Intra- and Inter-Observer Agreement of Different Endoscopic Classification Systems for Esophageal Varices

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Abstract
Background/Objectives: Variceal size and red wale marks determine hemorrhage risk and guide management in portal hypertension, so a reproducible classification is essential. The most widely used systems are Calès, Japanese Research Society for Portal Hypertension (JRSPH), and American Association for the Study of Liver Diseases (AASLD). We aimed to determine intra- and inter-observer concordance for variceal size using the mentioned classifications, and propose a simplified binary classification system based on the complete disappearance of the variceal relief during air insufflation. Methods: Descriptive cross-sectional study, using videos of esophagogastroduodenoscopy from pediatric and adult patients with esophageal varices, which were evaluated twice by three expert endoscopists. Cohen’s Kappa was used to assess agreement between two measurements, and Fleiss’s Kappa to evaluate the agreement of all three observers. Because some patients contributed more than one recording, confidence intervals were obtained by bootstrap resampling at the patient level. Results: A total of 78 videos were evaluated (58 adult, 20 pediatric). Intra-observer concordance for variceal size classification systems was: Calès κ = 0.41, JRSPH κ = 0.40, AASLD κ = 0.50, and new classification κ = 0.47. Inter-observer agreement was: Calès κ = 0.39, JRSPH κ = 0.24, AASLD κ = 0.31, and new classification κ = 0.47. Conclusions: Agreement for the commonly used variceal size classifications ranged from fair to moderate. Our proposed insufflation-based classification was the only system to achieve moderate agreement both within and between observers, offering a simpler criterion aligned with the treat-versus-observe decision. It should be regarded as a promising proposal rather than a validated tool: prospective multicenter validation against variceal bleeding outcomes is required before clinical use.
Funding Information
  • Latin American Society of Pediatric Gastroenterology Hepatology and Nutrition

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