The "ABCD" framework for assessment: a task-oriented approach to reconcile multimodal diagnostic discordance

Area of Science:

• Gastroenterology
• Surgical Diagnostics
• Medical Imaging Analysis

Background:

• Pre-operative hiatal hernia (HH) assessment frequently shows discrepancies between endoscopy, barium swallow, and high-resolution manometry (HRM).
• These diagnostic inconsistencies can result in uncertainty and suboptimal surgical planning for HH.
• A novel ABCD framework is proposed to integrate multimodal findings for a clinical-task-oriented decision process.

Purpose of the Study:

• To address diagnostic discordance in pre-operative hiatal hernia (HH) assessment.
• To propose the ABCD framework for integrating multimodal diagnostic data.
• To improve clinical decision-making and surgical planning for HH patients.

Main Methods:

• A comprehensive review of current diagnostic standards (Chicago 4.0, Lyon 2.0, AFS-LDF classification) and emerging technologies like artificial intelligence (AI).
• Identification of common points of diagnostic discordance and their clinical implications in HH assessment.
• Development of the ABCD framework to categorize HH assessment into four domains: anatomical, barrier, clinical consequences, and decision support.

Main Results:

• The ABCD framework categorizes HH assessment into anatomical confirmation, barrier phenotyping, clinical consequences, and decision support.
• Discordance, such as a large hernia on imaging with a functional barrier on HRM, reflects different dimensions of the esophagogastric junction (EGJ).
• AI-assisted endoscopic grading shows potential for improved reproducibility, pending external validation.

Conclusions:

• The ABCD framework provides a structured, task-oriented approach for multimodal HH assessment, aiding patient selection and perioperative decision-making.
• This framework shifts focus from identifying the 'best test' to addressing multidimensional clinical tasks.
• Prospective validation is required to confirm the impact of the ABCD framework on clinical outcomes.