Inter-observer agreement for diagnostic classification of esophageal motility disorders defined in high-resolution manometry.

High-resolution esophageal manometry (HRM) is a recent development used in the evaluation of esophageal function. Our aim was to assess the inter-observer agreement for diagnosis of esophageal motility disorders using this technology. Practitioners registered on the HRM Working Group website were invited to review and classify (i) 147 individual water swallows and (ii) 40 diagnostic studies comprising 10 swallows using a drop-down menu that followed the Chicago Classification system. Data were presented using a standardized format with pressure contours without a summary of HRM metrics. The sequence of swallows was fixed for each user but randomized between users to avoid sequence bias. Participants were blinded to other entries. (i) Individual swallows were assessed by 18 practitioners (13 institutions). Consensus agreement (≤ 2/18 dissenters) was present for most cases of normal peristalsis and achalasia but not for cases of peristaltic dysmotility. (ii) Diagnostic studies were assessed by 36 practitioners (28 institutions). Overall inter-observer agreement was 'moderate' (kappa 0.51) being 'substantial' (kappa > 0.7) for achalasia type I/II and no lower than 'fair-moderate' (kappa >0.34) for any diagnosis. Overall agreement was somewhat higher among those that had performed >400 studies (n = 9; kappa 0.55) and 'substantial' among experts involved in development of the Chicago Classification system (n = 4; kappa 0.66). This prospective, randomized, and blinded study reports an acceptable level of inter-observer agreement for HRM diagnoses across the full spectrum of esophageal motility disorders for a large group of clinicians working in a range of medical institutions. Suboptimal agreement for diagnosis of peristaltic motility disorders highlights contribution of objective HRM metrics.

Prediction scores or gastroenterologists' Gut Feeling for triaging patients that present with acute upper gastrointestinal bleeding.

INTRODUCTION: Several prediction scores for triaging patients with upper gastrointestinal (GI) bleeding have been developed, yet these scores have never been compared to the current gold standard, which is the clinical evaluation by a gastroenterologist. The aim of this study was to assess the added value of prediction scores to gastroenterologists' Gut Feeling in patients with a suspected upper GI bleeding. METHODS: WE PROSPECTIVELY EVALUATED GUT FEELING OF SENIOR GASTROENTEROLOGISTS AND ASKED THEM TO ESTIMATE: (1) the risk that a clinical intervention is needed; (2) the risk of rebleeding; and (3) the risk of mortality in patients presenting with suspected upper GI bleeding, subdivided into low, medium, or high risk. The predictive value of the gastroenterologists' Gut Feeling was compared to the Blatchford and Rockall scores for various outcomes. RESULTS: We included 974 patients, of which 667 patients (68.8%) underwent a clinical intervention. During the 30-day follow up, 140 patients (14.4%) developed recurrent bleeding and 44 patients (4.5%) died. Gut Feeling was independently associated with all studied outcomes, except for the predicted mortality after endoscopy. Predictive power, based on the AUC of the Blatchford and Rockall prediction scores, was higher than the Gut Feeling of the gastroenterologists. However, combining both the Blatchford and Rockall scores and the Gut Feeling yielded the highest predictive power for the need of an intervention (AUC 0.88), rebleeding (AUC 0.73), and mortality (AUC 0.71 predicted before and 0.77 predicted after endoscopy, respectively). CONCLUSIONS: Gut Feeling is an independent predictor for the need of a clinical intervention, rebleeding, and mortality in patients presenting with upper GI bleeding; however, the Blatchford and Rockall scores are stronger predictors for these outcomes. Combining Gut Feeling with the Blatchford and Rockall scores resulted in the most optimal prediction.