘mucosal break’. In addition, the LA classification puts more emphasis on the circumferential extent of involvement instead of longitudinal extent, which has been found to be less precise and reproducible. The LA classification has been extensively employed in clinical trials for the medical treatment of reflux esophagitis. These studies further validate the LA classification as a powerful tool for predicting healing and relapse of esophagitis with acid-suppressive therapy.4 The superiority of the LA classification is further supported by significantly higher levels of interobserver agreement compared to the other two commonly-used systems.5 The LA classification has also been used in long-term observational and community-based epidemiological studies.6,7 While the LA classification has been proven to be a robust system for the assessment of esophagitis in Western countries, its validity has not been scrutinized in Asian countries. There are several factors that may undermine the validity of the LA classification in Asia. First, GERD is relatively less prevalent in Asia. Reflux symptoms are often overlooked and misinterpreted as dyspepsia or chest pain owing to low awareness by both clinicians and patients. Endoscopists may therefore have little vigilance on the likelihood of reflux esophagitis in these patients. Second, endoscopists in Asia may be less experienced in the assessment of esophagitis because of a lower prevalence of GERD complications. It has been reported that experience is a determinant of interobserver and intraobserver agreement for the endoscopic grading of esophagitis using the LA classification.8 In this issue of the Journal of Gastroenterology and Hepatology, Wong et al. set out to determine the interobserver agreement and validity of the LA classification in Asian GERD patients.9 Using video endoscopic clips of GERD patients, esophagitis and endoscopically-suspected Barrett's esophagus were graded independently by three consultant endoscopists using the LA classification. An excellent interobserver agreement (kappa coefficient = 0.79) and good agreement (k = 0.48) were noted for the detection of esophagitis and endoscopically-suspected Barrett's esophagus, respectively. Interobserver agreement was also good (k = 0.58) for the grading of esophagitis. There was also a learning effect observed with increasing agreement as viewings progressed. This study further supports the validity of the LA classification for the assessment of esophagitis in Asian countries, where prevalence, awareness, and case load of esophagitis are lower than their Western counterparts. The reported interobserver agreement of esophagitis grading in this study is comparable to that of Western studies. In this study, high image quality endoscopic video clips were used and the observers were allowed to pause and review selected segments at their individual preference. The viewing protocol can therefore come close to emulating live endoscopy.Another interesting finding of this study is the learning effect observed with the increasing number of video clips viewed and the improvement in interobserver agreement reached a plateau after 16 cases were viewed. The relatively small number of cases required to achieve this plateau suggests a steep learning curve with the use of the LA classification; this further supports that the LA classification is simple and easy to use. Despite promising results on interobserver agreement and the steep learning curve reported in this study, there are issues that remain unresolved. Further studies are required to test the robustness of the LA classification in less specialized setting. In clinical practice, the assessment of esophagitis is primarily conducted by endoscopists who have lower vigilance and less experience with probably limited accuracy in symptom description on endoscopy referrals. Furthermore, discriminative power between low-grade (A/B) and high-grade (C/D) esophagitis could not be properly evaluated, as only one clip of grade C esophagitis was studied. In anticipation of an emerging patient population with severe esophagitis in Asia, it is of utmost importance for endoscopists to accurately detect high-grade esophagitis so that the injudicious use of step-down acid-suppressive therapy is avoided in this group of patients. Lastly, with the advent of high-resolution magnifying endoscopy, ‘traditional’ minimal changes of NERD have been revisited and incorporated into a modified version of the LA classification. While this version is still exclusively used by Japanese endoscopists and the reliability remains unproven, novel endoscopic criteria for NERD are emerging, and this remains a challenging area for research in the future. In summary, the LA classification remains the most accurate system for esophagitis grading worldwide. The study by Wong et al. underscores the validity and simplicity of this system in Asia. With an increasing prevalence of GERD and its complication in this part of the world, a more structured training program for endoscopists on the LA classification is deemed necessary and feasible. It is also time for a more systematic assessment of esophagitis to be adopted in clinical practice in order to facilitate longitudinal observational and epidemiological studies of this disease in Asia." @default.
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• W2091370036 date "2009-01-01" @default.
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• W2091370036 title "Endoscopic grading of reflux esophagitis in Asia: It's time to start" @default.
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