Download PDF
Endoscopy 2010; 42(9): 699-704
DOI: 10.1055/s-0030-1255629
Original article

© Georg Thieme Verlag KG Stuttgart · New York

Interobserver reliability in the endoscopic diagnosis and grading of Barrett’s esophagus: an Asian multinational study

Y.  C.  Lee1 , 2 , M.  B.  Cook3 , S.  Bhatia4 , W.  H.  Chow3 , E.  M.  El-Omar5 , H.  Goto6 , J.  T.  Lin1 , 7 , Y.  Q.  Li8 , P.  L.  Rhee9 , P.  Sharma10 , J.  J.  Y.  Sung11 , J.  Y.  Y.  Wong12 , J.  C.  Y.  Wu11 , K.  Y.  Ho12 , and the Asian Barrett’s Consortium
  • 1Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
  • 2Division of Biostatistics, College of Public Health, National Taiwan University, Taipei, Taiwan
  • 3Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA
  • 4Department of Gastroenterology, Seth GS Medical College and KEM Hospital, Mumbai, India
  • 5Division of Applied Medicine, Institute of Medical Sciences, Aberdeen University, Aberdeen, Scotland
  • 6Department of Gastroenterology, Nagoya University Graduate School of Medicine, Nagoya, Japan
  • 7Department of Internal Medicine, E-DA Hospital and I-Shou University, Yan-chau Shiang, Kaohsiung County, Taiwan
  • 8Department of Gastroenterology, Qilu Hospital, Shandong University, Jinan, China
  • 9Department of Medicine, Sungkyunkwan University School of Medicine, Samsung Medical Center, Seoul, Korea
  • 10Division of Gastroenterology and Hepatology, Veterans Affairs Medical Center and University of Kansas School of Medicine, Kansas City, Missouri, USA
  • 11Department of Medicine & Therapeutics, Prince of Wales Hospital, the Chinese University of Hong Kong, Hong Kong
  • 12Yong Loo Lin School of Medicine, National University of Singapore, Singapore
Further Information

Publication History

submitted 22 February 2010

accepted after revision 11 June 2010

Publication Date:
30 August 2010 (online)

Also available at
    Permissions and Reprints

Background and study aim: The establishment of precise and valid diagnostic criteria is important for any disease. We determined the interobserver reliability in the endoscopic diagnosis and grading of Barrett’s esophagus.

Patients and methods: Video clips of endoscopy in 21 patients with/without Barrett’s esophagus were used for training (n = 3) and for diagnosis/grading (n = 18) of Barrett’s esophagus by endoscopists from seven hospitals in Asia. Barrett’s esophagus was graded using the Prague C & M Criteria whereby the circumferential extent of the Barrett’s segment (C value), maximum extent of Barrett’s segment (M value), location of the gastroesophageal junction, and location of the diaphragmatic hiatus were scored. The intraclass correlation coefficients (ICC) were calculated as a measure of interobserver reliability.

Results: A total of 34 endoscopists participated. ICC values for the scores of the C value, M value, location of the gastroesophageal junction, and location of the diaphragmatic hiatus were: 0.92 (95 % confidence interval [CI] 0.88 – 0.97), 0.94 (95 %CI 0.90 – 0.98), 0.86 (95 %CI 0.78 – 0.94), and 0.81 (95 %CI 0.71 – 0.92), respectively, indicating excellent interobserver agreement. The differences in region/country, endoscopists’ experience, case volume of participating centers, or primary practice type had no significant effect on the reliability. The ICC values for recognition of Barrett’s esophagus of ≥ 1 cm were 0.90 (95 %CI 0.80 – 1.00) and 0.92 (95 %CI 0.87 – 0.98) for the C and M values, respectively, whereas the corresponding ICC values for Barrett’s segment of < 1 cm were 0.18 (95 %CI 0.03 – 0.32) and 0.21 (95 %CI 0.00 – 0.51), respectively.

Conclusions: Despite the uncommon occurrence of Barrett’s esophagus in Asia, our endoscopists exhibited excellent agreement in the endoscopic diagnosis and grading of Barrett’s esophagus using the Prague C & M Criteria. However, in view of the low interobserver reliability in recognizing Barrett’s segments of < 1 cm, future studies in Asia should take this into account when selecting the study population.

