Elsevier

Gastrointestinal Endoscopy

Volume 96, Issue 3, September 2022, Pages 457-466.e3
Gastrointestinal Endoscopy

Original article
Clinical endoscopy
Narrow-band imaging for the diagnosis of nonerosive reflux disease: an international, multicenter, randomized controlled trial

https://doi.org/10.1016/j.gie.2022.04.020Get rights and content

Background and Aims

We examined the accuracy of narrow-band imaging (NBI) findings in nonerosive reflux disease (NERD) patients compared with control subjects and the impact of proton pump inhibitor (PPI) therapy on these mucosal changes in a multicenter, double-blind, randomized controlled trial.

Methods

NERD patients (typical symptoms using a validated GERD questionnaire, absence of erosive esophagitis, and abnormal 48-hour pH study) and control subjects underwent high-definition white-light endoscopy followed by NBI and biopsy sampling of the distal esophagus. Then, NERD patients were randomized to esomeprazole 40 mg/day or placebo for 8 weeks, followed by repeat endoscopy. The presence of distal esophageal mucosal changes on NBI were recorded at baseline and after treatment: intrapapillary capillary loops (IPCLs; number, dilation, and tortuosity), microerosions, increased vascularity, columnar islands, and ridge/villous pattern (RVP) above the squamocolumnar junction.

Results

Of 122 screened, 21 NERD and 21 control subjects were identified (mean age, 49.5 ± 14.6 years; 62% men; and 85% white). The combination of IPCL tortuosity, RVP, and microerosions (62% vs 19%, P < .05) had a high specificity (86%) and moderate sensitivity (60%) for NERD with an area under the curve of .74. In 10 NERD patients treated with PPIs, resolution of microerosions was most significant (P = .047) compared with placebo (n = 11). RVP resolved in all NERD patients after therapy (P = .02) and correlated with acid exposure time (P = .004). Papillary length (P = .02) and basal cell thickness (P = .02) significantly correlated with a combination of IPCL tortuosity, RVP, and microerosions.

Conclusions

In this randomized controlled trial, RVP on NBI demonstrated a high specificity, correlated with acid exposure time, and improved with PPI therapy, suggesting that it could be used as a surrogate marker for diagnosis of NERD. (Clinical trial registration number: NCT02081404.)

Section snippets

Patients and eligibility

This was a randomized controlled trial conducted at 2 academic tertiary care sites: Kansas City Veteran’s Affairs Medical Center (Kansas City, Mo, USA) and Nottingham University Hospital (Nottingham, UK). Patients aged 18 to 80 years who were referred for EGD for any indication were screened for eligibility. Subjects with a history of significant comorbidities (oxygen-dependent chronic obstructive pulmonary disease, severe congestive heart failure, recent diagnosis of cancer with a life

Baseline characteristics

At both sites, 122 patients satisfied the inclusion criteria and completed the GERDQ (Fig. 1). After an upper endoscopy, 27 patients were excluded because of erosive esophagitis and 5 after an alternate diagnosis or withdrawal of consent. Of the 90 remaining patients who underwent NBI evaluation and pH monitoring, 47 patients were excluded because of withdrawal of consent for various reasons (55%) or failure to maintain acid suppression therapy (45%). Finally, there were 21 NERD and 21 control

Discussion

In a prospective, multicenter, randomized trial, we found that mucosal changes not seen with white light but detected by NBI could be used as surrogate markers for a NERD diagnosis. Absence of RVPs, microerosions, and IPCL tortuosity could exclude a NERD diagnosis with 90% certainty. The presence of these 3 features can reliably diagnose ∼75% of NERD subjects. In addition, RVP correlated well with acid exposure time and resolved after PPI therapy in all subjects, making it a single measure that

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  • DISCLOSURE: The following authors disclosed financial relationships: K. Ragunath: Consultant for Olympus and Boston Scientific. P. Sharma: Consultant for Medtronic, Olympus, Boston Scientific, Fujifilm, Salix Pharmaceuticals, and Lumendi; grant support from Ironwood, Erbe, Docbot, Cosmo Pharmaceuticals, and CDX Labs. M. Desai: Grant support from Intercept Pharma. All other authors disclosed no financial relationships.

    Drs Ragunath and Sharma contributed equally to this article.

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