Barrett's esophagus complicating achalasia after esophagomyotomy. A clinical, radiologic, and pathologic study of 70 patients with achalasia and related motor disorders

Of 70 patients with achalasia and related motor disorders, 3 developed Barrett's esophagus 5, 8, and 15 years after esophagomyotomy. One of the three had dysplastic changes in the Barrett's mucosa. Although an increased incidence of gastroesophageal reflux, esophagitis, and stricture are well-known complications after esophagomyotomy, the development of Barrett's mucosa has been only recently recognized. Diagnosis of Barrett's esophagus in such patients is difficult and requires a high index of awareness by the radiologist and an endoscopic biopsy for definitive diagnosis. The cumulative effects of achalasia and Barrett's esophagus predispose these patients to higher risks of developing esophageal carcinoma.

Mucoepidermoid (adenosquamous) carcinoma arising in Barrett's esophagus

A case of mucoepidermoid or adenosquamous carcinoma arising from the mucous epithelium of a Barrett's esophagus is presented. Immunohistologic examination demonstrated carcinoembryonic antigen (CEA) in both the glandular and squamous components, but keratin only in the latter. Although mucoepidermoid carcinoma of the esophagus is believed to arise from submucosal glands, heterotopic gastric surface epithelium may also give rise to this uncommon neoplasm.

[Precancerous conditions of the digestive system: true risk or a paper tiger? The esophagus]

The incidence of the squamous cell carcinoma of the esophagus shows geographical variations. As a rule it is found in heavy smokers and alcoholics. Multicentricity (mouth, hypopharynx, esophagus) is very frequent and accompanied by large dysplasias of different stages. The adenocarcinoma develops on the metaplastic cylindric epithelium of the Barrett esophagus. Positive dysplasias are highly suspicious of the development of a carcinoma and demand the reconfirmation of the finding by a second pathologist. In this case the resection of the esophagus has to be done. The abdominal-cervical method should be preferred.

The relationship between columnar epithelial dysplasia and invasive adenocarcinoma arising in Barrett's esophagus

The authors assessed the relationship between dysplasia in Barrett's esophagus and invasive adenocarcinoma in a study of both endoscopic biopsy specimens and esophagectomy specimens. They reviewed the pathologic findings and clinical follow-up of 14 patients with dysplasia in Barrett's mucosa in endoscopic biopsy specimens. They also studied systematically the histopathologic features of the Barrett's mucosa in 43 esophagectomy specimens resected for Barrett's carcinoma. In the biopsy specimens, dysplasia occurred in distinctive-type Barrett's mucosa of 13 patients (93%) but in cardiac-type mucosa of only 3 (21%). Six patients had high-grade dysplasia; five underwent esophagectomy and three of these were found to have superficially invasive adenocarcinoma. The other patient with high-grade dysplasia as well as eight patients with intermediate- or low-grade dysplasia are not known to have carcinoma on available follow-up. In the study of resection specimens, high-grade dysplasia was strongly associated with adjoining invasive adenocarcinoma, because 84% of areas with invasion had high-grade dysplasia and 92% of areas with high-grade dysplasia showed invasion. The authors' findings suggest that the dysplasia-carcinoma sequence most commonly occurs in Barrett's mucosa of the distinctive type; high-grade dysplasia in Barrett's mucosa is a marker indicating high probability of invasive carcinoma; the presence of high-grade dysplasia in biopsy specimens of Barrett's mucosa is an indication for esophagectomy in suitable surgical candidates.

Barrett's esophagus in children: a histologic and histochemical study of 11 cases

Columnar epithelium-lined esophagus is an acquired phenomenon arising secondarily to chronic mucosal injury from gastroesophageal reflux. This report documents 11 children with complications of reflux and the histologic finding of gastric mucosa in the esophagus. Five children had strictures, one requiring esophageal replacement and four treated by antireflux surgery followed by sleeve-resection of a short fibrotic stricture. Specimens from two patients showed mild dysplasia and from six others slight nuclear atypia. Intestinal metaplasia was apparent in one case on routine histology and was revealed in six other cases by mucin histochemical strains. The significance of the histopathologic findings is discussed in the context of possible malignant potential.

