Original Article
Which landmark results in a more consistent diagnosis of Barrett's esophagus, the gastric folds or the palisade vessels?

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Background

The endoscopic landmark used to diagnose Barrett's esophagus differs between Japanese and Western endoscopists.

Objective

To compare the degree of diagnostic variation in results achieved by Japanese endoscopists when using the palisade vessels as a landmark of the distal esophagus and when using the gastric folds; interobserver diagnostic concordance was evaluated.

Design

Eighty-four endoscopists classified 30 patients with Barrett's esophagus by viewing projected endoscopic photographs. The endoscopists were asked to identify the distal end of the esophagus, first by using the Japanese criteria and later by using the gastric folds after an explanation of the Prague C&M Criteria. Endoscopists were divided into groups according to years in practice as an endoscopist, presence or absence of board certification from the Japan Gastroenterological Endoscopy Society, and whether they had taken any special endoscopic training courses on GERD. The kappa coefficient of reliability was calculated for each group.

Results

The initial overall kappa value for all the endoscopists for the identification of the distal end of the esophagus was only 0.14, an unacceptably low value of concordance over and above chance agreement. The length of experience with diagnostic endoscopy, board license, or special training had no impact on the level of concordance. After an explanation of the C&M Criteria, however, there was a statistically significant improvement in the diagnostic concordance.

Conclusions

The upper end of the gastric folds, as used in C&M Criteria, may be a more suitable landmark than the palisade vessels for identifying the distal end of the esophagus by endoscopy.

Section snippets

Materials and methods

Eighty-four endoscopists, in practice from 2 to 35 years (median, 10 years), were enrolled in this study. Study participants were divided into groups according to years in practice as an endoscopist, presence or absence of board certification from the Japan Gastroenterological Endoscopy Society (JGES), and whether they had taken any special endoscopic training courses on esophagitis. Endoscopists receive board certification from the JGES after completing 5 years of training in a JGES-approved

Results

The degree of experience with diagnostic endoscopy of the 84 endoscopists is shown in Table 1. Forty-eight endoscopists were considered experienced. Twenty-one were board licensed by JGES and were considered experts. Twenty-seven had received training at Shimane University Hospital on the endoscopic diagnosis of GERD.

The overall kappa value and the 95% CI for endoscopist definition of the GEJ on the 30 photographs was 0.14 (0.13-0.16), as shown in Figure 3. The participants identified the GEJ

Discussion

The longitudinal esophageal palisade vessels, present in the mucosal layer of the lower esophagus, disappear into the submucosal layer at the GEJ.19, 20 Therefore, in Japan, the distal end of palisade vessels is considered to be the endoscopic landmark of the GEJ. The palisade vessels, however, can be difficult to identify endoscopically, particularly in BE where inflammation or mucosal dysplastic change may obscure them. Insufficient air inflation can also render them difficult to visualize.16

Acknowledgments

The authors thank Mr T. Kato (AstraZeneca Co, Ltd, Japan) for the excellent statistical support provided.

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