Reflux Disease and Barrett’s Esophagus

Diagnostic Aspects of Reflux Disease

In a large study from Sweden, 3000 randomly selected persons were sent a questionnaire (response rate 71 %); endoscopy was performed in 1000 of them, regardless of symptoms (from 1566 invited). Forty-five percent of the responders reported reflux symptoms in the previous 3 months; asymptomatic reflux esophagitis was detected endoscopically in 5 % [1]. Two retrospective analyses, one from the United States and one from France, dealt with endoscopic findings in patients with reflux symptoms; despite the increasing use of proton-pump inhibitors (but not increasing to more than 18 %), the frequency of erosive esophagitis on endoscopy remained constant at around 20 % in the United States [2]. In France, 74 % of patients with gastroesophageal reflux disease (GERD) underwent endoscopy, with a rate of 38 % of erosive esophagitis and 8 % for Barrett’s [3]. In an attempt to make esophageal screening for patients with reflux easier, a short, battery-powered endoscope with a diameter of 4 mm was introduced, which can also be used by nurse practitioners, as shown in 111 patients [4]. When the same group compared findings obtained with this small endoscope introduced by nurse practitioners with standard video endoscopy performed by gastroenterologists in 43 cases, the sensitivity and specificity of all the esophageal findings were 74 % and 98 %, with slightly better values for Barrett’s esophagus [5]. In another study, decreasing the diameter of this endoscope further to 3mm was not found to increase patient tolerance [6].

In patients with esophagitis, the best classification system for severity is still being studied. Comparing the Savary-Miller and the Los Angeles classifications of gastroesophageal reflux (GERD) in 70 patients before and after proton-pump inhibitor (PPI) therapy, the healing rates (overall 86 %) did not significantly differ between the two classifications [7]. In another study, the reproducibility of the Savary-Miller, Los Angeles, and MUSE (mucosa, ulceration structure, and endoscopic appearance) classifications was tested in 60 patients, videotapes of whom were shown to nine investigators with various degrees of experience. The results showed that reproducibility was best with the MUSE classification, although the Los Angeles classification was somewhat easier to use [8]. The Hill classification of the gastroesophageal junction viewed in retroflexion was shown to correlate with endoscopic findings of esophagitis [9], but this classification is not widely used.

In patients with symptomatic GERD but no signs on endoscopy, subtle abnormalities can be seen on high-resolution magnification endoscopy. In a blinded assessment comparing patients with pathological 24-h pH-metry and normal control individuals, pinpoint vessels and triangular indentation of the esophagogastric junction were more frequent in reflux patients - but it is questionable whether these differences are sufficient for a reliable differential diagnosis to be made [10]. Histology is commonly believed to be of little value in endoscopy-negative GERD patients. In a study from Italy, intraepithelial infiltration by neutrophils and basal-cell hyperplasia were found more frequently in symptomatic patients than in controls [11], but this is not convincing evidence for a supplementary role of histology. DeMeester’s group in Los Angeles demonstrated that postprandial reflux after a standardized meal may increase the sensitivity of the standard 24-h pH-metry [12]. Intraesophageal stasis and intraesophageal reflux (not gastroesophageal reflux) seen on barium radiography were found very frequently in patients with GERD [13], but the clinical significance of this is not entirely clear.

References

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