Effects of long-term medical treatment with cimetidine and bethanechol in patients with esophagitis and Barrett's esophagus

To evaluate long-term medical therapy in patients with Barrett's esophagus, six patients were studied before and after long-term therapy with cimetidine for a mean period of 11.7 months. Some patients also received bethanechol. All had severe symptoms of gastroesophageal reflux resistant to intensive antacid therapy, specialized columnar epithelium by biopsy, and endoscopic evidence of severe inflammation. Esophageal manometry documented a hypotensive lower esophageal sphincter in three patients and low peristaltic amplitude in the distal esophagus in four. Treatment was begun with cimetidine, 300 mg orally four times daily. If symptoms did not totally abate, bethanechol, 25 mg orally four times daily, was added. Cimetidine completely relieved or dramatically reduced symptoms in all patients. Adding bethanechol produced further symptomatic improvement in three of four patients. After initial dilatation in the two patients with strictures, there was no recurrence. Endoscopic evidence of inflammation resolved completely in four patients and was markedly improved in two. Treatment with both drugs was well tolerated by all patients. The abnormally placed squamo-columnar junction did not regress during follow-up.

A mixed pattern of endocrine cells in metaplastic Barrett's oesophagus. Evidence that the epithelium derives from a pluripotential stem cell

In order to characterize the differentiation of endocrine cells present in Barrett's oesophagus and to determine if they express a single or multiple hormonal pattern, endoscopic biopsies were taken from both the lesion and the fundus of 45 patients and studied at the light microscopical level. Conventional histology revealed three different epithelial patterns: gastric atrophic fundic, intestinal and junctional. A mixture of these patterns was present in 28 cases (62%) and the single type was identified in 17 cases (38%). The use of three silver staining methods and antibodies to human chromogranins allowed us to identify numerous endocrine cells in all but 1 case. Eleven sera against all the most common hormones stored in the endocrine cells of the gut were used to identify the main products of the cells. The following immunoreactivities were identified: 5-hydroxytryptamine (5-HT) (in 75% of the studied cases), somatostatin (87%), motilin (31%), pancreatic polypeptide (PP) (20%), glucose-dependent insulinotropic polypeptide (20%), gastrin (15%), glucagon (15%), peptide tyrosine tyrosine (13%), secretin (7%) and neurotensin (2%). No cholecystokinin-immunoreactive cells were identified. Our results indicated that, in Barrett's epithelium, both gastric and intestinal endocrine cells differentiate, in accordance with the variability of differentiation in the non-endocrine cells present in the different types of columnar epithelium. These findings provide support for the conclusion that Barrett's epithelium arises from a pluripotential stem cell capable of both gastric and intestinal differentiation.

The relationship of endocrine cells, dysplasia and carcinoembryonic antigen in Barrett's mucosa to adenocarcinoma of the oesophagus

This study was undertaken to assess the prevalence and characteristic hormonal profile of endocrine cells in Barrett's mucosa and to determine to what extent this profile was shared by endocrine cells of adenocarcinomas arising therefrom. In addition, lower oesophageal carcinomas, not associated with columnar metaplasia, were examined to see if they exhibited a different hormonal profile. The patients studied comprised 43 who had had multiple oesophageal biopsies. 35 who had had oesophagogastric resection for adenocarcinoma arising in Barrett's mucosa and 26 in whom the resection showed no metaplastic epithelium adjacent to tumour. Argyrophil cells were present in 90% of biopsies and resections of Barrett's mucosa combined, irrespective of the histological type of metaplastic epithelium. By immunocytochemistry the most frequently identified substance in mucosal endocrine cells was serotonin (82%) followed by somatostatin (54%), secretin (22%) and pancreatic polypeptide (17%). Gastrin, bombesin, cholecystokinin, ACTH and substance P were not identified in metaplastic mucosa in any case. The difference in expression of serotonin by endocrine cells of tumours arising in Barrett's mucosa (31%) and those not (3.8%) was statistically significant (P less than 0.0186). Carcinoembryonic antigen (CEA) was demonstrated in 60% of oesophageal carcinomas, both endocrine positive and endocrine negative. Focal CEA expression was seen in 4.6% of biopsies and 14% of Barrett's mucosa adjacent to tumour. These results indicate a higher prevalence of endocrine cells in Barrett's mucosa than hitherto documented and suggest that serotonin may be a useful marker in distinguishing between primary oesophageal and putative gastric cancers at the gastro-oesophageal junction. The identification of CEA in oesophageal columnar epithelium is of little value in predicting the development of malignancy.

