The Los Angeles classification system is the most widely employed criteria associated with the greatest interobserver agreement among endoscopists. In Japan, the Los Angeles classification system has been modified (modified LA system) to include minimal changes as a distinct grade of reflux esophagitis, rather than as auxiliary findings. This adds a further grading M defined as minimal changes to the mucosa, such as erythema and/or whitish turbidity. The modified LA system has come to be used widely in Japan. However, there have been few reports to date that have evaluated the interobserver agreement in diagnosis when using the modified LA classification system incorporating these minimal changes as an additional grade. A total of 100 endoscopists from university hospitals and community hospitals, as well as private practices in the Osaka-Kobe area participated in the study. A total of 30 video clips of 30-40 seconds duration, mostly showing the esophagocardiac junction, were created and shown to 100 endoscopists using a video projector. The participating endoscopists completed a questionnaire regarding their clinical experience and rated the reflux esophagitis as shown in the video clips using the modified LA classification system. Agreement was assessed employing kappa (kappa) statistics for multiple raters. The kappa-value for all 91 endoscopists was 0.094, with a standard error of 0.002, indicating poor interobserver agreement. The endoscopists showed the best agreement on diagnosing grade A esophagitis (0.167), and the poorest agreement when diagnosing grade M esophagitis (0.033). The kappa-values for the diagnoses of grades N, M, and A esophagitis on identical video pairs were 0.275-0.315, with a standard error of 0.083-0.091, indicating fair intraobserver reproducibility among the endoscopists. The study results consistently indicate poor agreement regarding diagnoses as well as fair reproducibility of these diagnoses by endoscopists using the modified LA classification system, regardless of age, type of practice, past endoscopic experience, or current workload. However, grade M reflux esophagitis may not necessarily be irrelevant, as it may suggest an early form of reflux disease or an entirely new form of reflux esophagitis. Further research is required to elucidate the pathophysiological basis of minimal change esophagitis.

These results suggest that the incidence of HCC in HBV patients with cirrhosis can be reduced in those with an MVR induced by consecutive LAM treatment.

Abstract. Leiomyosarcoma constitutes approximately 0.5% of the malignant neoplasias of the esophagus and its association with megaesophagus has not been described. We report on a case of a woman with dysphagia that was slowly progressive from the age of 19 due to chagasic megaesophagus. The woman was subjected to cardiomyotomy at the age of 49. She presented a rapid worsening of the dysphagia due to leiomyosarcoma at the age of 61, and was subjected to subtotal esophagectomy with cervical esophagogastroplasty. She developed pulmonary and hepatic metastases 14 months after surgery and died six months later.Chagasic megaesophagus, like idiopathic achalasia or megaesophagus, is related to an increased risk of epidermoid carcinoma of the esophagus. 1-5 However, we are unaware of any studies showing an association between megaesophagus and leiomyosarcoma. We report herein a case of chagasic megaesophagus who developed leiomyosarcoma of the esophagus. CASE REPORTThe subject was a 61-year-old woman (housewife) who had been living in rural conditions in central Brazil. She stated that she did not smoke or drink alcoholic beverages. She had a history of dysphagia from the age of 19 that became accentuated with time and was referred to as chagasic. After a diagnosis of chagasic megaesophagus was made, she was subjected to cardiomyotomy at the age of 49 and showed a distinct improvement. She maintained an unchanged state until two months before her last hospitalization, a time when the dysphagia became aggravated to a point where she had difficulty even in ingesting liquid alimentation, which was accompanied by significant weight loss and anemia. Results of serologic examinations for Chagas' disease were positive using three different techniques (complement fixation, immunofluorescence, and hemagglutination). Endoscopic examination revealed a vegetating lesion obstructing the passageway through the distal third of the esophagus, which showed dilation. A diagnosis of malignant neoplasia was confirmed by biopsy. Thoraco-abdominal tomography and abdominal ultrasound did not reveal metastases. She was subjected to subtotal esophagectomy with esophagogastroplasty and anastomosis in the lower cervical region.Macroscopic examination of the surgical specimen showed a polypoid tumor occupying the distal third of the esophagus. It measured 9 ϫ 5 ϫ 4.5 cm, was covered by mucosa with dispersed erosions, had an elastic, off-white, striated appearance at cut surfaces, and infiltrated the wall to a depth of up to 0

IVR is a useful factor for predicting the emergence of LAM-resistant virus in CHB patients treated with LAM. For IVR-negative patients, therapeutic options other than LAM monotherapy should be used because of the high incidence of the emergence of LAM-resistant virus.

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