MATERIALS AND METHODS
In a prospective study, a total of 100 patients were selected from those undergoing upper digestive endoscopy between January and July 2009 at the Endoscopy Service – Santa Casa School of Medical Sciences (Santa Casa de São Paulo Medical School), São Paulo, Brazil. This study was approved by the local Research Ethics Committee, and patients were included only after signing informed consent forms.
Fifty sequential patients with portal hypertension of various etiologies previously diagnosed based on clinical, laboratory and imaging exams who presented with esophageal varices were selected (Table (Table1).1). All patients with clinical or endoscopic signs of upper hemorrhage were included in this study. A control group was formed, consisting of 50 sequential patients with dyspeptic symptoms referred for upper digestive endoscopy without portal hypertension or a previous history of hepatopathy or congestive cardiopathy, abdominal ultrasounds disclosing normal liver and spleen, and a portal vein caliber of less than 12 mm.
Exams were performed under sedation and digitally recorded. Six images were selected from recordings, consisting of two from the antrum, two from the gastric body and two from the gastric fundus (not showing varices). The images were then analyzed by five independent expert endoscopists with over 15 years of experience in our service. First, the examiners were familiarized with the standards used in this trial and subsequently evaluated the selected images of each patient while blinded to patients’ clinical information. The varices were deliberately excluded from the images that were presented in sequential order to each endoscopist. The endoscopists were also blinded to each other’s comments and evaluations.
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An electronic questionnaire, which included endoscopic criteria from PHG classifications (McCormack, NIEC and Baveno) and recorded the presence or otherwise of elevated or flat antral erosive gastritis, was used to collect and collate the results (Figure (Figure1).1). The results were independently analyzed to determine their relationship with PHG.
Figures Figures22--44 compare endoscopic aspects with their classifications.
Due to inconsistencies in the medical literature on the role of histological analysis of standard endoscopic biopsies for diagnosing PHG, we decided not to perform biopsies in this study[29-31]. Due to the absence of an established gold standard for diagnosing PHG, the statistical analysis was performed in two stages. The first stage verified the correlation between each endoscopic criterion and the presence of PH, with the group of 50 patients without PH serving as a control. The second stage determined the correlation between each endoscopic criterion and the diagnosis of PHG. The establishment of a relationship between the endoscopic criterion and the presence of PH was a prerequisite for the potential correlation between the same criterion and PHG. If any criterion demonstrated an apparent relationship with PHG but not with PH, then it was deemed logically false.
The Statistical Package for Social Sciences version 17.0 was utilized for statistical analysis, adopting a 5% level of significance on Fisher’s Exact Test. Cronbach’s alpha was used to determine reliability among the five endoscopists, with values between 0 and 0.60 considered Unsatisfactory, values between 0.60 to 0.69 as Satisfactory, and values between 0.70 to 1.00 as a High degree of reliability.