Colorectal neoplasms and Barrett's esophagus

Prospective colonoscopic study of 36 patients with Barrett's esophagus found colorectal adenomas in 33% of patients. Of patients aged less than 60, four of 17 (24%) had adenomas, while patients aged 60 or more had adenomas in eight of 19 (42%) cases. All adenomas were less than or equal to 10 mm diameter. No colorectal malignancies were found in these patients. This prevalence of neoplasms is consistent with results of autopsy studies. It is concluded that no increased risk of colorectal neoplasms was found in this group of patients with Barrett's esophagus.

Barrett's ulcer of the esophagus. Previously unrecognized cause of acquired esophagorespiratory fistula

Acquired fistulas between the esophagus and tracheobronchial tree are usually associated with malignancy of the esophagus, lung, or trachea. Less commonly, fistulas result from trauma or inflammation involving these structures. Untreated fistulas of any cause lead to fatal complications of aspiration. Although the prognosis in cases of malignant fistula is poor, the recognition and surgical management of nonmalignant fistulas may result in cure. An acquired esophagobronchial fistula resulting from a Barrett's ulcer of the esophagus, a previously unreported cause, is described, and the differential diagnosis and treatment of nonmalignant esophagorespiratory fistulas are discussed.

Histological and histochemical changes in the columnar lined (Barrett's) oesophagus

Multiple endoscopic specimens were obtained from 58 patients with a columnar lined gesophagus to study the histological and histochemical features of this metaplastic epithelium. Five patients (8.6%) had presented with a primary oesophageal adenocarcinoma. Three different epithelial types, junctional, atrophic fundic and intestinal were identified. Twenty two (38%) patients had just one type of epithelium present, the other 36 (62%) having a combination of two or three different types. Intestinal type of epithelium, either alone or in combination with gastric type epithelium was present in 48 (83%) patients. In every case this intestinal type epithelium took the form of an incompletely differentiated variant of intestinal metaplasia, although complete intestinal metaplasia as a focal change was also present in 14 of these patients. Histochemically, sulphomucins were present in the biopsies of 43 (74%) of the patients studied. They were seen in both goblet and columnar mucous cells with almost equal frequency. Incomplete intestinal metaplasia with sulphomucin production was present in four of the five patients with an oesophageal adenocarcinoma. In the columnar lined oesophagus sulphomucin production is common and its presence does not help to identify those individuals at particular risk of developing an adenocarcinoma.

Barrett's oesophagus and adenocarcinoma--a case report

Since Barrett's original description of the columnar lined lower oesophagus in 1950, this condition has been linked with over 140 cases of adenocarcinoma in the English literature. To date the youngest reported cases are a 23 year old male and a 25 year old male. This report concerns what is believed to be the youngest reported case of adenocarcinoma in a Barrett's oesophagus.

Gastroesophageal reflux and Barrett's esophagus in developmentally disabled patients

Twenty-seven patients from an institution for the developmentally disabled underwent endoscopy for evaluation of vomiting, regurgitation, rumination, or upper gastrointestinal bleeding. The presence of gastroesophageal reflux and Barrett's esophagus was determined retrospectively. Twenty-three patients had an IQ less than 20, 19 were nonambulatory, and 14 were taking at least one neuroleptic drug daily. Seven patients (26%) had histologically documented Barrett's esophagus of the specialized-columnar type. Two patients with Barrett's esophagus had benign esophageal strictures, but no cases of adenocarcinoma were found. There were no significant differences (p greater than 0.05) between patients with or without Barrett's esophagus in regard to symptoms, age, sex, IQ, medications, or ambulatory status. The present data suggest that Barrett's esophagus may frequently occur in developmentally disabled patients with symptoms and signs of gastroesophageal reflux.

