Can mucosal damage in gastroesophageal reflux disease be graded endoscopically Gastroesophageal reflux disease (GERD) is in essence due to excessive exposure of the esophagus to refluxing gastric acid secretions.
Sudden loss of muscle tone of the lower esophageal sphincter (LES), the so called transient relaxations, is one of the leading mechanisms causing reflux events. The subsequent acid induced injury is at first non symmetrical but focalized by the fold pattern in the distal esophagus. This acid peptic related damage of the squamous mucosa starts from well defined usually longitudinally directed erythematous streaks to exudate covered breaks in the squamous layer. When the damage progresses, the lesions become confluent and ultimately the entire circumference of the distal esophagus is evaded. The degree of squamous damage correlates rather closely with the degree of esophageal acid exposure. Also the efficacy of acid suppressing healing or maintenance therapy depends upon the endoscopic severity of mucosal damage. Because of michael kors bag light pink these www michael kors bags correlations, endoscopic grading is clinically relevant and useful. Well over 100 grading systems have been used in the literature which has caused major confusion and chaos. A major point of debate concerns the inclusion or exclusion of the so called "minor" or "minimal" or "equivocal" changes such as focal erythema, friability or blurring of the squamocolumnar mucosal junction. Table I summarizes the latest version of the Savary Miller system and Table II, a system which I have used over the past years. As all currently available reflux grading systems have major flaws and shortcomings, a working team has attempted to come up with a more universally acceptable grading system for reflux esophagitis. This system called the Los Angeles grading system aims to describe the extent of mucosal damage as simply and unambiguously as possible avoiding wording open to interpretation such as confluent, or circumferential or terminology that imply assumptions about the process. Note that michael kors black and gold purse the recording of minimal changes and of complications (ulceration, stricturing) is kept separate from the scoring of the extent of the esophagitis (Table III). The term "mucosal break" was introduced with the hope of avoiding confusion in the use of the term "erosion" and "ulceration". A mucosal break was defined as an area of slough or erythema with a discrete demarkation between it and the adjacent mucosa. The area involved could be either round or linear in form. The peaks of mucosal folds are used as landmarks since these should be identifiable during partial air inflation and exsufflation. For the sake of simplicity the scoring of the linear extent is designed to be less or more than 5 mm. The scoring of extent was designed to michael kors hobo bag be as simple as possible but with adequate unambiguous discrimination between the degrees of severity of esophagitis for clinical and for research purposes. From the initial analysis of the Los Angeles system it would appear that single mucosal breaks confined to the mucosal folds can be accurately and reproducibly assessed. Also mucosal breaks involving most of the esophageal circumference can be accurately diagnosed. Kappa values for mucosal breaks involving 2 or more folds and the valeys in between are rather low. This needs to be improved through teaching sessions . The inclusion of minimal or equivocal lesions in the endoscopic diagnosis of reflux damage has been found to improve the sensitivity of endoscopy at the expense of a markedly decreased specificity. From reviewing the literature it might be concluded that these minor endoscopic stigmata represent disputable endoscopic lesions. Yet experienced endoscopists apparently can reproducibly record increased vascularity, local erythema and friability. In contrast blurring of the gastroesophageal mucosal junction and edema are much more difficult to diagnose. Nevertheless additional information on interobserver variability with respect to minimal changes is required.
This new endoscopic classification system still represents a working model which is not yet ready for universal clinical application. Forthcoming studies are underway to determine its usefulness in clinical practice compared to other grading systems and to analyze the interobserver agreement on various issues such as radial extent of mucosal breaks, confluent erosions extending into the valeys between the folds, etc. Finally the predictive value of the proposed grading system in short or long term outcome of therapy in reflux disease needs to be determined.
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