Linked color imaging improves detection of minimal change esophagitis in non-erosive reflux esophagitis patients

Abstract

Background and study aims Non-erosive reflux disease (NERD) includes minimal change esophagitis (MCE) and no endoscopic abnormalities. However, for most endoscopists, it is difficult to detect MCE with conventional white-light endoscopy (WLE). Linked color imaging (LCI) technology is the most recently developed image-enhancing technology and improves detection and differentiation of subtle mucosal changes using a color contrast method. This study assessed the efficacy of WLE combined with LCI for diagnosing MCE compared with WLE.

Patients and methods Between February and May 2017, 44 NERD patients and 40 healthy subjects were enrolled in our study. First, the distal esophagus was examined using WLE followed by LCI. Second, three experienced endoscopists observed all the patients’ white-light (WL) images and corresponding images of WL and LCI and then recorded presence or absence of minimal change esophagitis (MCE +/–). The proportion of minimal change between the two groups was then compared. Third, five blinded endoscopists with different levels of endoscopic experience assessed whether MCE was present. Intraobserver reproducibility and interobserver agreement were described using the kappa value.

Results The proportion of MCE in the NERD group (70.8 %, 35/48) was higher than that in the control group (22.5 %, 9/40, P < 0.001) when diagnosed by the three experienced endoscopists. Detection rates for MCE using WLE combined with LCI were higher than those using WLE (43/88, 48.9 % vs. 29/88, 33.0 %, P < 0.001). With WLE combined with LCI, intraobserver reproducibility significantly improved, indicating that the combined approach can improve interobserver agreement compared with using WLE alone.

Conclusions Endoscopic diagnosis of MCE using WLE combined with LCI images is effective. Intraobserver reproducibility and interobserver agreement in MCE can be improved when LCI is applied with conventional imaging (Clinical trial registration number: NCT03068572).

^* Drs. Deng and Min: These authors contributed equally.

• References

• 1 Vakil N, van Zanten SV, Kahrilas P. et al. The Montreal definition and classification of gastroesophageal reflux disease: a global evidence-based consensus. Am J Gastroenterol 2006; 101: 1900-1920
• 2 Nakamura T, Shirakawa K, Masuyama H. et al. Minimal change esophagitis’s disease with characteristic differences to erosive oesophagitis. Aliment Pharmacol Ther 2005; 212 (Suppl. 01) 19-26
• 3 Armstrong D, Bennett JR, Blum A. et al. The endoscopic assessment of esophagitis: a progress report on observer agreement. Gastroenterology 1996; 111: 85-92
• 4 Sharma P, Wani S, Bansal A. et al. A feasibility trial of narrow band imaging endoscopy in patients with gastroesophageal reflux disease. Gastroenterology 2007; 133: 454-464
• 5 Hongo M. Minimal changes in reflux esophagitis: red ones and white ones. J Gastroenterol 2006; 41: 95-99
• 6 Miwa H, Yokoyama T, Hori K. et al. Interobserver agreement in endoscopic evaluation of reflux esophagitis using a modified Los Angeles classification incorporating grades N and M: a validation study in a cohort of Japanese endoscopists. Dis Esophagus 2008; 21: 355-363
• 7 Min M, Deng P, Zhang W. et al. Comparison of linked color imaging and white-light colonoscopy for detection of colorectal polyps: a multicenter, randomized, crossover trial. Gastrointest Endosc 2017; 86: 724-730
• 8 Okada M, Sakamoto H, Takezawa T. et al. Laterally spreading tumor of the rectum delineated by linked color imaging technology. Clin Endosc 2016; 49: 207-208
• 9 Osawa H, Yamamoto H. Present and future status of flexible spectral imaging color enhancement and blue laser imaging technology. Dig Endosc 2014; 26 (Suppl. 01) 105-115
• 10 Jones R, Junghard O, Dent J. et al. Development of the GerdQ, a tool for the diagnosis and management of gastro-oesophageal reflux disease in primary care. Aliment  2009; 30: 1030-1038
• 11 Kim JB, Shin SR, Shin WG. et al. Prevalence of minimal change lesions in patients with non-erosive reflux disease: a case-control study. Digestion 2012; 85: 288-294
• 12 Kim JH, Park H, Lee YC. et al. Is minimal change esophagitis really part of the spectrum of endoscopic findings of gastroesophageal reflux disease? A prospective, multicenter study. Endoscopy 2011; 43: 190-195
• 13 Lee YC, Lin JT, Chiu HM. et al. Intraobserver and interobserver consistency for grading esophagitis with narrow-band imaging. Gastrointest Endosc 2007; 66: 230-236
• 14 Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977; 33: 159-174
• 15 Yoshikawa I, Yamasaki M, Yamasaki T. et al. Lugol chromoendoscopy as a diagnostic tool in so-called endoscopy-negative GERD. Gastrointest Endosc 2005; 62: 698-703
• 16 Falk GW. Is conventional endoscopic identification of non-erosive reflux disease adequate?. Digestion 2008; 78 (Suppl. 01) 17-23
• 17 Gomes JrCA, Loução TS, Carpi G. et al. A study on the diagnosis of minimal endoscopic lesions in nonerosive reflux esophagitis using computed virtual chromoendoscopy (FICE). Arq Gastroenterol 2011; 48: 167-170
• 18 Fock KM, Teo EK, Ang TL. et al. The utility of narrow band imaging in improving the endoscopic diagnosis of gastroesophageal reflux disease. Clin Gastroenterol Hepatol 2009; 7: 54-59
• 19 Kodashima S, Fujishiro M. Novel image-enhanced endoscopy with i-scan technology. World J Gastroenterol 2010; 16: 1043-1049
• 20 Netinatsunton N, Sottisuporn J, Attasaranya S. et al. i-Scan detection of minimal change esophagitis in dyspeptic patients with or without Gastroesophageal Reflux disease. BMC Gastroenterol 2016; 16: 4
• 21 Sun X, Dong T, Bi Y. et al. Linked color imaging application for improving the endoscopic diagnosis accuracy: a pilot study. Sci Rep 2016; 6: 33473
• 22 Pittayanon R, Aumkaew S, Rerknimitr E. et al. Flexible spectral imaging color enhancement and probe-based confocal laser endomicroscopy in minimal change esophageal reflux disease. Korean J Gastroenterol 2016; 68: 29-35
• 23 Fass R, Ofman JJ, Gralnek IM. et al. Clinical and economic assessment of the omeprazole test in patients with symptoms suggestive of gastroesophageal reflux disease. Arch Intern Med 1999; 159: 2161-2168
• 24 Gasiorowska A, Fass R. The proton pump inhibitor test in GERD: does it still have a role?. J Clin Gastroenterol 2008; 42: 867-874
• 25 Dent J. Microscopic esophageal mucosal injury in nonerosive reflux disease. Clin Gastroenterol Hepatol 2007; 5: 4-16