Histologic changes in gastroesophageal reflux

Three aspects of the esophageal mucosal injury that occur in gastroesophageal reflux disease are discussed in this article. First, the histologic changes in the squamous epithelium-lined esophagus are variable. Some patients with reflux symptoms do not have histologic evidence of inflammatory cell infiltration within the mucosa, but rather may have more subtle effects of mucosal injury, namely, thickening of the basal regenerative layer, elongation of the papillae, or intraepithelial eosinophils. However, these more subtle findings often are merely confirmatory of other clinical indicators of gastro-esophageal reflux; they may have their most practical application to the research investigation of reflux disease. Second, the presence of esophageal mucosal inflammation may adversely affect lower esophageal sphincter function. This phenomenon can be demonstrated in the cat model. Whether it is operative in humans is unclear. Finally, the development of columnar metaplasia (Barrett's epithelium) is more than a histologic curiosity because this condition confers an increased risk of developing adenocarcinoma of the esophagus. Among several unanswered questions about Barrett's epithelium is what is an appropriate surveillance program for patients with Barrett's epithelium to detect the presence of, or predict the development of, cancer?

Adenomatous polyp arising in Barrett's esophagus

A 40-year-old woman with chronic symptoms of gastroesophageal reflux had a 1.5-cm filling defect in the distal esophagus on esophagogram. Endoscopy revealed distal esophagitis and, immediately above a hiatal hernia, a pedunculated polyp on a short stalk, which was removed by snare cautery. The polyp was an adenoma composed of tubular glands and covered by intestinal-type epithelium. Serial distal esophageal biopsies confirmed Barrett's metaplasia with areas of specialized columnar epithelium with goblet cells. These findings suggest that the full expression of neoplasia in Barrett's esophagus includes the development of adenomatous polyps as well as dysplasia and adenocarcinoma.

Barrett's esophagus: clinical, endoscopic, and histologic spectrum in fifty patients

The columnar lined (Barrett's) esophagus is an acquired condition resulting from chronic gastroesophageal reflux. The clinical spectrum of 50 consecutive cases of endoscopically consistent, histologically proven Barrett's esophagus was reviewed. The mean age of patients was 65.9 +/- 12.4 (SD) years with only four patients younger than 50 years. The predominant presenting symptoms were dysphagia, heartburn, and regurgitation. At endoscopy, the columnar lined segment extended over 6.5 +/- 3.0 cm of the lower esophagus. Specialised columnar (intestinal) epithelium was the most frequent histological type identified. Radiologic or endoscopic evidence of a hiatal hernia was present in the majority. Complications were present at endoscopy in 38 (76%) patients. Reflux esophagitis (56%) was present at the area of the squamo-columnar junction. Stricture formation (38%) and ulceration (36%) were located either at the squamo-columnar junction or more distally within the columnar epithelium. Two patients (4%) had adenocarcinoma arising in a segment of Barrett's esophagus at presentation. Treatment included physical measures, dilatation, and cimetidine. Bougienage in 20 patients was successful in alleviating dysphagia but multiple treatment sessions were often necessary. Although esophagitis readily resolved with cimetidine therapy, ulceration was generally resistant to medical therapy. Indeed, by two months, healing was achieved in only five of 12 patients. Endoscopic surveillance of 12 patients who received cimetidine (1 g/day) for at least 12 months showed no regression of the metaplastic mucosa.

Familial Barrett's oesophagus?

Two sisters presenting with Barrett's oesophagus both at the age of 66, are described. The endoscopic appearances revealed striking similarities in terms of severity and extent of the lesion and the presence of a hiatus hernia. At oesophageal manometry low lower oesophageal sphincter pressures were recorded in each case. These observations raise the possibility that familial factors may influence the development of this condition, and likely mechanisms are discussed.

Barrett's mucosa with multiple carcinomas of the esophagus and oral cavity

A 62-year-old man with carcinoma of the tongue had two separate asymptomatic carcinomas of the esophagus, one squamous and the other adenocarcinoma arising from Barrett's mucosa. We review the multicentric origin and synchronous occurrence of tumors in the oropharyngoesophageal area with and without Barrett's mucosa to emphasize the importance of complete evaluation of the esophagus in patients with oropharyngeal malignancy.

