The endoscopic diagnosis of nonerosive reflux disease using flexible spectral imaging color enhancement image: a feasibility trial

Abstract

Nonerosive reflux disease (NERD) is classified into grade M (minimal change, endoscopically; erythema without sharp demarcation, whitish turbidity, and/or invisibility of vessels due to these findings) and grade N (normal) in the modified Los Angeles classification system in Japan. However, the classification of grades M and N NERD is not included in the original Los Angeles system because interobserver agreement for the conventional endoscopic diagnosis of grades M or N NERD is poor. Flexible spectral imaging color enhancement (FICE) is a virtual chromoendoscopy technique that enhances mucosal and vascular visibility. The aim of this study is to evaluate whether the endoscopic diagnosis of grades M or N NERD using FICE images is feasible. Between April 2006 and May 2008, 26 NERD patients and 31 controls were enrolled in the present study. First, an experienced endoscopist assessed the color pattern of minimal change in FICE images using conventional endoscopic images and FICE images side-by-side and comparing the proportion of minimal change between the two groups. Second, three blinded endoscopists assessed the presence or absence of minimal change in both groups using conventional endoscopic images and FICE images separately. Intraobserver variability was compared using McNemar's test, and interobserver agreement was described using the kappa value. Minimal changes, such as erythema and whitish turbidity, which were detected using conventional endoscopic images, showed up as navy blue and pink-white, respectively, in color using FICE images in the present FICE mode. The NERD group had a higher proportion of minimal change, compared with the control group (77% and 48%, respectively) (P= 0.033). In all three readers, the detection rates of minimal change using FICE images were greater than those using conventional endoscopic images (P= 0.025, <0.0001, and 0.034 for readers A, B, and C, respectively). The kappa values for all pairs of three readers using FICE images were between 0.683 and 0.812, while those using conventional endoscopic images were between 0.364 and 0.624. Thus, the endoscopic diagnosis of grades M or N NERD using FICE images is feasible and may improve interobserver agreement.

Feasibility Trial of the Newly Introduced Optical Enhancement Technology in Patients with Gastroesophageal Reflux Disease

“…Similar minimal changes in the squamocolumnar junction of the esophagus have been reported in other studies comparing the utility of i-scan, FICE with that of WLE [6,7,[25][26][27][28]. In all these trials, image-enhanced endoscopy increased the diagnostic yield of reflux esophagitis by detecting, in accordance with our results, mucosal and vascular alterations at the distal esophagus adjacent to the Z-line.…”

High-definition endoscopy withiScan and Lugol's solution for the detection of inflammation in patients with nonerosive reflux disease: histologic evaluation in comparison with a control group

“…No distinction was made in this study between NERD and GERD patients, but high‐resolution and virtual chromoendoscopy were found to demonstrate the small changes in great detail . These changes are still not incorporated in commonly used classifications, but are always described as minimal change esophagitis in published studies …”

“…A further study comprising 26 NERD patients and 31 controls with no symptoms was based on the use of virtual chromoendoscopy equipped with Fuji intelligent color enhancement technology (FICE, Fujinon, Japan); the authors found minimal mucosal lesions in 77% of NERD patients and 48% of the original controls . One limitation of the study was again the absence of histological confirmation of newly found lesions.…”

Identifying Minimal Changes in Nonerosive Reflux Disease

“…21 As noted above, these virtual chromoendoscopy procedures may improve interobserver variability, beyond conventional endoscopy. 19,20 …”

“…Proposed minimal changes include: vascular changes at the SCJ (vascular spots above the Z-line, punctate erythema/shining of blood vessels through the mucosa, loss of long blood vessels above the Z-line, intraepithelial papillary capillary loop dilation or tortuosity), white mucosal turbidity at the SCJ, irregular Z-line, horizontal erosions, and triangular indentation into the squamous mucosa. 10,[15][16][17][18][19][20][21] Using pH monitoring as the standard, these minimal changes have a sensitivity for the assessment of NERD that ranges from 60% to 90%, and a specificity from 64% to 83%. Despite multiple studies and modalities for the diagnosis of minimal changes, there is no current consensus regarding the definition of "minimal changes.…”