References

  • 1 Sandler R S, Everhart J E, Donowitz M. et al . The burden of selected digestive diseases in the United States.  Gastroenterology. 2002;  122 1500-1511
    CrossrefPubMedGoogle Scholar
  • 2 Botterweck A A, Schouten L J, Volovics A. et al . Trends in incidence of adenocarcinoma of the oesophagus and gastric cardia in ten European countries.  Int J Epidemiol. 2000;  29 645-654
    CrossrefPubMedGoogle Scholar
  • 3 Fléjou J F. Barrett’s oesophagus: from metaplasia to dysplasia and cancer.  Gut. 2005;  54 Suppl 1 i6-i12
    CrossrefPubMedGoogle Scholar
  • 4 Ho K Y. Gastroesophageal reflux disease in Asia: a condition in evolution.  J Gastroenterol Hepatol. 2008;  23 716-722
    CrossrefPubMedGoogle Scholar
  • 5 Fernandes M L, Seow A, Chan Y H, Ho K Y. Opposing trends in incidence of esophageal squamous cell carcinoma and adenocarcinoma in a multi-ethnic Asian country.  Am J Gastroenterol. 2006;  101 1430-1436
    CrossrefPubMedGoogle Scholar
  • 6 Yee Y K, Cheung T K, Chan A O. et al . Decreasing trend of esophageal adenocarcinoma in Hong Kong.  Cancer Epidemiol Biomarkers Prev. 2007;  16 2637-2640
    CrossrefPubMedGoogle Scholar
  • 7 Kusano C, Gotoda T, Khor C J. et al . Changing trends in the proportion of adenocarcinoma of the esophagogastric junction in a large tertiary referral center in Japan.  J Gastroenterol Hepatol. 2008;  23 1662-1665
    CrossrefPubMedGoogle Scholar
  • 8 Goh K L, Wong H T, Lim C H, Rosaida M S. Time trends in peptic ulcer, erosive reflux oesophagitis, gastric and oesophageal cancers in a multiracial Asian population.  Aliment Pharmacol Ther. 2009;  29 774-780
    CrossrefPubMedGoogle Scholar
  • 9 Chung J W, Lee G H, Choi K S. et al . Unchanging trend of esophagogastric junction adenocarcinoma in Korea: experience at a single institution based on Siewert’s classification.  Dis Esophagus. 2009;  22 676-681
    CrossrefPubMedGoogle Scholar
  • 10 Chen M J, Lee Y C, Chiu H M. et al . Time trends of endoscopic and pathological diagnoses related to gastroesophageal reflux disease in a Chinese population: eight years single institution experience.  Dis Esophagus. 2010;  23 201-207
    CrossrefPubMedGoogle Scholar
  • 11 Lu C L, Lang H C, Luo J C. et al . Increasing trend of the incidence of esophageal squamous cell carcinoma, but not adenocarcinoma, in Taiwan.  Cancer Causes Control. 2010;  21 269-274
    CrossrefPubMedGoogle Scholar
  • 12 Wu J C, Mui L M, Cheung C M. et al . Obesity is associated with increased transient lower esophageal sphincter relaxation.  Gastroenterology. 2007;  132 883-889
    CrossrefPubMedGoogle Scholar
  • 13 Moki F, Kusano M, Mizuide M. et al . Association between reflux oesophagitis and features of the metabolic syndrome in Japan.  Aliment Pharmacol Ther. 2007;  26 1069-1075
    CrossrefPubMedGoogle Scholar
  • 14 Chung S J, Kim D, Park M J. et al . Metabolic syndrome and visceral obesity as risk factors for reflux oesophagitis: a cross-sectional case-control study of 7078 Koreans undergoing health check-ups.  Gut. 2008;  57 1360-1365
    CrossrefPubMedGoogle Scholar
  • 15 Lee Y C, Yen A M, Tai J J. et al . The effect of metabolic risk factors on the natural course of gastro-oesophageal reflux disease.  Gut. 2009;  58 174-181
    CrossrefPubMedGoogle Scholar
  • 16 Asian Barrett’s Consortium Web Site. Asian Barrett’s Consortium’s statement concerning its research objectives and plans. http://dceg.cancer.gov/newsletter/nov08/article_08_EsophagealDiseasesConsortium.shtml; Publication date: Oct 5, 2009
    Google Scholar
  • 17 Armstrong D, Bennett J R, Blum A L. et al . The endoscopic assessment of esophagitis: a progress report on observer agreement.  Gastroenterology. 1996;  111 85-92
    CrossrefPubMedGoogle Scholar
  • 18 Sharma P, Dent J, Armstrong D. et al . The development and validation of an endoscopic grading system for Barrett’s esophagus: the Prague C & M criteria.  Gastroenterology. 2006;  131 1392-1399