Radiologic diagnosis of Barrett's esophagus: critical analysis of 65 cases

A recent increase in the number of Barrett's esophagus being diagnosed is probably directly related to a proportional increase in endoscopic biopsies of the esophagus and awareness of premalignant potential of Barrett's mucosa. While the endoscopist can detect Barrett's mucosa with fair degree of accuracy, the radiologic diagnosis of Barrett's esophagus still remains a diagnostic challenge despite several well established radiologic features. We reviewed 65 patients with pathologically proven Barrett's esophagus and found a wide spectrum of radiologic features. These include hiatus hernia in 49, gastroesophageal reflux in 38, strictures in 32, esophagitis in 20, and characteristic Barrett's ulcer in 12. In addition ascending or migrating strictures were found in 10, mucosal pattern simulating areae gastricae in 5, cricopharyngeal dysfunction in 4, and fixed spiral folds in 3 patients. This constellation of radiologic features, some of which have not been previously emphasized, should further assist radiologists in suggesting the diagnosis of Barrett's esophagus.

Barrett's esophagus in childhood

This study describes the clinical, radiologic, esophageal function test, endoscopic, and histologic findings of Barrett's esophagus in 11 children aged 6-14 yr. All had long-standing symptoms of gastroesophageal reflux, which had begun in the first year of life in 10 of the 11. Eight of the 11 patients had mid or upper esophageal strictures and 10 of the 11 required fundoplication. Most patients had low lower esophageal sphincter pressures and abnormal pH probe studies. Only 6 of the 11 children had the characteristic pink-red appearance of the mucosa at endoscopy. Fifty endoscopic biopsy specimens taken at multiple levels in the esophagus contained columnar-lined epithelium above the gastroesophageal junction. Five of the patients had specialized (intestinal-type) epithelium as part of the histologic spectrum. The clinical expression of Barrett's esophagus in children is similar to that in adults except that strictures appear to be more common in children, and the endoscopic appearance of the mucosa is not always typical in color. As in adults, gastroesophageal reflux appears to be the etiology. In children beyond infancy, Barrett's esophagus is the most common indication for antireflux surgery at our institution. Biopsy specimens should be taken from multiple levels in the esophagus to avoid overdiagnosis and to establish the diagnosis with certainty.

Barrett's esophagus complicating scleroderma

Two patients with scleroderma whose esophageal involvement was associated with long-standing reflux esophagitis were found to also have Barrett's esophagus. Since Barrett's esophagus is a premalignant condition, these patients with scleroderma should be considered at high risk for the development of adenocarcinoma of the esophagus.

Adenocarcinoma in columnar-lined Barrett's esophagus. Analysis of 13 esophagectomies

From 1977 to 1982, 13 patients with adenocarcinoma arising in the distal esophagus lined by columnar epithelium underwent esophagectomy with detailed analysis of the pathologic specimen. In three patients, microinvasive carcinoma was detected before dysplasia occurred. In five patients, the ectopic mucosa was discontinuous, prolonged cranially by islands of columnar epithelium scattered in the squamous mucosa. Variable degrees of dysplasia were found in the columnar epithelium in seven specimens in areas of intestinal metaplasia. In four patients with high-grade dysplasia, several foci of intramucosal carcinoma were identified. They were scattered over the whole length of the ectopic mucosa. These data strongly suggest that adenocarcinoma develops from dysplasia, the real premalignant lesion. Careful periodic screening must be carried out in patients identified as having Barrett's esophagus. Dysplasia may be detected and located by endoscopy with dye spraying with directed biopsies. Patients with high-grade dysplasia should undergo esophagectomy with resection of the whole ectopic mucosa because they are at high risk for development of carcinoma.

Dysplasia in Barrett's esophagus

In a retrospective histological study, resected specimens obtained from 23 patients with adenocarcinoma in Barrett's esophagus (Group I) and endoscopic multiple (step) biopsies from 38 patients without carcinoma in Barrett's esophagus (Group II) were investigated for dysplastic changes. Dysplasia was most frequently found in the type of mucosa comprising intestinal metaplasia. There seem to be two pathways to dysplasia in Barrett's esophagus. In Group I dysplasia was found in 18 out of 23, and in Group II in 2 out of 38 patients. In Barrett's esophagus, dysplasia may be considered not only a precursor of carcinoma, but also a marker for coexisting carcinoma.

