Which landmark results in a more consistent diagnosis of Barrett's esophagus, the gastric folds or the palisade vessels?

Background: The endoscopic landmark used to diagnose Barrett's esophagus differs between Japanese and Western endoscopists. Objective: To compare the degree of diagnostic variation in results achieved by Japanese endoscopists when using the palisade vessels as a landmark of the distal esophagus and when using the gastric folds; interobserver diagnostic concordance was evaluated. Design: Eighty-four endoscopists classified 30 patients with Barrett's esophagus by viewing projected endoscopic photographs. The endoscopists were asked to identify the distal end of the esophagus, first by using the Japanese criteria and later by using the gastric folds after an explanation of the Prague C&M Criteria. Endoscopists were divided into groups according to years in practice as an endoscopist, presence or absence of board certification from the Japan Gastroenterological Endoscopy Society, and whether they had taken any special endoscopic training courses on GERD. The kappa coefficient of reliability was calculated for each group. Results: The initial overall kappa value for all the endoscopists for the identification of the distal end of the esophagus was only 0.14, an unacceptably low value of concordance over and above chance agreement. The length of experience with diagnostic endoscopy, board license, or special training had no impact on the level of concordance. After an explanation of the C&M Criteria, however, there was a statistically significant improvement in the diagnostic concordance. Conclusions: The upper end of the gastric folds, as used in C&M Criteria, may be a more suitable landmark than the palisade vessels for identifying the distal end of the esophagus by endoscopy.