    CrossrefPubMedGoogle Scholar
  • 19 Lundell L R, Dent J, Bennett J R. et al . Endoscopic assessment of oesophagitis: clinical and functional correlates and further validation of the Los Angeles classification.  Gut. 1999;  45 172-180
    CrossrefPubMedGoogle Scholar
  • 20 Lee Y C, Lin J T, Chiu H M. et al . Intraobserver and interobserver consistency for grading esophagitis with narrow-band imaging.  Gastrointest Endosc. 2007;  66 230-236
    CrossrefPubMedGoogle Scholar
  • 21 Chang C Y, Lee Y C, Lee C T. et al . The application of Prague C and M Criteria in the diagnosis of Barrett’s esophagus in an ethnic Chinese population.  Am J Gastroenterol. 2009;  104 13-20
    CrossrefPubMedGoogle Scholar
  • 22 Akiyama T, Inamori M, Akimoto K. et al . Risk factors for the progression of endoscopic Barrett’s epithelium in Japan: a multivariate analysis based on the Prague C & M Criteria.  Dig Dis Sci. 2009;  54 1702-1707
    CrossrefPubMedGoogle Scholar
  • 23 Hwang J K, Hong S G, Joo M K. et al . Application of Prague C & M Criteria to endoscopic description of CLE in Korea. [Article in Korean].  Korean J Neurogastroenterol Motil. 2008;  14 Suppl 1 P10
    PubMedGoogle Scholar
  • 24 Wong W M, Lam S K, Hui W M. et al . Long-term prospective follow-up of endoscopic oesophagitis in southern Chinese – prevalence and spectrum of the disease.  Aliment Pharmacol Ther. 2002;  16 2037-2042
    CrossrefPubMedGoogle Scholar
  • 25 Rosaida M S, Goh K L. Gastro-oesophageal reflux disease, reflux oesophagitis and non-erosive reflux disease in a multiracial Asian population: a prospective, endoscopy based study.  Eur J Gastroenterol Hepatol. 2004;  16 495-501
    CrossrefPubMedGoogle Scholar
  • 26 Sollano J D, Wong S N, Andal-Gamutan T. et al . Erosive esophagitis in the Philippines: a comparison between two time periods.  J Gastroenterol Hepatol. 2007;  22 1650-1655
    CrossrefPubMedGoogle Scholar
  • 27 Tseng P H, Lee Y C, Chiu H M. et al . Prevalence and clinical characteristics of Barrett’s esophagus in a Chinese general population.  J Clin Gastroenterol. 2008;  42 1074-1079
    CrossrefPubMedGoogle Scholar
  • 28 Okita K, Amano Y, Takahashi Y. et al . Barrett’s esophagus in Japanese patients: its prevalence, form, and elongation.  J Gastroenterol. 2008;  43 928-934
    CrossrefPubMedGoogle Scholar
  • 29 Chen X, Zhu L R, Hou K H. The characteristics of Barrett’s esophagus: an analysis of 4120 cases in China.  Dis Esophagus. 2009;  22 348-353
    CrossrefPubMedGoogle Scholar
  • 30 Park J J, Kim J W, Kim H J. et al . H. pylori and GERD Study Group of Korean College of Helicobacter and Upper Gastrointestinal Research. The prevalence of and risk factors for Barrett’s esophagus in a Korean population: a nationwide multicenter prospective study.  J Clin Gastroenterol. 2009;  43 907-914
    CrossrefPubMedGoogle Scholar
  • 31 Lee I S, Choi S C, Shim K N. et al . Prevalence of Barrett’s esophagus remains low in the Korean population: nationwide cross-sectional prospective multicenter study.  Dig Dis Sci. 2010;  55 1932-1939
    CrossrefPubMedGoogle Scholar
  • 32 Amano A, Kinoshita Y. Barrett esophagus: perspectives on its diagnosis and management in Asian populations.  Gastroenterol Hepatol. 2008;  4 45-53
    PubMedGoogle Scholar
  • 33 Paris workshop on columnar metaplasia in the esophagus and the esophagogastric junction, Paris, France, December 11 – 12, 2004.  Endoscopy. 2005;  37 879-920
    Article in Thieme ConnectPubMedGoogle Scholar
  • 34 International Working Group for the Classification of Oesophagitis (IWGCO) Web Site. Interactive Prague Barrett’s C & M Criteria. http://iwgco.com/; Publication date: April 27, 2010
    Google Scholar
  • 35 Fleiss J L, Cohen J. The equivalence of weighted kappa and the intraclass correlation coefficient as measures of reliability.  Educ Psychol Meas. 1973;  33 613-619