[Barrett esophagus. Retrospective study of 258 cases]

Barrett's esophagus, nearly always an acquired disease, is neither rare nor a curiosity, having been diagnosed in 258 out of 2573 patients with reflux esophagitis. It was associated with esophageal adenocarcinoma in 29 cases (11.2%) and with non-esophageal cancer in 72 cases (27.9%).

Dysplastic Barrett's esophagus in scleroderma

A review of 107 patients with Barrett's esophagus revealed three patients who concomitantly had scleroderma. Two of the three patients had pathological evidence of high-grade dysplasia of the columnar-lined epithelium, and the third patient had nondysplastic columnar-lined epithelium in the distal esophagus. Patients with scleroderma often have an incompetent lower esophageal sphincter, poor or absent distal esophageal peristalsis, and reflux esophagitis, all of which are believed to predispose to Barrett's esophagus. The importance of Barrett's esophagus is its potential for malignant transformation. Identification of such patients permits aggressive medical treatment and endoscopic and pathological surveillance.

Regulatory peptides in Barrett's oesophagus

Barrett's epithelium refers to the presence of ectopic mucosal types in the squamous-lined oesophagus. Previous studies have documented argentaffin and argyrophil-positive cells as well as gastrin-like immunoreactivity in oesophageal tissue extracts from patients with Barrett's mucosa. In the present study, 125 oesophageal biopsies obtained under direct vision at endoscopy from 22 patients with Barrett's oesophagus were systematically studied using fluorescence and peroxidase antiperoxidase single and double-staining immunocytochemical methods employing highly specific antibodies to localize the following peptide-containing cell types in Barrett's mucosa: gastrin, somatostatin, gastric inhibitory polypeptide, motilin, neurotensin and pancreatic glucagon. In addition, EC cells were localized using a cytochemical silver staining method. The results of this study indicate that EC cells and gastrin- and somatostatin-containing endocrine cells are detectable in Barrett's epithelium.

Barrett's esophagus in a patient with achalasia

Barrett's esophagus has been reported in patients with achalasia who have undergone esophagomyotomy. The condition was thought to be acquired from gastroesophageal reflux secondary to the iatrogenically produced incompetent sphincter. We present the case of a patient with Barrett's esophagus and achalasia without any previous surgical intervention.

Barrett's oesophagus

The bulk of available evidence supports the view that Barrett's oesophagus is an acquired condition due to chronic gastro-oesophageal reflux. It is possible that a few cases are congenital. Barrett's oesophagus gives rise to severe stricture and ulceration and has a significant malignant potential. Treatment is designed to prevent reflux and, if possible, to reverse the metaplastic change. Dysplasia is of ominous significance and requires frequent careful surveillance.

Barrett's oesophagus and colonic tumours

Of 65 patients with Barrett's oesophagus, all of whom were white, 29 (44.6%) had colonic tumours; 19 were benign and 10 were malignant. The frequency of colonic cancer was especially high (38%) in patients with Barrett's oesophagus aged 64 years or older. 7 of the 65 patients had had previous colonic resections for cancer and 3 were found prospectively to have malignant tumours. Benign tumours had been removed by colonoscopic polypectomy in 3 of the 19 patients; in 16 patients the tumours were diagnosed prospectively. In comparison with two other high risk groups, malignant tumours were found in 7.7% of 325 symptomatic patients admitted for colonoscopy and in 11.3% of 120 symptom-free patients with occult blood in the stools. The probability of finding this number of malignant tumours in an age-matched random sample of the general population is less than one in a million.

Focal lymphoid hyperplasia (pseudolymphoma) of the esophagus

Focal lymphoid hyperplasia is an uncommon but ubiquitous lesion. It occurs most commonly in the gastrointestinal tract in association with chronic peptic ulcer disease of the stomach. We describe the hitherto unrecognized association of lymphoid hyperplasia in the esophagus with chronic stenosing ulcerating esophagitis and Barrett's mucosa. This association is considered to be analogous to the more prevalent coexistence of lymphoid hyperplasia and chronic peptic ulcer disease in the stomach.

