Significance of non-erosive minimal esophageal lesions in gastro-esophageal reflux disorder

[Minimal Change Esophagitis]

Gastroesophageal reflux disease (GERD) is defined as a condition which develops when the reflux of gastric contents causes troublesome symptoms and long-term complications. GERD can be divided into erosive reflux disease and non-erosive reflux disease based on endoscopic findings defined by the presence of mucosal break. The Los Angeles classification excludes minimal changes as an evidence of reflux esophagitis because of poor interobserver agreement. In the Asian literature, minimal changes are considered as one of the endoscopic findings of reflux esophagitis, but the clinical significance is still controversial. Minimal change esophagitis is recognized quite frequently among patients with GERD and many endoscopists recognize such findings in their clinical practice. This review is intended to clarify the definition of minimal change esophagitis and their histology, interobserver agreement, and symptom association with GERD.

Vegetarianism as a protective factor for reflux esophagitis: a retrospective, cross-sectional study between Buddhist priests and general population

BACKGROUND/AIMS

Several risk factors for reflux esophagitis, such as smoking, alcohol consumption, obesity, and metabolic syndrome, are recognized. But vegetarianism as a protective factor for reflux esophagitis has not been reported. The aim of this study is to elucidate the protective effect of vegetarianism for reflux esophagitis.

METHODS

This is a cross-sectional study that compared the prevalence of reflux esophagitis of 148 Buddhist priests, who are obligatory vegetarians with that of age- and sex-matched controls who underwent health checkups in a health promotion center.

RESULTS

The prevalence of reflux esophagitis was higher in the control group than in the Buddhist priest group (21.6 vs 12.2 %). Weight, body mass index, waist circumference, waist-to-hip ratio, and abdominal adipose tissue area were higher and high density lipoprotein (HDL) cholesterol and total cholesterol were lower in the Buddhist priest group. The prevalence of metabolic syndrome was higher in the Buddhist priest group than the control group (30.4 vs 17.6 %). In univariate analysis, male sex (odds ratio [OR] = 3.325; 95 % confidence interval [CI], 1.659-6.666), current smoking (OR = 3.37; 95 % CI, 1.439-7.881), alcohol consumption (OR = 2.75; 95 % CI, 1.375-5.481), waist circumference (OR = 1.99; 95 % CI, 1.062-3.739), negative for Helicobacter pylori IgG antibody (OR = 1.89; 95 % CI, 1.018-3.491) and non-vegetarianism (OR = 1.99; 95 % CI, 1.062-3.739) were associated with reflux esophagitis. According to multivariate analysis, male sex (OR = 3.44; 95 % CI, 1.698-6.970), non-vegetarianism (OR = 2.08; 95 % CI, 1.086-3.974) and negative H. pylori IgG antibody (OR = 1.96; 95 % CI, 1.039-3.712) were significantly associated with reflux esophagitis.

CONCLUSIONS

A non-vegetarian diet is associated with reflux esophagitis.

Halimeter ppb Levels as the Predictor of Erosive Gastroesophageal Reflux Disease

BACKGROUND/AIMS

In a previous issue published in Gut and Liver, we found that erosive changes in the esophagogastroduodenal mucosa were strongly correlated with increased levels of volatile sulfur-containing compounds (VSC), suggesting that halitosis could be a symptom reflecting the erosive status of the upper gut mucosa. Together with other studies showing a possible association between halitosis and gastroesophageal reflux disease (GERD), under the premise that halitosis could be one of extraesophageal manifestations of erosive GERD (ERD), we investigated the significance of Halimeter ppb levels on ERD compared to non-erosive gastroesophageal reflux disease (NERD).

METHODS

Subjects were assigned to the NERD group if there was no evidence of esophageal erosive changes on endoscopy, despite reflux symptoms, and to the ERD group if they had GERD A, B, C, or D (according to the Los Angeles classification). The VSC levels were measured in all patients with either a Halimeter (before endoscopy) or by gas chromatography of the gastric juices aspirated during endoscopy.

RESULTS

The VSC level differed significantly between the NERD and ERD groups (p<0.0001), suggesting that this can be used to discriminate between NERD and ERD. However, the VSC level did not differ significantly with the severity of GERD. Even though hiatal hernia and a body mass index of >24 kg/m(2) was significantly associated with ERD, there was no correlation with Halimeter ppb levels. Minimal-change lesions exhibited the highest VSC levels, signifying that minimal change lesions can be classified as ERD based on our finding that halimeter ppb levels were descrimitive of erosive change.

CONCLUSIONS

Erosive changes in the esophageal mucosa were strongly associated with VSC levels, supporting the hypothesis that halitosis can be a potential biomarker for the discrimination between ERD and NERD, reflecting the presence of erosive change in the lower esophagogastric junction.

Validation of structured scoring using the LA classification for esophagitis and endoscopically suspected Barrett's esophagus in a tertiary Asian endoscopy center

AIM

To determine the inter-observer agreement and validity of the LA Classification in scoring the severity of esophagitis in Asian patients.

METHODS

Video endoscopy clips were selected from 45 consecutive patients participating in reflux studies. The videos were viewed by endoscopists who then independently scored the presence, severity and distribution of esophagitis, including endoscopically suspected Barrett's esophagus (ESBE). Each video was discussed and a consensus on findings reached. Kappa (k) correlation was calculated to describe inter-observer agreement.

RESULTS

Thirty-five clips were scored (no esophagitis 20%, grade-A 54%, grade-B 23%, grade-C 3%, respectively and 10 clips were excluded for poor imaging). Excellent agreement was noted on the presence of esophagitis (mean k = 0.79, range 0.77-0.82). Fifteen patients (42%) had ESBE with a mean k of 0.48 (range 0.39-0.60). Inter-observer agreement on the LA grade was good (mean k = 0.58, range 0.55-0.63), whilst in agreement between endoscopists and consensus grading, the mean kappa rose to 0.77 (range 0.73-0.81). There was a trend of increasing agreement as viewings progressed, with superior kappa correlation after 16 cases. Evaluation of the extent of esophagitis showed good k values using the alternative approach of grouping by circumferential extent (mean k = 0.64, range 0.60-0.67) at the lower categories of severity.

CONCLUSIONS

Scoring using the LA classification for esophagitis and the concurrence on the presence of ESBE showed moderate to strong agreement amongst Asian endoscopists. Our results also suggested that an alternative method of scoring esophagitis based on proportion of circumferential involvement was reliable. A learning effect was observed and reliable scoring was achieved after 16 patients.