Korean J Gastroenterol.  2020 Sep;76(3):134-141. 10.4166/kjg.2020.76.3.134.

Endoscopic Prediction for Acid Reflux in Patients without Hiatus Hernia

• Kim JY
• Shin IS
• Min YW
• Kim K
• Lee H
• Min BH
• Lee JH
• Kim JJ
• Rhee PL

• KMID: 2506669
• DOI: http://doi.org/10.4166/kjg.2020.76.3.134

Abstract

Background/Aims
A diagnosis of gastroesophageal reflux disease is challenging in patients who have reflux symptoms but do not respond to proton pump inhibitors nor have reflux esophagitis and hiatal hernia (HH) on endoscopy. This study examined the predictive role of the endoscopic findings, including the flap valve grade for pathologic acid exposure (PAE) to establish an endoscopic prediction model in patients with neither reflux esophagitis nor HH.
Methods
Five hundred seventy-eight patients who underwent upper endoscopy and 24 hours pH monitoring for reflux esophageal symptoms without evidence of reflux esophagitis and HH were analyzed. The gastroesophageal flap valve (GEFV), esophageal metaplasia, and chronic atrophic gastritis were assessed. The association between the endoscopic parameters and PAE was evaluated.
Results
Four hundred ninety-four patients were enrolled. The most common complaint was chest discomfort (42.3%) followed by globus (31.8%), dysphagia (7.9%), and heartburn (7.7%). PAE was present in 43 patients (8.7%). Multivariable analysis revealed PAE to be associated with the GEFV grade (p<0.001) and inversely associated with the chronic atrophic gastritis grade (p=0.005). Using these features, a predictive model was established and showed an area under the receiver operating characteristic curve of 0.705 (95% CI 0.619-0.790). The cutoff value of 12.0 had a sensitivity and specificity of 44.0% and 84.0%, respectively.
Conclusions
A loosened GEFV is associated with a risk of PAE in patients with neither reflux esophagitis nor HH, while atrophic gastritis is preventive. On the other hand, the endoscopic predictive model revealed a low sensitivity for detecting PAE. Thus, reflux testing needs to be performed further when gastroesophageal reflux disease is suspected, even without endoscopic evidence.

Keyword

Gastritis; atrophy; Gastroesophageal reflux; Risk factors

Figure

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  Fig. 1 Flow chart of patient selection. Among the 578 patients who underwent esophagogastroduodenoscopy (EGD) and 24 hours pH monitoring (24 hours pH) within a 1-month interval, patients who underwent an esophagectomy or pneumatic dilatation were excluded. Patients with erosive esophagitis on EGD were also excluded. After excluding 84 subjects, 494 subjects were enrolled. To validate the prediction modeling procedure, the subjects were divided randomly into two groups in a ratio of 7:3 (derivation set: validation set) three separate times.

• 

  Fig. 2 Representative images of the gastroesophageal flap valve (GEFV) grade. (A) Grade 0. GEFV opening width ≤1 cm. (B) Grade 1. GEFV opening width less than 1.5 cm (1-1.5cm). (C) Grade 2. GEFV opening width less than 2 cm (1.5-2 cm). (D) Grade 3. GEFV opening width greater than 2 cm.

• 

  Fig. 3 Multivariable logistic regression with a stepwise selection. The patients were divided randomly into two groups at a ratio of 7:3 : a derivation group and a validation group. (A-C) show the results of the first, second, and third trials, respectively. In each trial, the derivation group was analyzed by multivariable logistic regression with stepwise selection. The endoscopic grades of the gastroesophageal flap valve and chronic atrophic gastritis showed consistent correlations with the pathologic acid exposure.

• 

  Fig. 4 Receiver operating characteristics curve of the established endoscopic prediction model for PAE. The area under the receiver operating characteristics curve of the final mathematical prediction model for PAE was 0.705 (95% CI 0.619-0.790). AUC, area under the receiver operating characteristic curve; CI, confidence interval; PAE, pathologic acid exposure.

• 

  Fig. 5 Nomogram for the endoscopic prediction of pathologic acid exposure in patients with reflux symptoms. Each point of the endoscopic parameter was calculated. The total points were added, and a vertical line was drawn from the total points’ row to obtain the endoscopic reflux score, which is associated with the PAE risk. The endoscopic reflux score cutoff value of 12, which corresponded to the total point cutoff value of 63, showed the best performance for predicting PAE with an accuracy, sensitivity, and specificity of 0.81, 0.44, and 0.84, respectively. GEFV, gastroesophageal flap valve; CAG, chronic atrophic gastritis; PAE, pathologic acid exposure.

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