Atypias, dysplasias, and neoplasias of the esophagus and stomach

Our understanding of the origin and evolution of gastrointestinal mucosal dysplasias and neoplasias has been greatly expanded in recent years by the marked increase in the number of endoscopic biopsies, which are facilitated by the use of flexible instruments with a remarkable safety record. The availability of specimens and the development of special procedures to examine them allows the detailed study of the normal and abnormal gastrointestinal mucosa, as determined by histochemical procedures. Similarly, immunocytochemistry has been used to determine the presence of oncofetal antigens as an expression of neoplastic transformation and/or evolution. Finally, the ease of repeat endoscopic procedures has permitted close observation of the natural or therapeutically modified history of mucosal lesions. The majority of the pathologic findings were in specimens obtained during endoscopic procedures ("grasp or pinch biopsies"), which generally yield superficial fragments of mucosa. Suction biopsies have been recently proposed as an alternative since such specimens contain portions of the whole mucosal layer and part of the submucosa. Our institution performs over 3,000 endoscopic procedures per year; the experience gathered with this material constitutes the basis for this review of esophageal and gastric preneoplastic and neoplastic mucosal lesions obtained by endoscopic and suction biopsies. Data obtained from conventional surgical specimens are also included.

Morphological findings in peptic esophageal stenosis with Barrett's ulcer in children

The morphological findings in three resected specimens of Barrett's ulcer in children are discussed. Nearly identical morphologic changes are found in all cases, even in adults. This pathologic condition is understood as the third or fourth stage of reflux esophagitis. Perforation or even malignant degeneration is described in these cases. Therefore mainly all therapeutic aims must be to prevent these stages.

Barrett's esophagus: its prevalence and association with adenocarcinoma in patients with symptoms of gastroesophageal reflux

The pathologic reports of all 1,020 esophageal biopsy specimens obtained between 1975 and 1981 in patients with symptoms of gastroesophageal reflux were reviewed. Barrett's esophagus was identified in 84 patients (8 percent). The 362 patients seen between 1980 and 1981 were reviewed in detail. The symptoms in patients with Barrett's esophagus differed from those of the patients without Barrett's esophagus. Dysphagia was more often present in the former group (34 percent versus 16 percent, p less than 0.05) and epigastric distress was less frequent (11 percent versus 27 percent, p less than 0.05). Objective findings of hiatal hernia, esophageal stricture, and esophageal ulcers occurred more commonly in patients with Barrett's esophagus than in those without Barrett's esophagus (70 percent versus 48 percent, 31 percent versus 4 percent, and 14 percent versus 6 percent, respectively, p less than 0.05). Mid esophageal strictures were associated almost exclusively with Barrett's esophagus (five of six patients). At esophagoscopy, erythema was seen more commonly with Barrett's esophagus. The diagnosis was suspected by the endoscopist in only 34 percent of patients subsequently demonstrated histopathologically to have Barrett's esophagus. There was no significant difference in the prevalence of a positive Bernstein test result or gastroesophageal reflux on upper gastrointestinal series in patients with and without Barrett's esophagus. However, a hypotensive lower esophageal sphincter was found more commonly in patients with Barrett's esophagus (100 percent versus 53 percent, p less than 0.05). Thirteen of the 84 patients with Barrett's esophagus (15 percent) had a coexistent adenocarcinoma arising from Barrett's mucosa. These patients, when compared with the patients with Barrett's esophagus without carcinoma, were more often male (77 percent versus 51 percent, p = 0.1), more often had dysphagia (69 percent versus 34 percent, p less than 0.05), and more frequently had a comparatively short duration of symptoms (67 percent versus 36 percent, p less than 0.05). Our findings suggest that patients with Barrett's esophagus have a high risk of development of carcinoma. Because the entity is often not recognized at endoscopy, routine esophageal biopsy should be performed on all patients undergoing esophagoscopy for symptoms of gastroesophageal reflux. Patients with known Barrett's esophagus should be followed closely with repeated endoscopy and biopsy.