    CrossrefPubMedGoogle Scholar
  • 36 Walter S D, Eliasziw M, Donner A. Sample size and optimal designs for reliability studies.  Stat Med. 1998;  17 101-110
    CrossrefPubMedGoogle Scholar
  • 37 Spechler S J. Short and ultrashort Barrett’s esophagus – what does it mean?.  Semin Gastrointest Dis. 1997;  8 59-67
    PubMedGoogle Scholar
  • 38 Derakhshan M H, Malekzadeh R, Watabe H. et al . Combination of gastric atrophy, reflux symptoms and histological subtype indicates two distinct aetiologies of gastric cardia cancer.  Gut. 2008;  57 298-305
    CrossrefPubMedGoogle Scholar
  • 39 Shimoda T, Kushima R, Takizawa H. Pathological feature of esophagogastric adenocarcinoma. [Article in Japanese].  Stomach and Intestine (Tokyo). 2009;  44 1083-1094
    PubMedGoogle Scholar
  • 40 Sharma P, Morales T G, Sampliner R E. Short segment Barrett’s segment: the need for standardization of the definition and of endoscopic criteria.  Am J Gastroenterol. 1998;  93 1033-1036
    PubMedGoogle Scholar
  • 41 Fujiyama Y, Ishizuka I, Koyama S. Histochemical diagnosis of short segment Barrett’s esophagus. [Article in Japanese].  Nippon Rinsho. 2005;  63 1420-1426
    PubMedGoogle Scholar
  • 42 Amano Y, Ishimura N, Furuta K. et al . Which landmark results in a more consistent diagnosis of Barrett’s esophagus, the gastric folds or the palisade vessels?.  Gastrointest Endosc. 2006;  64 206-211
    CrossrefPubMedGoogle Scholar
  • 43 Kusano C, Kaltenbach T, Shimazu T. et al . Can Western endoscopists identify the end of the lower esophageal palisade vessels as a landmark of esophagogastric junction?.  J Gastroenterol. 2009;  44 842-846
    CrossrefPubMedGoogle Scholar
  • 44 Amano Y, Ishimura N, Koshino K. et al . Endoscopic diagnosis of the esophagogastric junction. [Article in Japanese].  Stomach and Intestine (Tokyo). 2009;  44 1065-1074
    PubMedGoogle Scholar
  • 45 Amano Y, Ishimura N, Furuta K. et al . Interobserver agreement on classifying endoscopic diagnoses of nonerosive esophagitis.  Endoscopy. 2006;  38 1032-1035
    Article in Thieme ConnectPubMedGoogle Scholar
  • 46 Hongo M. Minimal changes in reflux esophagitis: red ones and white ones.  J Gastroenterol. 2006;  41 95-99
    CrossrefPubMedGoogle Scholar
  • 47 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
    CrossrefPubMedGoogle Scholar
  • 48 Wani S, Sharma P. Endoscopic surface imaging of Barrett’s esophagus: an optimistic view.  Gastroenterology. 2007;  133 11-13
    CrossrefPubMedGoogle Scholar
  • 49 Corley D A, Kubo A, DeBoer J, Rumore G J. Diagnosing Barrett’s esophagus: reliability of clinical and pathologic diagnoses.  Gastrointest Endosc. 2009;  69 1004-1010
    CrossrefPubMedGoogle Scholar
  • 50 Rubenstein J H. It takes two to tango: dance steps for diagnosing Barrett’s esophagus.  Gastrointest Endosc. 2009;  69 1011-1013
    CrossrefPubMedGoogle Scholar
  • 51 Goda K, Tajiri H, Ikegami M. et al . Usefulness of magnifying endoscopy with narrow band imaging for the detection of specialized intestinal metaplasia in columnar-lined esophagus and Barrett’s adenocarcinoma.  Gastrointest Endosc. 2007;  65 36-46
    CrossrefPubMedGoogle Scholar
  • 52 Yoshida T, Shimizu Y, Kato M. et al . Advances in endoscopic diagnosis for Barrett’s esophagus and adenocarcinoma: overview. [Article in Japanese].  Endoscopia Digestiva. 2009;  21 1185-1198
    PubMedGoogle Scholar
  • 53 Chey W D, Sharma P. Emerging imaging modalities to diagnose Barrett’s esophagus. Expert insights in IBS, constipation and acid-related disorders. Bethesda, Maryland; American Gastroenterological Association 2010
    PubMedGoogle Scholar

K. Y. HoMD 

Yong Loo Lin School of Medicine
National University of Singapore

5 Lower Kent Ridge Road
Singapore 65
Singapore

Fax: +65-67794112

Email: khek_yu_ho@nuhs.edu.sg

      >