Endoscopy 2011; 43(6): 554
DOI: 10.1055/s-0030-1256490
Letters to the Editor

© Georg Thieme Verlag KG Stuttgart · New York

Reply to R. Rerknimitr

J.-H.  Kim, H.  Park, Y.  C.  Lee
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Publication History

Publication Date:
26 May 2011 (online)

We appreciate the interest of Dr. Rungsun Rerknimitr’s interest in our paper and his critical appraisal of our results.

As we mentioned in our paper, the high prevalence of reported minimal changes, and the high interobserver variation, when there is no clear definition of what constitutes minimal changes, suggest that many endoscopists may be overdiagnosing minimal-change esophagitis [1]. This is why we wished to investigate the clinical significance of endoscopically suspected minimal-change esophagitis.

As Dr. Rerknimitr remarks, we should have validated the six endoscopic findings of minimal-change esophagitis, and should have evaluated interobserver agreement among the 30 study centers. However, our point is that minimal-change esophagitis is diagnosed very frequently clinically, despite the fact that the endoscopic findings of minimal change are problematic (i. e., the lack of an exact definition and the interobserver variation). We attempted to reduce interobserver variation in endoscopic findings by means of consensus criteria using index figures and explanations. Then we investigated the clinical significance of endoscopically defined minimal-change esophagitis based on the consensus criteria. We used the previously published criteria [2] to categorize the endoscopic findings of minimal change using six components. Although, as Dr. Rerknimitr comments, the criteria used in our paper were based on conventional endoscopy and fiberoptic scopes [2] [3], we also used index figures and detailed explanations of six endoscopic findings based on images from high-definition endoscopes. Of course, other subtle mucosal abnormalities could have been detected. Consequently, as we mentioned in the limitations of our study in the manuscript, the index figures used in our study should have been validated.

Recently, high-resolution endoscopic techniques such as narrow-band imaging, Fuji Intelligent Color Enhancement (FICE), and i-Scan have been introduced, providing good sensitivity, specificity, and interobserver agreement for detecting gastroesophageal reflux disease (GERD). However, it is unclear whether the resulting findings have greater clinical value in GERD than findings based on conventional endoscopy. Thus, we believe it is necessary to examine whether the more frequently detected findings based on high-resolution techniques in fact have greater clinical significance than findings based on conventional endoscopy.

The definition of GERD is based on symptoms and mucosal abnormalities. According to this definition, the significance of minimal-change esophagitis is controversial. Therefore, a definition of GERD based on symptoms may be appropriate in those patients who do not have definite mucosal abnormalities. This is why, in our patients with endoscopically suspected minimal-change esophagitis, we defined the GERD group on the basis of symptoms. We found that many of the patients with endoscopically suspected minimal-change esophagitis did not have GERD symptoms. Of course, a difference in the threshold for reflux pain and the lack of validation of the Korean GerdQ questionnaire are limitations of our study. However, if minimal changes without overt symptoms have clinical significance, the natural course of these minimal changes should be described. Although there are several limitations to our study, we found that the clinical significance of minimal-change esophagitis may be somewhat overestimated. Of course, this result should be confirmed in future work.

References

  • 1 Kim J H, Park H, Lee Y C 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
  • 2 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
  • 3 Hongo M. Minimal changes in reflux esophagitis: red ones and white ones.  J Gastroenterol. 2006;  41 95-99

H. ParkMD, PhD 

Department of Internal Medicine, Institute of Gastroenterology, Gangnam Severance Hospital, Yonsei University College of Medicine

Gangnamku

Dogok-dong 146–92

Seoul 135–720

Republic of Korea

Fax: +82–2-3463-3882

Email: JPARK21@yuhs.ac

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