Stricture location in Barrett's esophagus

Twenty-eight patients with Barrett's esophagus were studied and strictures were present in 13. Two strictures were malignant. Of the 11 benign strictures, six were located at the squamocolumnar junction, while five were located below the squamocolumnar junction. Contrary to previous reports, benign esophageal strictures often occur below the squamocolumnar junction in patients with Barrett's esophagus.

Adenocarcinoma and Barrett's esophagus. An overrated risk?

The risk of developing esophageal cancer in Barrett's esophagus has been estimated at about 10%. This estimate is based primarily on data concerning the prevalence of that association in series of hospitalized patients and autopsies--a practice that tends to exaggerate the risk. We have reviewed retrospectively our experience with 115 patients whom we treated for Barrett's esophagus between September 1962 and March 1983, and have distinguished our data on the prevalence of esophageal cancer from that on incidence. For 8 patients, we found both Barrett's esophagus and esophageal adenocarcinoma during the initial evaluations for a prevalence ratio of 7%. We followed 105 patients not found to have esophageal cancer initially for a total of 350 person-years. Only 2 patients developed adenocarcinoma during that follow-up period for an incidence of 1 case per 175 person-years. This incidence, although some 40-fold greater than that of the general population, is substantially lower than previously estimated. Routine endoscopic and histologic surveillance has been recommended for patients with Barrett's esophagus because of the alleged high incidence of esophageal cancer. Inasmuch as that incidence now appears to be low, we question the value of such surveillance for these patients.

The spectrum of carcinoma arising in Barrett's esophagus. A clinicopathologic study of 26 patients

The clinical and pathologic features of carcinoma arising in Barrett's esophagus were studied in resection specimens from 26 patients. White males predominated (73%). A history of symptomatic gastroesophageal reflux was frequently absent, being elicited in only eight of 14 patients (57%) with a carefully obtained history at the time of presentation with carcinoma. Survival was relatively short with a median survival of 23 +/- 5 months, and only three patients had a disease-free survival longer than 2 years. A pathologic spectrum of carcinoma was found: differentiation ranged from well to poorly differentiated in the 20 patients with a single adenocarcinoma; two separate carcinomas were found in four patients; and a spectrum of differentiation in a single tumor was found in the other two cases, one an adenocarcinoid tumor and the other an adenosquamous carcinoma. The tumors were generally far advanced, with extension through the esophageal wall in 23 of 26 cases (88%) and metastases to lymph nodes in 17 of 24 cases (71%). Epithelial dysplasia, including carcinoma in situ in some cases, was found in Barrett's mucosa adjacent to the tumor in all 26 patients. Our findings suggest that a surveillance program for dysplasia in patients known to have Barrett's esophagus is warranted in an attempt to improve the outcome. However, the impact of surveillance on the incidence of Barrett's carcinoma may be lessened by its frequent occurrence in patients with asymptomatic gastroesophageal reflux.

Mucin histochemistry of the columnar epithelium of the oesophagus (Barrett's oesophagus): a prospective biopsy study

Columnar epithelium-lined oesophagus (CELO) is an acquired disorder associated with a high incidence of cancer. CELO consists of three histological types of epithelium: gastric-fundic, junctional, and specialised columnar, the last resembling intestinal metaplasia of the stomach. In a previous study of CELO an incompletely differentiated variant of intestinal metaplasia secreting sulphomucins (type II B) was found. This was shown to be associated with well differentiated adenocarcinoma, as in the stomach. The purpose of this paper has been to define by histochemistry the mucin profile of CELO in 17 patients and to compare it with the mucin profile of the gastroesophageal junction in 27 patients without CELO. In CELO a specialised columnar epithelium was always found and type II B intestinal metaplasia (with sulphomucins) showed the highest incidence (53%). In normal subjects, this type of intestinal metaplasia was found in only three of 27 cases. Type II B intestinal metaplasia has often been considered as a precancerous lesion or as an equivalent of dysplasia; consequently, its high incidence in our study on CELO raises the question of whether this lesion should be considered a high risk condition for adenocarcinoma of the lower oesophagus.