USEFULNESS OF VIDEODUODENOSCOPY AND VITAL DYE STAINING AS INDICATORS OF MUCOSAL ATROPHY OF CELIAC-DISEASE - ASSESSMENT OF INTEROBSERVER AGREEMENT

Background: The present study was designed to determine the diagnostic usefulness of videoduodenoscopic inspection alone and the addition of vital dye staining in the detection of celiac disease. We additionall y sought to evaluate interobserver agreement for specific duodenoscopi c markers of mucosal atrophy. Methods: One hundred sixty-seven consecu tive subjects who underwent duodenoscopy for intestinal biopsy were in cluded in a prospective controlled study. Endoscopic examination was p erformed by experienced endoscopists according to a set protocol using methylene blue (1%) dye. All procedures were recorded on videotape, b ut only 20 (10 with atrophy and 10 normal) were used in a blinded, ind ependent, randomized analysis by five reviewers to evaluate interobser ver agreement. Endoscopic signs indicative of mucosal atrophy were as follows: reduction in the number or loss of Kerkring's folds, ''scallo ped'' folds, ''mosaic pattern,'' and visualization of the underlying b lood vessels. Results: Eighty-seven patients had celiac disease (57 ne wly diagnosed, 30 when treated). Seven treated patients had nonatrophi c mucosa. In 80 patients the final diagnosis excluded celiac disease. Videoendoscopic inspection alone correctly identified 75 of 80 patient s with complete mucosal atrophy and 86 of 87 with normal mucosa. False -negative diagnoses occurred in treated celiac patients with mild atro phy. Mosaic pattern (89%) and scalloped folds (86%) were the most usef ul endoscopic signs. Vital dye staining, as assessed by experienced en doscopists, provided identical results to those obtained by inspection alone. Sensitivity, specificity, and positive and negative predictive values for the presence of one or more than one feature were 94%, 100 %, 100%, and 96%, respectively. The agreement (kappa statistics) among observers was excellent for the mosaic pattern (kappa: 0.76 for both the videoendoscopic inspection alone and dye staining) and the scallop ed folds (kappa: 0.83 and 0.76, respectively) and was fair (kappa: 0.4 1 and 0.59, respectively) for the reduction in the number or loss of d uodenal folds. Conclusion: This study confirms that videoduodenoscopy is useful in the detection of intestinal atrophy. Dye staining produce s a better delineation of scalloped folds and mosaic pattern in the at rophic mucosa, but did not provide additional information to the exper t endoscopist. Finally, interobserver agreement was excellent for the most prevalent signs.