John E. Pandolfino

Comparison of inter- and intraobserver consistency for grading of esophagitis by expert and trainee endoscopists ☆ ☆☆

BACKGROUNDnThis study evaluated intra- and interobserver variability in the endoscopic scoring of esophagitis by using two grading schemes, the Los Angeles and Hetzel-Dent scales.nnnMETHODSnThree hundred twenty-five endoscopic photographs of esophagitis or healed esophagitis were randomly displayed twice to 9 endoscopist evaluators (4 experts, 5 trainees) by means of a CD-ROM. Evaluators scored each photograph by using both classification schemes. The analysis was based on the kappa (kappa) statistic as a measure of consistency.nnnRESULTSnFor trainees, intraobserver reproducibility was good (kappa = 0.436) when using the Los Angeles classification and marginal (kappa = 0.395) by using the Hetzel-Dent classification. For experts, intraobserver reproducibility was better by using both the Los Angeles (kappa = 0.545) and Hetzel-Dent classification (kappa = 0.552). Interobserver consistency for trainees was good when using both classifications (Los Angeles, kappa = 0.459; Hetzel-Dent, kappa = 0.427). Again, intraobserver reproducibility was better for experts when using both classifications (Los Angeles, kappa = 0.556, Hetzel-Dent, kappa = 0.571). By using the Los Angeles classification, only 5.1% and 7.5% of the photographs were interpreted to be more than 1 grade different from the mean grade for, respectively, experts and trainees. This same consistency was found by using the Hetzel-Dent classification scheme (experts 5.1%, trainees 10.2%).nnnCONCLUSIONSnReproducibility in grading esophagitis was good for both expert endoscopists and fellows, although there was greater consistency among the experts. Both the Los Angeles and Hetzel-Dent scoring systems are reproducible.

The epidemiology and pathophysiology of gastroesophageal reflux disease

present in individuals with a symptomatic condition or histopathological alteration resultant from episodes of gastroesophageal reflux. Reflux esophagitis is present in a subset of GERD patients with lesions in the esophageal mucosa. However, reflux often causes symptoms in the absence of esophagitis. Although GERD is widely reported to be one of the most prevalent clinical conditions afflicting the gastrointestinal tract, incidence and prevalence figures must be tempered with the realization that there is no “gold standard” definition of GERD. Thus, epidemiological estimates regarding GERD make assumptions; the most obvious being that heartburn is a symptom of GERD and that when heartburn achieves a certain threshold of frequency or severity, it defines GERD. A cross-sectional study surveying hospital employees in the United States in the 1970s found that 7% of individuals experienced heartburn daily, 14% weekly, and 15% monthly. Ten years later, a Gallup survey of 1000 randomly selected persons found a 19% prevalence of weekly GERD symptoms. Ten years later yet, a survey in Olmstead County found a 20% prevalence of at least weekly heartburn. With respect to age, the Olmstead County data showed no correlation whereas a recent report by El-Serag et al. showed a slight correlation with advancing age ranging from a 24% weekly heartburn prevalence among 18–24 year olds to a 33% prevalence in those >55 years of age. With respect to esophagitis, even though endoscopic changes in the esophageal mucosa represent objective diagnostic criteria, it is less clear what proportion of heartburn sufferers are so affected. Early reports using ambulatory esophageal pH monitoring to define GERD found that 48–79% of patients with pathologic acid exposure had esophagitis. More recent reports, perhaps less subject to selection bias, have suggested that the prevalence of esophagitis among the GERD population is lower, ranging from 19 to 45%. Very recently, a population-based study found endoscopic esophagitis in 22% of 226 individuals with heartburn at least once weekly. Similar to esophagitis, the prevalence of Barrett’s metaplasia is difficult to determine in the absence of a characteristic symptom profile or population studies. Illustrative of this, an autopsy study suggested that fewer than one in six patients with Barrett’s metaplasia was recognized clinically prior to death. GERD is equally prevalent among males and females, but there is a male preponderance of esophagitis (2 :1 to 3 :1) and of Barrett’s metaplasia (10 :1). Pregnancy is associated with the highest incidence of GERD with 48–79% of pregnant women complaining of heartburn. All forms of GERD affect Caucasians more frequently than other races. However, this trend may be changing in the United States suggesting it is at least partially influenced by geography. In fact, there is substantial geographic variation in prevalence with very low rates in 1